Pan American Health Organization

Health system transformations toward universal health

  • Introduction
  • Health policies as components of systems for social protection in health
  • Health Reforms
  • The challenges of moving toward systems with universal access to health and universal health coverage
  • References
  • Full Article
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Introduction

The right to health, equity, and solidarity are values that have guided health system transformations in the Region of the Americas. However, health inequities and social and economic inequality in the Region continue to pose challenges that health systems must confront. New pressures have arisen from the emergence and influence of new health problems, such as the growing burden of noncommunicable diseases, increasing violence and road injuries, and demographic changes reflected in the rapid aging of the population ().

In order to advance toward universal health, health systems must take these transformations further by strengthening the stewardship of the health authorities, boosting regulatory mechanisms, and investing more public funds in health (including efficient and equitable financing). Efforts should also be made to increase and better allocate human resources in line with a people-centered and community-centered health care model ().

At the same time, it is essential for health to be understood as a key component of the social development agenda and, consequently, of countries’ social protection systems. Health inequities are an expression of social problems, determined largely by the structure of existing social protection systems in the countries. For this reason, the transformation of health systems should be viewed through the lens of the new social protection systems being developed and the commitments countries have made through the 2030 Agenda for Sustainable Development ().

This topic presents the key characteristics for describing and evaluating the various ways in which health systems are transforming. It examines the content of health policies as well as aspects of economic policy associated with the formulation and implementation of health policy. This framework helps describe health system transformation processes in the Region these past few years. It also offers a forward-looking analysis whose reference point is the strategy for universal access to health and universal health coverage.

Health policies as components of systems for social protection in health

The right to health, equity, and solidarity are the core values of the strategy for universal access to health and universal coverage (universal health). They also serve as the basis for development of systems for social protection in health ().

The United Nations’ Commission for Social Development defines social protection as “a set of public and private policies and programs undertaken by societies in response to various contingencies in order to offset the absence or substantial reduction of income from work; provide assistance for families with children; and provide people with health care and housing” ( p. 3). According to the Commission, these measures address the need for coverage and promotion of those living in poverty and extreme poverty, as well as the insurance needs of those who, while not necessarily poor, need to feel safe when facing adverse circumstances or certain stages of the life course ().

The rationale behind the strategy for universal access to health and universal health coverag requires an understanding of social protection that is explicitly aligned with the right to health. This means the focus must remain on people and communities in all stages of the life course, and social determinants of health must be an indispensable component ().

Within this framework, stronger social protection helps create more inclusive and just societies in which all people can exercise their health-related rights. This occurs in a context of respect for all economic, political, social, and cultural rights, promoted by public policies that favor sustainable human development ().

Problems and challenges

One of the main challenges faced by health systems is the persistence of inequities1 in income and in health outcomes. As was mentioned previously under inequities and barriers in health systems, these are important issues for social protection systems and, therefore, must be addressed if conditions of inequity in the Region are to be reversed ().

This perspective assumes that conditions of economic growth do not suffice to address the challenges of inequity. On the contrary, far-reaching changes must be made in the institutional structures of the health systems (the financing model, how health services are organized, human resources, technology, and social determinants of health) to ensure that they have an impact on health equity.

Definitions, history, and evolution of social protection systems

The ways that social issues are addressed by government, as well as the priorities established, have evolved over time in the Region of the Americas. This is the result of different approaches to social policy at different times in history, as well as the dynamics of power among the parties involved in decision-making ().

Although they manifest differently in the various countries, the evolution of social protection systems can be grouped into four main stages. In each of these we recognize certain unique features linked to development and to contributory social protection policies (social security), and to the main directives governing non-contributory social protection. In each case, these models give rise to specific concepts regarding the role of the State and of social protection ().

In the first stage, prior to the Great Depression of 1929, social policy tended not to be based in sectors or institutions. When social protection institutions first began to play a leading role in the community, they were contributory in nature, particularly for health in some countries of the Region. This was done through mutual societies and collective insurance, primarily for urban wage-earners and with little State regulation. During the second stage, with greater industrialization and more government planning, the main social policy issues were related to justice, social order, and social security, applied universally, albeit in a fragmented or stratified fashion (). However, there were serious limitations on coverage with marked differences between those who earned formal wages and those who did not. The challenges of adopting a comprehensive approach to include both contributory and non-contributory interventions yielded a lack of coordination, preventing comprehensive interventions. Funding for non-contributory social policy came primarily from the State and resource distribution basically involved subsidizing supply. This allowed the State to extend its presence in service delivery, with scant participation from the private sector.

The third stage, during the last two decades of the 20th century, was marked by economic adjustment processes and a diminished State role in social policies (). These changes had an impact on both the contributory and noncontributory components. Changes to the contributory component took place through privatization and deregulation of health social security systems. New private actors were allowed to manage social security resources through competitive frameworks. The noncontributory component underwent reforms to introduce economic incentives for health service providers. There were innovative funding models which sought to move from funding supply to funding demand by separating funding from health service delivery. This same logic was promoted in other social policies, targeting the population living in poverty ().

At present, a new paradigm of social protection has emerged, based on protection of human and social rights, in keeping with the values and principles established in Chapter 1, which underpin the strategy for universal access to health and universal health coverage ().
Access and coverage have particular relevance in transformation initiatives, with differential consequences for the contributory and noncontributory components. In some countries, these initiatives have focused on strengthening the contributory schemes, with innovations in insurance coverage systems aimed at expanding coverage to the entire population, including those not formally employed. In other countries, initiatives have focused on strengthening the public, noncontributory system. These efforts are geared to strengthening and transforming health services by expanding access and promoting intersectoral policies. But these processes have not been uniform across countries.

Health reforms

Health reforms can be defined as processes aimed at introducing substantive changes to health systems through their various entities, levels, and functions. Changes are achieved through strategies and actions, with the ultimate goal of better meeting the health needs of the population (). Thus, we should define what we mean by health system. The World Health Organization (WHO) states that a health system “consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health”; in other words, a group of actors that carry out health-related activities, understood as any action in the sphere of personal or collective health, public health services, or intersectoral initiatives whose main goal is to improve the standard of health of individuals, communities, or populations ().

Reform processes have affected health systems in most regions and countries of the world since the 1990s. Reform proposals and processes based on the unique characteristics of each region and country have developed in accordance with each specific political, economic, and social context. Still we can identify features of reform that are common to different regions and countries, essentially responding to the social protection models implemented and the prevailing ideas during certain periods, promoted by international organizations. The reform proposals have combined population health objectives (including access to services, expansion of coverage, and improved health service performance) with objectives for changing conditions within institutions (such as segmenting health systems according to different insurance systems and organizational changes associated with the fragmentation of health services).

Plans and strategies for reform are based on one or all of the main elements of health systems: the funding, organization, and delivery of health services, and institutional frameworks. Through this approach, reform processes set strategies associated with the most relevant variables, such as equity, access, efficiency, quality, effectiveness, financial protection, expectations of the population, solidarity, sustainability, and participation.

Two of the most interesting aspects are access and equitable access, considered to be among the central objectives of transformation processes. Access is the capacity to use health services when they are needed. It includes activities targeting the entire population as well as individuals. Access also includes the diverse array of conditions in which the population lives, and the differentiated needs of individuals and population groups. It entails activities to promote health and prevent disease, and to provide whatever health care is needed. Access to health is related to the health needs of populations and the conditions under which the system is used. This is determined by various individual, community, and sociocultural factors, as well as by the characteristics of the health system itself. In other words, access is determined by the interaction between people and their health needs, and the health system ().

Health equity is the absence of unjust differences in one’s health status, in access to health care, and to healthy environments, and in the treatment received in the health system and other social services ().

Equity in financial coverage requires an equitable funding model, with special attention to financial coverage. This is reflected in differences in the allocation of resources (per capital spending) that are not justified by different health needs, but rather by a different ability to contribute, with different parts of the system having differentiated resources to respond to different needs, but inversely—i.e., more resources for groups that likely have fewer health needs (the wealthiest) and fewer resources for those who might fall ill more often and more seriously (the poorest).

Contents and processes of health system transformations

Health system transformations can generally be evaluated in light of two complementary aspects: the content of the reforms and the processes by which they are formulated and implemented.

When examining content, we look at the objectives, tools, and strategies used and how they are applied. This allows us to recognize two types of reforms discussed under the topic of stewardship and governance in Chapter 1 of this publication: i) reforms promoted through innovation in how health systems are organized and the model of care; and ii) reforms through changes to the population’s health insurance mechanism. The objectives of these two kinds of reform are easily differentiated: the former is a matter of increasing access to health services, while the latter increases financial coverage for health services. There is also differentiation in how they are applied, because the first kind of reforms focus on the public sector, while the second kind takes place within the social security system.

An analysis of the processes whereby reforms are formulated and implemented includes an examination of the actors involved, in light of their interests, values, and understanding. This analysis must be conducted to address issues of political economy that underlie the strategies for universal access to health and universal health coverage. The approach includes three interrelated dimensions: i) creation of new institutional frameworks making it possible to establish systems for universal access and coverage; ii) the stakeholders who should participate in the social dialogue; and iii) challenges to the transformation process. This analysis should consider the fragmentation and segmentation of health systems to be key challenges ().

Achieving universal coverage and universal access requires relevant institutional innovations, rather than just maintaining structures that perpetuate the status quo in the Region’s health systems. A political economy analysis requires the identification and description of the institutional arrangements involved in transformation processes, namely: those related to the funding model, how the health services are organized, and how social determinants are addressed. Only by identifying and describing each of these components can the underlying stakeholders, interests, and conflicts be acknowledged ().

When considering the players involved in creating a system to ensure universal access and universal coverage, we must consider the types of actors, the relationships between them, and their technical and political capacity (). As for the kinds of actors involved in these processes of change, a distinction must be drawn between those in the health system and those in the area of finance or other sectors or social contexts. It is also essential to acknowledge their unique interests, perspectives on the problems, and positions regarding the measures promoted to move toward universal health. As for the relationships between the actors, we can imagine a scale going from full cooperation to outright conflict.

Technical and political capacities should acknowledge the conditions needed to build and sustain a universal health agenda. Political capacity is related to the inclusion of new players within a framework of collective leadership with partnership agreements (). Technical capacity is related to the ability of actors to interpret the challenges and prepare interventions.

Finally, conflicts () among the stakeholders must be analyzed when designing transformation strategies. This transcends a financial, organizational, or technical analysis and underscores the political nature of the transformation process involved in moving toward universal health.

Although there are sufficient social values and arguments for promoting universal health, many decisions and measures may be perceived as threats or as contrary to the interests of certain social groups. If these issues are analyzed, it may be possible to enhance the effectiveness of policy formulation and implementation processes. These disputes do not manifest themselves uniformly across the health system’s institutions (). The different types of political economy issues should be recognized according to the type of institutional arrangements in play during the processes of transforming health systems.

Analysis of transformation processes

The processes of transforming health systems can be characterized in terms of two core areas: equitable access and fragmentation of health services; and equitable financial coverage and segmentation of health systems. These core areas allow us to conduct a dynamic analysis of the countries of the Region through the following diagram.

Figure 1 lays out four scenarios. The graph has a horizontal axis indicating higher to lower segmentation of health systems, while the vertical axis indicates higher to lower fragmentation of health services. Each of these scenarios makes it possible to describe different transformation processes, in different countries at different times. Both axes incorporate an analysis of equity conditions. While reduced fragmentation brings improvements in equitable access, reduced segmentation brings more equity in financial coverage.

Figure 1. Health systems transformations

The two extremes are reflected in scenario one (upper-right quadrant of Figure 1) called integral reforms, and scenario three (lower-left quadrant of Figure 1) corresponding to adjustment reforms. While the upper-right quadrant depicts scenarios of less fragmentation simultaneous with less segmentation, the lower-left quadrant depicts reforms that have increased both fragmentation and segmentation.

Structural adjustment policies

The lower-left quadrant of Figure 1 depicts structural adjustment policies. It encompasses reforms to health systems that occurred within the structural adjustment policies implemented during the last two decades of the 20th century. Public sector transformations–including policies that targeted those living in extreme poverty with a limited set of services–had negative effects and increased both segmentation and fragmentation. Segmentation was exacerbated by multiple coverage systems for different populations groups, defined by their own targeting criteria. Fragmentation in the organization of services was a result of initiatives limited to sets of limited services, without a comprehensive health service perspective ().

These kinds of reforms are characterized by a reduced role for the State, with the weak participation of social actors; they are vulnerable to pressure exerted by private actors who stand to benefit from the changes ().

21st century transformations

Changes over the past decade are characterized by two types of reforms: those geared to expanding access and those focused on expanding coverage. Reforms geared to expanding access (upper-left quadrant of Figure 1) focused on developing service systems centered on people, families, and communities. The platform for these transformations has been the public sector, but there has been limited coordination with social security and the private insurance sector. These reforms did not achieve significant progress in terms of universal coverage with reduced segmentation of health systems, and they were limited to the public sector.

This type of reform was characterized by the emergence of new social actors who acquired greater influence on health policy decision-making and implementation. There are three groups of actors. First, health professionals (family doctors and general practitioners, psychologists, social workers) changed the way the health services are organized by playing an important role in forming new health teams and, therefore, direct service delivery. Second, social movements also provided new actors, particularly those making their own demands to improve access to health services. Both the professionals and social movements contributed ideas, values, and interests associated with these initiatives. They were complemented by the presence of actors with academic traditions and reputations, who influenced the decision-making processes and the formulation and implementation of reform policies. Finally, some of these transformations included coordination with other sectors and social policies. Multi-sectoral governance has played an essential role in coordinating implementation of reform policies throughout each country’s territory, and therefore, addressing social determinants of health ().

Reforms geared to expanding coverage (lower-right quadrant of Figure 1) are characterized by efforts to move toward universal coverage by reducing segmentation in the health systems. These include innovations in funding, particularly for insurance. A common feature of these processes is to encourage the convergence, or at least harmonization, of social security and the public sector. However, these reforms have still not made enough progress to sustain transformations in how services are organized, with a people- and community-centered model of care, since the market mechanisms have not been effective enough and provider incentives have not yet achieved the desired results.

Formulating and implementing these kinds of reforms brought in new strategic actors, either through the development of new State structures, or through greater coordination with academic institutions capable of influencing health policy-making.

The challenges of moving toward systems with universal access to health and universal health coverage

Figure 1 can be explained with the following selected cases. Starting with the structural adjustment reforms of the 1990s, the following countries promoted reforms to improve their health systems. In Bolivia, Ecuador, and El Salvador, reform processes that prioritized primary care moved them closer to comprehensive care (). However, convergence of the contributory and noncontributory subsystems still needs to be addressed. Chile may also be included in this group, but with a different strategy, starting with the development of explicit health guarantees (GES) (). Colombia, the United States, and Uruguay took a different approach and made progress in reducing segmentation (). However, the variable of equity must be included so that within each group there are cases that promote greater equity and others that still face challenges in reducing levels of inequity.

In the countries that managed to move toward a scenario of less segmentation (lower-right quadrant of Figure 1), significant progress was made in terms of greater financial coverage. However, several challenges remain on the path to equity in financing and in access to health services (). As regards equitable financing, two types of challenges remain. Progress with coverage does not necessarily mean improved equity in financing, because different population groups have coverage systems with very different levels of financial protection. In order to reduce this gap, additional fiscal resources must be invested in the public sector.2 In addition, some transformation processes geared to changing the insurance model are still facing major problems in terms of pooling social security resources. Progress along these lines requires changes to the mechanisms for regulating risk management in the private organizations that manage social security resources.

The greatest weakness of these reforms is the scant progress made in transforming the model under which the health services are organized. Therefore, this kind of reform requires strategies to introduce regulatory mechanisms for new health service delivery models, with appropriate incentives in the forms of payment and explicit targets in terms of equitable access to health services. Furthermore, these changes will only be sustainable if changes are made to the mechanisms for regulating human resources, bringing them in line with the new models of care and including clear targets for expanding equitable access to health services.

Health system transformations have made significant strides in terms of equitable access to services by changing the way the services are organized, but challenges still remain. These are related to the need to reduce segmentation, and the need to sustain improvements in access to services. These kinds of reforms tend to be limited to the public sector, and have little influence on social security. Progress must be made in coordinating or integrating the public sector and social security, which is key to achieving equity and efficiency in the funding model. Such changes are feasible if more public funds are spent (allocated to the public sector), and by introducing pooling mechanisms which make it possible to assume the health needs and financial risks of both sectors together ().

These reforms will also require that progress made in access be sustained, if there is to be consistency in the development of new mechanisms for the regulation of human resources and incentive systems aligned with the new models under which health services are organized.

Strategic interventions for health system transformations toward universal health

In order to advance toward universal health and health equity and guarantee the right to health, it is necessary to make organizational, institutional, and policy changes, with additional efforts to invest in human resources and public financing. The shift toward a people- and community-centered care model (recognized by a majority of countries in the Region), should be the focus of health system transformations in the 21st century.

This section presents the strategic lines of action for transforming health systems in order to advance toward universal health, in light of the policy changes needed to strengthen the stewardship of the health authorities. It includes a social dialogue with a broad array of stakeholders, institutional changes related to reducing segmentation and fragmentation, and the need to increase public investment in human and financial resources.

Strengthening the stewardship of the health authorities and social dialogue

The stewardship of the health authorities is understood as their leadership in instituting and supporting collective action to bring about the institutional and organizational changes required for health system reform. This is an essential political ingredient, because it determines how these transformation processes will be developed and implemented ().

It is crucial to include and empower State actors (with health authority duties that cannot be delegated—including special emphasis on the regulation of health systems) as well as other social stakeholders committed to furthering the cause of universal health. This should include the participation of social movements, health professionals, and academics that help analyze, evaluate, produce, and manage knowledge about the transformation of health systems ().

“Social dialogue” is both a tool and a platform for raising issues about access and coverage, and for legitimizing the needed transformations. Evaluation, debates, and social forums on the limitations and transformation of health systems are typical examples of this type of initiative. It is essential to include key actors, members of the health sector, and people from other social sectors in order to formulate and implement health policies. Similarly, it is fundamental to allow the health sector to participate in the formulation and implementation of social and economic policies that have an impact on the social determinants of health.

Analysis and evaluation activities afford opportunities to interpret the issues and provide ways to target different audiences. These activities include not only stakeholders in collective health, but also those interested in formulating other social policies, such as housing, social development, nutrition, etc., and those working in public finance and economic policy. Work teams should be interdisciplinary and include multiple sectors, allowing information and knowledge from the social, economic, and health sectors to come together.

All of these analysis and evaluation activities require the formation of multidisciplinary and multisectoral teams capable of addressing these complex issues and finding strategies to move toward universal access to health and universal health coverage. The information and agreements resulting from the social dialogue should meet these three criteria: i) consistency in the inclusion and relationships among the main components, which lends technical legitimacy; ii) social and political legitimacy of the actors involved in producing institutional arrangements that contribute to universal health; and iii) the drafting of reports targeting different audiences, with direct or indirect influence on the remaining challenges for universal access to health and universal health coverage.

The political capacity needed to make health a greater priority in the development of inclusive social policies requires greater integration and coordination between the health system and the housing, nutrition, education, security, labor, and environmental sectors. Strengthening the health authorities and establishing collective leadership in the formulation and implementation of social policies are essential components for staying on track toward universal health ().

Strengthening the essential functions of public health and the resiliency of health systems

Health systems and the populations they serve continue to be very vulnerable to risks that directly affect the capacity of systems to serve the needs of the population. These risks include disease outbreaks, natural and other disasters, climate change, economic and social crises, among others. Such risks can significantly jeopardize health at the local, national, and global levels by weakening the response capacity of health systems and reversing progress made with health outcomes. Thus, the fragility of national health systems poses a problem for individual, collective, national, and global health. The H1N1 virus pandemic in 2009, the Ebola virus outbreak in West Africa in 2014 and 2015, and introduction of the chikungunya (2013) and Zika (2015) viruses in the Region of the Americas revealed the serious impact that a disease outbreak can have on the health system, particularly the demand for integrated and emergency health services. Inadequate surveillance, response, and health information systems; lackluster execution of infection prevention and control strategies; health professionals insufficiently prepared to handle communicable disease outbreaks; inaccessible health services and health institutions that lack adequate infrastructure; and the need to rapidly mobilize additional financial resources to support surveillance and response activities constitute important structural deficiencies in the current health systems. These deficiencies at the national level are also failures in the application, implementation, and compliance with the International Health Regulations (IHR) ().

The IHR is a global legal instrument whose scope and purpose are “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade” (). They accomplish this by strengthening and maintaining essential public health functions at the national level—defined in the IHR as core competencies—which constitute the foundations of a system to manage public health events worldwide, in a holistic and cross-sectoral fashion. The common provisions adopted in the IHR text at the World Health Assembly in 2005 entered into force in 2007. As globalization increases, health systems are increasingly interconnected. Consequently, investment in the resiliency of national health systems should be considered a global public good supporting national health and well-being, reducing risks to health systems beyond national borders, and safeguarding social capital, confidence in health systems, and health governance mechanisms at all levels of the global health system.

Intersectoral interventions that address the social determinants of health

One of the central features of health system transformation—considered to be an integral part of the emergence of a new paradigm in social protection systems—is the development of intersectoral interventions to address the social determinants of health (). These intersectoral interventions, which are expressions of the health in all policies approach, are indispensable for making progress toward universal health ().

First, the development of mechanisms to regulate the production and consumption of mass-produced goods (e.g., the food industry, use of pesticides, regulation of alcohol, drug, and tobacco use) serve to curtail risk factors for the health of the population. These strategies use mechanisms to regulate activities and processes outside the health system, generally at the macro-national level, with a significant impact on the health of the population. In such cases, the advocacy and technical capacity of the health authorities are key factors in getting the most out of regulations, which were previously in the exclusive purview of other areas of government (Ministries of Finance, Trade, or Agriculture). In recent years, the health authorities have joined forces with social movements to increase their influence by establishing economic and trade mechanisms, marking a departure from the health sector’s traditional role.

Second, certain intersectoral interventions complement reform processes that seek to expand coverage under the social protection systems. These regulatory frameworks play a cross-sectoral role to the degree that they include public health conditions as a risk factor related to social protection or to certain social conditions (poverty) or demographics (children or the elderly) that have an impact on public health. Processes based on increasing formal coverage—with explicit benefits, beneficiaries, and resources administered by new actors or agencies—have gone hand-in-hand with the expansion of social protection system reforms. In this case, the relationship between the health sector and other sectors is complemented by mechanisms to regulate social protection systems by adding benefits and beneficiaries to coverage expansion initiatives.

Third, a set of intersectoral initiatives should be encouraged. These innovations are characterized by the emergence of State entities and structures that seek to coordinate public policies, traditionally working from within the various social sector ministries and managed by them. But here, the intersectoral approach is linked to efforts to integrate social policies, with the objective of expanding access to public services. The issue addressed by these initiatives is the fragmentation of social policies and their limited effectiveness. These new entities or intersectoral structures (created ad-hoc to manage across sectors), include the participation of social movements with a presence on the ground as a way to improve coordination with social organizations in different parts of the territory.

Finally, other intersectoral interventions with a major impact on the social determinants of health should be promoted at the locations where health services are delivered and managed. Such efforts aim to shift the model of care toward greater focus on the needs and culture of people, families, and communities. The human security approach has been used as a strategy to promote local intersectoral interventions, in which empowerment of the population and the community plays an active role.

Reducing the segmentation of health systems

There are many problems related to the multiplicity of insurers, in which risks and resources are not regulated or compensated. First, the large number of organizations performing this function makes it hard to reach a critical threshold for pooling resources and spreading health risks, as required by insurance. Second, when different insurers (or groups of them) have different levels of resources, coverage rules, access rules, and population needs for health services, it is difficult to ensure equity and efficiency with the available financing.

Most countries in the Region of the Americas (with some exceptions, e.g., Canada, Costa Rica, Cuba, and Uruguay) have high levels of segmentation and inequity (see in topic 5 of Chapter 1, “Health Financing in the Americas“).

Reducing segmentation in health insurance would entail confronting a wide array of rules, depending on the structure in each country. Addressing the social security system’s impact on the segmentation of health will require changes to the system’s rules on contributions, redistribution mechanisms, coverage, and definition of services covered. Similarly, integrating and coordinating public subsystems (financed with revenue from taxation or the exploitation of natural resources) and social security entities would also help reduce segmentation. In the latter case, the institutional innovations required would range from the creation of regulatory mechanisms and standardization of coverage rules to the pooling of financial resources.

While the kinds of reforms aimed at reducing segmentation will determine which stakeholders are affected or involved, the central players are the contributors who pay into each insurance system and the corresponding beneficiaries. What is in dispute is the redistributive capacity of insurers, when those who benefit most are those who have the least ability to pay into the system but the greatest need of health services.

An important component of the relationships among the actors with an impact on reforms is the positioning of professionals and for-profit private corporations involved in providing goods and services. Often, while the inclusion of insurers enhances the capacity to negotiate better prices for services (thus reducing costs for the health system), and improves the ability to regulate effectively, private actors may resist.

This shows that reducing segmentation not only creates more equity; it also improves efficiency in financing. However, it is necessary to consider matters of political economy, given the weight of the forces aligned with the status quo. In order to address these issues, other actors in the regions and health funds need to be empowered with political capacity, which will enable them to adopt redistributive mechanisms to mitigate inequity. The technical challenge is to analyze inequities and gaps between different coverage funds or geographical regions that receive fiscal monies, compared to the health service needs of the population and the resources allocated. This implies that work must be done to integrate fiscal and financial information, and examine epidemiological conditions and the clinical effectiveness of health interventions.

Depending on the magnitude of the segmentation issues and the types of institutional innovations, there may be opportunities to open a social dialogue with a broader group of stakeholders. An analysis of the gaps between social security organizations and the public sector points to the need for political actors and the most financially vulnerable beneficiaries to be included and empowered, in order to achieve universal health.

When the agenda for debate revolves around regional differences, there is a need to strike a better geographical balance to empower a broader spectrum of stakeholders from the most disadvantaged areas. Among the countries studied, there are high levels of regional inequality when resource allocation mechanisms for the health sector are geared toward subnational agencies. There is no proper analysis of the health service needs of those regions, which not only causes inefficient allocation of resources, but also replicates and exacerbates inequities in access to health services between regions.

Finally, greater equity in the insurance and financing models, within social inclusion for health policies, has positive effects for all of civil society—both the for-profit and non-profit sectors. A society that is experiencing less conflict, due to financial protection from a system moving toward universal health, engenders greater social cohesion and a better business climate, improved conditions for developing quality health services, and greater productivity for human talent.

Reduced fragmentation

Improving how health services are organized is a strategy that will yield results in terms of more equitable access and more efficient performance by the health services. In keeping with the resolution on universal health, we must not only strengthen the response capacity of primary care by putting together trained and motivated health teams, and making sure that drugs, technology, and the necessary infrastructure are available, but also by transforming the model of care and strengthening coordination between different organizations and levels of care ().

The problems of political economy are explained by the radical change entailed in this new organizational model for the health services system. Different groups of professionals and suppliers vie for organizational spaces, jurisdiction over the scope of professional practices, as well as regulatory mechanisms and criteria, and professional autonomy.

In each country, the players involved in these innovative processes will vary, depending on the type, scope, and progress of reforms implemented, and the organizational capacity and positioning of the players. The SAFCI program in Bolivia took the path of radically changing the model of medical care in a context of latent conflict with medical associations (). However, its development is still incipient and it is not yet fully integrated with the health services network. Brazil has been an emblematic case after two decades of a family health program that has managed to significantly expand coverage (). Under this model, Cuban physicians were sent to the most socially vulnerable regions where there is no access to services, making it possible to address persistent challenges. However, the open conflicts between health authorities and professional associations reveal some of the issues of political economy mentioned before, in which State regulation is pitted against professional practice.

In all of these cases, disputes over changes in how health services are organized have arisen between groups of health workers and professional, political, and technical actors in government, reverberating within the health sector. The technical complexity mentioned above, along with the professional nature of these disputes, has limited this discussion to a small circle of parties. Social dialogue would be one strategy for expanding the debate to make it more constructive and innovative, including activities such as a review of experiences in other countries, and taking a systematic approach to alternatives, while looking at potential costs and effects in moving toward universal health ().

Fiscal space to increase public health expenditures and efficiently decrease inequity

The benchmark for public financing of health has been set at 6% of GDP. This money is to be used efficiently, sustainably, and in a fiscally responsible way to expand access and reduce inequities through increased financial protection and efficient interventions. Increased financial protection will reduce inequities in access to health, through a planned and progressive process with the growing use of collective mechanisms that tap into various sources of funding to replace out-of-pocket payments.

Within each country’s unique circumstances, new spending should aim to strengthen primary care in order to boost its response capacity—the ultimate proof of its effectiveness and its capacity for coordination within service networks.

Political will and social dialogue play an essential role in creating fiscal space (). Connecting social need with political decision-making requires transparency and justified use of resources (). Political consensus is a characteristic shared by countries that have been successful in improving access to health care and public spending on health.

International evidence shows that it is technically possible to create fiscal space; all that is needed is the political will to do so. It is also advisable to diversify funding sources to ensure that it is sustainable, because diversification helps stabilize the economy and maintain fiscal balance. Furthermore, it also seems advisable to mobilize more internal than external sources of funding, and to use tax revenue and non-tax revenue rather than outside money in the form of aid and loans. External funding may be highly volatile and additional debt could destabilize the fiscal balance and not be sustainable over the long run. Tax increases, a review of tax-related expenditures, the establishment or increase of taxes on products that are harmful to health, more efficient public spending, and better tax administration are fundamental options when facing this challenge.

Strengthening of human resources

The shortage of health workers, their inadequate distribution, and the need to ensure consistency between skills and job requirements in order to enhance the efficiency of the sector require innovative solutions tailored to the countries of the Region of the Americas ().

The United Nations recently provided an initial response to this need by drafting the report, “Working for health and growth: investing in the health workforce” (). This is particularly relevant to the transformations underway in the health systems of the countries in the Region. The report reaffirms the idea that the health sector is essential for the economy as a whole. It adds that the sector is vital to production and the creation of decent jobs, for inclusive economic growth, for human security, and for sustainable development (). It also argues that in order to make the changes needed to redefine health priorities—such as changes in demographics, morbidity, technology, and economic conditions— a major transformation in the health workforce is needed. Health workers must be able to address social determinants and take on the priorities of health promotion, disease prevention, and development of primary health care, at different levels and through different entities, which will inevitably lead to expanded education for health workers. Finally, the United Nations High-Level Commission on Health Employment and Economic Growth calls for countries to make a political commitment and work collaboratively to help workers realize their social and economic potential in the health sector, and to do so in accordance with the SDGs ().

Furthermore, strengthening the governance of human resources for health (addressed in the sections on stewardship and governance) entails a need for new regulatory mechanisms in the job market, a new understanding of professionalization aligned with innovations in the models of care, and processes of continuing and ongoing education. This is an indispensable (and often pending) aspect of sustaining the health system transformations of the past decade.

Sustainability of health systems for universal health

In the Region of the Americas, health systems will need to make progress sustainably. In addition to the problems of fragmentation and segmentation, which exacerbate inequity, there are challenges associated with the growing costs of health care due to the introduction of new technologies, aging and epidemiological change, and growing public expectations of receiving timely, quality service.

Although these phenomena are observed in other regions of the world, they are likely occurring more quickly in the Region of the Americas. For example, according to the Pan American Health Organization (), population aging can be considered a result of improvements in the health of the population, and a consequence of successful public health policies aimed at development. Indeed, economic and social development has given rise to increased life expectancy, which together with a decline in fertility rates, determines population aging. Developed countries such as Japan, the U.S., and some European countries have already experienced this demographic transition. But the process is currently happening more quickly in developing countries and this is regarded as a worldwide phenomenon ().

In this context, policies to contain costs through efficiency and equity face problems with implementation. These are due to the complexity of existing health systems, posing problems in terms of coordination and regulation of the various institutions involved, regardless of the specific arrangements in each country.

The financial expression of health systems and public spending, which occurs in budget formulation and execution, has special connotations for budget management at this level. Planning, transfer, and resource utilization mechanisms, within a context of fiscal sustainability, require the creation of appropriate tools for governance, operations, and regulation. For this reason, it is particularly important to have updated and accurate financial and budget information, along with systems to flag problems so that they can immediately be corrected. It is also important to coordinate budget execution at the national and subnational level.

At the same time, several commonly promoted mechanisms have yet to be seriously examined in the Region. Some entail providing incentives for the transfer of resources; others include appropriate policies to regulate systems, particularly when insurance offers incentives for overuse and discrimination in terms of benefits and beneficiaries, tends to waste resources and not help strengthen primary care, and fails to encourage health promotion and prevention—the building blocks of sustainability. In the sphere of technology, it is essential to promote the use of generic drugs and procurement policies that reduce prices, and to list medications and assess the economic impact of new techniques and technologies. Furthermore, it is imperative to strengthen management systems as well as policies on revenue generation, and to create fiscal space to address the problem of insufficient public spending in the Region.

In conclusion, health systems will become sustainable through health promotion, which includes addressing the social determinants of health through intersectoral interventions. Similarly, it is essential to improve disease prevention and early detection (particularly for chronic diseases) to reduce the incidence of catastrophic illnesses, and to give timely access to health services, particularly primary care. In the area of financing, as direct payment at the time of service delivery is eliminated, progress will be made by pooling funds, developing integrated health service networks, and improving the quality of expenditures and interventions.

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9. Ministerio de Salud, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). Diseño e implementación de una metodología de evaluación, seguimiento y acompañamiento de la reforma de la salud de Chile. Informe final. Santiago de Chile, 2012;

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20. Urriola C, Infante A, Aguilera I, Ormeño H. La reforma de salud chilena a diez años de su implementación. Salud Pública de México 2016;58(5):514–521.

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23. Pan American Health Organization. Report of the Regional Forum on Universal Health: an indispensable investment for sustainable human development [unpublished report]. Washington, D.C.: PAHO; 2015. https://www.paho.org/salud-en-las-americas-2017/?p=73.

24. Arbulo V, Pagano JP, Rak G, Rivas L. El camino hacia la cobertura universal en Uruguay. Análisis de la cobertura poblacional del Sistema Nacional Integrado de Salud y de la incorporación de colectivos al Seguro Nacional Salud. 2012.

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×

Reference/Note:

1. Twenty-nine percent of the population living below the poverty line and the poorest 40% of the population receiving less than 15% of all income.

2. This point was specifically addressed Chapter 1, topic 5, “Health Financing in the Americas”.

The quest for universal health: summary of indicators on health systems performance

  • Introduction
  • Universal access and coverage of quality health services
  • Health financing and elimination of direct payments
  • Health care capacity and activities
  • Highlights
  • References
  • Full Article
Page 1 of 6

Introduction

Health systems aim to improve the health and well-being of the entire population through the progressive attainment of universal access to health and universal health coverage (hereinafter called universal health) (). Appropriate governance, human resources, and financing ensure the capacity and preparedness of the health system to deliver treatment, prevention, rehabilitation, and palliative health services to the entire population. This capacity and preparedness are measured in the availability of infrastructure, equipment, essential technologies and medicines, human resources, and information systems that are appropriate and necessary for offering health services to the population (). While securing coverage of health services is necessary for the health and well-being of the population, health systems also require the definition and implementation of policies and actions with a multisectoral approach to address the social determinants of health and equity. Income, education, gender, ethnicity, and age are some of the social determinants that affect people’s access to health and well-being. Access to health is then measured in the capacity of the population to use comprehensive, appropriate, timely, and quality health services when needed, without encountering barriers when trying to use those services. Both universal access to health and universal health coverage are necessary in order to improve equity in health outcomes and other basic objectives of health systems ().

This section examines the progress made in the last 5 to 10 years on health systems’ performance and impact on universal health metrics across the Region of the Americas. Broad measures of population health status attributable to health service delivery, such as the mortality rate due to chronic conditions, are addressed in previous sections of this chapter. PAHO’s resolution for universal access to health and universal health coverage provides the mandate to the Pan American Sanitary Bureau (PASB) to measure progress towards universal health using the indicators identified in the Strategic Plan of the Pan American Health Organization 2014-2019 () and to report on the advances through the biennial assessments on the implementation of the Strategic Plan. To fulfill this mandate, the Department of Health Systems and Services of the PASB has developed a monitoring and measuring framework and tool in collaboration with Member States (). Based on that framework, the PASB has been supporting Member States to monitor and measure their progress towards universal health. Part of the metrics and information presented herein were selected based on this monitoring and measuring framework. Access to health is measured based on proxy indicators such as utilization of health services, likelihood to report unmet medical needs, and perceived access barriers. Health coverage is thus measured using metrics such as population coverage, availability and distribution of human and physical resources, essential technologies and medicines, and information systems. These measures are analyzed with an equity lens, to present results beyond averages and establish the linkages with the social determinants of health.

Acknowledging that Member States have used different approaches to organize their health systems, the analysis presented here does not intend to compare health systems among countries in the Region. Instead the aim is to identify gaps and priority areas that need special attention and document successful experiences and lessons learned to help guide the policy-making process taking place in the Region. Furthermore, the findings presented here need to be interpreted with caution and within the economic, political, legal, historical, and cultural context of each particular country, with their own health challenges and priorities. This analysis illustrates how health systems have changed over the last years along three dimensions: (1) universal access and coverage of quality health services, (2) health financing and elimination of direct payments, and (3) capacity of health care services and activities.

Universal access and coverage of quality health services

Universal access to health

Most of the global discussion on monitoring and evaluation strategies for universal health has focused on two elements for assessing universal health coverage, namely, service coverage and financial protection (). While these metrics offer a comprehensive understanding of the quality, pertinence, and affordability of the services provided to the population, measures are needed that can describe more accurately the different dimensions of access to health (). Measuring patterns of service use does not provide the full picture about the different barriers that individuals might encounter when trying to access health services nor does it inform policymakers on what types of interventions and programs are necessary to improve access to health care (). Monitoring universal health requires metrics that can properly capture the dimensions of both access and coverage that are behind this initiative.

Coverage, utilization, and access barriers to health

Despite Member States’ efforts to collect information to systematically monitor and evaluate health access and coverage of health services, greater efforts are needed to track progress beyond averages with quality data disaggregated by key dimensions such as income, education, migrant status, indigenous status, ethnicity and disability, and urban-rural areas. Figure 1 presents data available for population coverage, access barriers, and utilization of preventive services for Chile, Colombia, Mexico, Peru,the United States, and Uruguay between 2010 and 2015. The data show that these countries have made improvements in both coverage and access metrics and that this has been, in general, accompanied by reductions in income-related inequities over time. The results also show how the coverage and access metrics compare and complement each other and illustrate how both dimensions, access and coverage, are necessary to improve health equity.

Figure 1. Evolution of income-quintile distribution of population coverage, preventive visits, and access barriers, 2010–2015

Source: Prepared by the authors based on data from Encuesta Nacional de Calidad de Vida – ECD, 2010 to 2015, Colombia; Encuesta de Caracterización Socioeconómica Nacional, 2013 and 2015, Chile; Encuesta Nacional de Ingresos y Gastos de los Hogares 2012 and 2014, Mexico; Encuesta Nacional de Hogares, 2010 to 2015, Peru; and Medical Expenditure Panel Survey, 2014, United States.
Notes: * Utilization of preventive services for both private and public institutions. The rate of utilization of preventive services tends to be higher in public facilities, particularly in Chile.
**Access barrier measures the percentage of the population who had a health problem and did not receive medical services due to lack of money, time, difficulties obtaining medical appointment, and/or preference.

Between 2014 and 2015, levels of population coverage were high across the countries studied: from around 98% in Chile and Uruguay, 95% in Colombia, 90% in the United States, 80% in Mexico, and 73% in Peru. Levels of coverage were, however, lowest in the poorest households, particularly for the United States and Colombia, while this relation was the opposite in Peru. It is worth noting that high levels of population coverage did not always coincide with high rates of utilization of preventive health care visits or low rates of people reporting access barriers.

Ensuring access to preventive health care visits is a fundamental element of universal health. Preventive visits are critical to promote and maintain the health of the population through the prevention and early diagnosis of diseases as well as the screening of risk factors and the promotion of healthy lifestyles (). Furthermore, it is expected that all adults have at least one preventive health care visit every year (). Data available for 2011 to 2015 show that countries in the Region have high inequalities and diverse levels of utilization of preventive health care services, from 21.04% in Peru, followed by the United States (24%), Chile (24.3%), Colombia (68.25%), and Mexico (76.3%) of the adult population having at least one preventive visit yearly in 2015 or most recent year (Figure 1). Overall data trends show that the utilization of preventive health care services increased, particularly in Colombia and Mexico, and became less unequal in most countries studied, though with persistent gaps between the poorest and richest families. In the United States, Colombia, Mexico, and Peru, utilization of preventive services was highest in the richest households, while this relation was the opposite in Chile in the 2013–2015 period. The interpretation of the data presented is limited as no further information exists on the quality of the care provided, and the reasons why the use of preventive visits varies across countries. With respect to barriers to access health services, the percentage of the population reporting access barriers between 2014 and 2015 varied from around 66% in Peru to 36.9% in the United States, 28.8% in Colombia, 20% in Mexico, and 6.8% in Chile. Similarly, the percentage of households reporting access barriers was highest in the poorest households, particularly in Colombia and Mexico. It is noteworthy that disparities have declined in most countries for all metrics studied, indicating improvements in equity.

Coverage of reproductive, maternal, and child health services

The Region of the Americas has achieved significant progress in the last two decades in the areas of maternal and child health, especially for maternal and under-5 mortality rates, which declined by 40% and 69%, respectively, in Latin America and the Caribbean (LAC) between 1990 and 2013 (). Despite this progress, the Region fell short of the MDG target of a 75% reduction in the maternal mortality rate by 2015, with persisting inequalities between the poorest and wealthiest countries and population groups. In light of the continued commitment to women and children’s health in the post-2015 development agenda, further efforts are necessary to reduce socioeconomic inequalities that hinder universal access to the health services that women seek for themselves and their children before, during, and after pregnancy. Strong health systems prepared and equipped for the provision of preventive and treatment interventions across the continuum of care for reproductive, maternal, newborn, and child health are proven to be key to reduce maternal and child mortality and morbidity ().

In 2015, most countries in the Region reached universal (100%) or near universal (93%) aggregate coverage of key reproductive and maternal health interventions, though with important gaps between the wealthiest and poorest countries in the Region (Figures 2a to 2c). Coverage of skilled attendance at birth ranged from 100% (or nearly 100%) in most countries to a low of about 50% in Haiti, followed by Guatemala and Bolivia with 67% and 74%, respectively. The poorest countries also had the lowest coverage rates for antenatal care visits, with Guatemala having by far the lowest coverage rate (43%), followed by Dominica with 56% and Suriname and Haiti with 67% each. The proportion of women with unmet family planning ranged from about 10% in Costa Rica, Cuba, Canada, and Uruguay to a high of 39% in Bolivia, followed by Haiti, Peru, and Guyana. Regarding the indicators included for child health services, most countries in the Region reached high coverage (93 to 100%) of DPT3 immunization, with the exception of Ecuador, Guatemala, Haiti, and Panama, which had less than 80% aggregated coverage (Figure 2d).

Figures 2. Infant and maternal health services coverage, Region of the Americas, 2015 or 2016

Data available to measure the reduction of inequities in the utilization of maternal and child services within countries show that overall, the utilization of these services has become more equitable in the Americas over the last decade, though in some countries the gap is still large between the lowest income quintiles (quintiles I and II). For instance, in Peru the gap between the richest and the poorest women using maternal and reproductive health services has significantly narrowed between 2000 and 2015, yet women in the lowest income quintile still lag far behind their wealthier peers (Figures 3). It is noteworthy that the increase observed in the utilization of these services is mainly due to the expansion of coverage among women in the lowest income quintiles (quintile I and II) as coverage was already high among high-income women (quintiles 4 and 5) in Peru at the beginning of the evaluated period (Figure 3). Data for Bolivia, Colombia, Dominican Republic, and Haiti on utilization of maternal and child health services show similar trends, with Colombia and the Dominican Republic achieving greater improvements in reducing disparities in the use of these services, while Bolivia and Haiti are lagging behind (Figures 4 and 5). Despite the improvements, significant income-related inequalities persist in all countries evaluated.

Figure 3. Income-quintile distribution of access and reproductive health services in Peru from 2000 to 2015

Source: Prepared by the authors based on data from Peru, Encuesta Demográfica y de Salud Familiar (ENDES), 2000, 2005, 2010, 2011, 2012, 2013, 2014, and 2015.

Universal access to quality maternal and child health interventions is key to reduce inequities and improve maternal and child health; however, the data available do not allow for this type of analysis. Coverage for health services measures the number of individuals receiving a set of health services expressed as a percentage of the corresponding midyear population for a specific year, in a given country, territory, or geographic area. This measure captures intervention use, but does not focus on the quality of the intervention measures as the actual health benefit experienced from the service. Most importantly, these sources of information do not capture the gap between crude (i.e., vaccination) and effective coverage (i.e., seroconversion), which, for example, can be higher than 20% for immunization (). Within this context, effective coverage has been proposed as an ideal metric because it unifies in a single metric service use (utilization of service), need (individual/population in need of a particular service), and quality (actual health benefit experienced from the service), but there are insufficient data in the Region to conduct that type of study (). Furthermore, the increased use of health services is associated with decreased likelihood to report unmet medical needs; however, perceived access barriers are more desirable measures of access because realized utilization does not necessarily mean that people do not face significant obstacles when seeking health services. Conversely, lack or poor use of services does not always imply that people have poor access ().

Figure 4. Evolution of income-quintile distribution of maternal health interventions, selected countries and years

4a

4b

Source: Prepared by the authors based on data from WHO Health Equity Monitor; data are based on Demographic and Health Surveys (DHS).

Comprehensive, quality, people- and community-centered health services

Mortality amenable to health care. Mortality amenable to health care refers to a subset of premature deaths that should have not occurred with timely health care interventions (). While this measure provides an indication of the quality and accessibility of health services, it is not a definite measurement of the quality of health care in countries. Other factors beyond health systems performance and health policies influence amenable mortality rates. Furthermore, although statistics on death are widely available across Member States, persistent problems with death under-registration and data quality limit the interpretation of the data presented. Monitoring amenable deaths can nonetheless highlight areas that can be further studied.

Data for the Region of the Americas indicate that between 2013 and 2014, more than 1.2 million deaths could have potentially been avoided in the Region with health care systems offering accessible, quality, and timely health care. There were, however, large variations in amenable mortality rates across countries (Figure 5a). Amenable mortality rates ranged from about 47 to 350 deaths per 100,000 population. Death rates were lowest for Anguilla, Honduras, Cayman Islands, and Canada, with age-standardized mortality rates from around 47 to 62 deaths per 100,000 population. On the other hand, amenable mortality rates were highest in Guyana, St. Vincent and the Grenadines, Suriname, Grenada, and Belize, with figures ranging from 194 to 350 deaths per 100,000 population.

Figure 5. Amenable mortality rates (a) 2000, 2010, and 2014 (or nearest year); (b) rate change from 2010 to 2014 )

5a

Between 2010 and 2014, the rate of amenable deaths decreased in most countries of the Region, though with important exceptions. Amenable deaths declined at the highest pace in Belize, Anguilla, Montserrat, and Suriname, while they increased in St. Vincent and the Grenadines, St. Kitts and Nevis, and the Dominican Republic (Figure 5b).

5b

Source: (a) Prepared by the authors based on data from PAHO Health Information Platform for the Americas (PLISA). Data retrieved in November 2016. Data for Bahamas, Barbados, Cayman Islands, Colombia, El Salvador, French Guiana, Guadaloupe, Honduras, Martinique, Nicaragua, and Venezuela correspond to 2013. Data for Dominican Republic, Guyana, St. Kitts & Nevis, and Virgin Islands (US) refer to 2012, and data for Canada and Jamaica refer to 2011.

Figure 6 presents the average amenable mortality rate for countries in the Region distributed by income for 2000, 2010, and 2014. Overall, income-related inequalities in amenable mortality have decreased over time and between countries, but there remain persistent gaps. It is noteworthy that the rate of amenable mortality was mostly invariant for countries in the richest income quintile between 2010 and 2014, while poorer countries experienced important reductions. Interestingly, countries in the second income quintile bear the biggest burden of amenable mortality rate. Disparities related to sex are also visible in all countries studied, with men being more affected than women (Figure 7).

Figure 6. Income-tertile distribution between countries for mortality amenable to health care, 2000, 2010, and 2014

Source: Prepared by the authors based on data from PAHO Health Information Platform for the America (PLISA). Data retrieved in November 2016.

Figure 7. Mortality amenable to health care, by sex, 2014 (or 2013)

Source: Prepared by the authors based on data from PAHO Health Information Platform for the Americas (PLISA). Data retrieved in November 2016.

Hospitalizations for ambulatory care-sensitive conditions. In light of the growing prevalence of chronic conditions in the Americas, and the associated need to improve health promotion and disease prevention activities, it is a key priority that countries recalibrate their health systems to invest in quality, comprehensive, accessible, and effective primary- and community-care-led services. In most countries of the Region, health services development and investments have largely focused on hospitals and highly specialized, costly technology. This has compromised in many cases the development of the first level of care (). Strengthening the first level of care is essential to achieve universal health as in the Region of the Americas and in the wider global context the availability of quality and effective services in these care settings has long been associated with health systems that are able to respond adequately to the health problems of the people and communities with equity and efficiency (). A first level of care with resolution capacity to provide comprehensive and coordinated care to all, including patients with complex health care needs through multidisciplinary health teams and intersectoral partnerships, is a requirement of a people- and community-centered model of care ().

The assessment of ambulatory care-sensitive conditions (ACSC) evaluates the response capacity of the first level of care in terms of avoidable hospitalizations, under the logic that hospital admissions for conditions such as asthma, diabetes, or hypertension, for example, can be avoided or reduced with better health promotion programs, specific interventions for prevention, and timely access to the first level of care (). Hospitalization for ACSC is an indicator of hospital activity that has proven useful as an indirect measure of the functioning of the first level of care. It can inform the process of decision-making regarding the configuration of integrated health service networks and contributes to the effectiveness of care. Moreover, the assessment of ACSC may provide evidence on the technical quality, effectiveness, and continuity of care. Figures 8a and 8b show the average hospital admission rates for ACSC between 2001 and 2009 for Argentina, Colombia, Costa Rica, Ecuador, Mexico, and Paraguay. Hospitalization rates ranged from 10.8% for Costa Rica to 21.6% for Colombia. Infectious gastroenteritis had the largest share of avoidable hospitalizations in Argentina, Ecuador, and Paraguay, accounting for 33%, 27%, and 22% of all ACSC reported cases, respectively. Lower airway diseases, which comprise diagnoses such as bronchitis and emphysema, occupied the highest percentage of ACS for Colombia and Costa Rica, with an average of 15%. Mexico had by far the highest rate of hospitalizations for diabetes (16%) compared to other countries (average of 5%). The result of this indicator should be interpreted in relation to the situation in each country because the demand for hospitalization in some locations may be related to the availability of resources, epidemiological transition leading to growing prevalence of noncommunicable diseases (NCD), and the deficiencies of the health system. Therefore, it is important to consider other issues affecting the response capacity of the health service network to evaluate this indicator. One goal of PAHO’s Strategic Plan 2014-2019, as agreed by Member States, is to reduce by at least 10% hospitalizations for ACSC in 2019; hence, it is paramount that countries continue measuring and reporting progress in this indicator.

Figure 8. Hospitalizations for ambulatory care-sensitive conditions, selected countries and average 2001–2009

(a) percentage of total

Source: Figure prepared using data in Guanais F, Gómez-Suárez R, Pinzón L. Series of avoidable hospitalizations and strengthening primary health care: primary care effectiveness and the extent of avoidable hospitalizations in Latin America and the Caribbean. Washington, D.C.: Inter-American Development Bank; 2012. Data presented by the respective national health authorities for studies commissioned by the Inter-American Development Bank in 2012.

(b) grouped by condition

Access to essential medicines and other health technologies

Access to medicines and other health technologies remains a priority for Member States. Inequities in access to health services and medicines are still pronounced in LAC countries, and occur both between countries and between different social groups and areas within the same country (). This section provides an overview of some critical indicators and data sources to better understand the current situation on access to safe, quality-assured, and effective pharmaceuticals, biologics including blood and blood products, as well as critical radiological services. For the purpose of this document, medicines and other health technologies include medical products such as pharmaceuticals, biologicals (including blood and blood products), medical devices, and diagnostics.

Countries in the Region have adopted policies and strategies aimed at addressing these inequities and improving access to cost-effective, quality-assured, safe, and efficacious medical products. Comprehensive national policies for medicines and other health technologies are a necessary condition to achieve universal access to health and universal health coverage and thus improve the health and quality of life of the population. Yet, not all countries in the Region have adopted these policies. In 2014, only 13 of 28 surveyed countries had a national pharmaceutical policy (46%), while 18 of 35 countries had a national blood policy (51%).

Having a functional National Regulatory System for medicines and other health technologies is critical for ensuring that the medical products that are introduced to the health systems are quality assured, safe, and effective. Moreover, national regulatory authorities (NRA) act as gatekeepers for the introduction of medical products and are critical in determining the rate of introduction of new products. While the Region has experienced a well-documented improvement in regulatory capacities in many Member States, a significant number of countries have yet to improve their regulatory capacities to the point of being considered functional (Figure 9). Countries with weak regulatory capacities may struggle to ensure the availability of quality-assured products and, consequently, generate a public health risk. In addition, the inappropriate use of medicines and other health technologies jeopardizes the quality of care and/or the efficiency of the health system. The extent of the development of the pharmaceutical sector, the availability of trained human resources and financial resources, and the existence of adequate infrastructure influence the performance of these functions.

Figure 9. Basic medicines regulatory capacity achievement by geographical subregion in the Americas

Source: Bulletin of the Observatory – PRAIS. Year 1, No. 1, March 2014. Basic medicines regulatory capacity in the Americas, Pan American Health Organization.

Pharmaceutical expenditure. The escalating cost of medical products poses a particular challenge for improving equitable access to medicines and other health technologies and to the sustainability of health systems. Costly products have become a very significant portion of medical expenditure. The total pharmaceutical expenditure per capita, as a percentage of the GDP and as a percentage of the total health expenditure (2010–2012), is highly variable among countries (Figures 10a, 10b, and 10c) and, in many cases, a high budgetary burden on health budgets. Importantly, in many countries pharmaceutical expenditure is financed through private out-of-pocket spending, increasing the risk of people incurring financial difficulties, impoverishment, and exposure to catastrophic expenditure (Figure 10d.).

Figure 10. Total pharmaceutical expenditure, selected countries, 2010–2012

(a) as percentage of GDP

Source: WHO Pharmaceutical Sector Country Profile 2010–2012.

(b) per capita (US$)

Source: WHO Pharmaceutical Sector Country Profile 2010-2012.

(c) as percentage of the total expenditure in health

Source: WHO Pharmaceutical Sector Country Profile 2010-2012.

(d) public and private pharmaceutical expenditure per capita (US$)

Diagnostic imaging and radiotherapy. Radiological services are essential for providing comprehensive and quality health care. These services rely heavily on the availability of appropriate and quality medical devices in addition to trained human resources. The Region is benefiting to some extent from advances in diagnostic imaging technologies. Depending on their income level, countries are incorporating state-of-the-art technology to one degree or another, primarily in the private sector. Table 1 presents the total density of complex diagnostic imaging technologies per million inhabitants. It must be noted that the number shown is just a general indicator of the technology reported, but the population’s access to it still depends on many economic and geographic factors, among others. Furthermore, the indicator does not necessarily mean that the technology is used in an efficient manner or that the quality of the services provided is similar in all facilities. To incorporate complex health technologies within health services, it is necessary to consider during the planning process many aspects, including human resources, functioning costs, sustainability, epidemiological data, and geographical circumstances. Proper assessments at the local levels are therefore mandatory before the decision is made.

Table 1. Total density of complex diagnostic imaging technologies per million inhabitants

  Total density per million population: magnetic resonance imaging Total density per million population: computed tomography units Total density per million population: positron emission tomography* Total density per million population: gamma camera or nuclear medicine*
ANI 11.1 22.2 N/A N/A
BAH 2.65 13.3 0 0
BAR 0 7 0 3.51
BLZ 3.01 12 0 0
CAN 7.99 13.8 1.14 20.4
CHI 4.37 13.6 0 N/A
CRI 0.82 5.1 0.21 1.23
CUB 0.8 4.9 N/A 1.24
DOM N/A 13.9 N/A N/A
ECU 0.13 1.6 0.13 0.13
ELS 1.1 4.7 0 0.95
GRA 9.44 18.9 0 0
GUY 1.25 3.8 N/A N/A
HAI N/A 0.3 N/A N/A
HON 1.11 2.1 0 0.12
JAM 1.44 1.4 0 N/A
MEX 1.41 3.7 0.1 0.76
NIC 0.16 0.5 0 0.16
PAN 2.85 9.6 0 2.07
PAR 0.29 1 0 0
SCN 0 18.4 0 0
SAL 10.9 11 0 0
SAV 0 0 0 0
SUR 3.71 7.4 0 0
TTO 2.98 3 0 2.24
URU 2.94 12.9 0.3 2.94

Source: World Health Organization. Baseline country survey on medical devices, 2014 update. Available from: http://www.who.int/diagnostic_imaging/collaboration/global_collab_maps/en/. Accessed 29 November 2016.
*N/A = not available.

Similarly, radiation therapy has improved significantly in recent years, although some of the Region’s countries still lack the necessary technology and human resources to provide cancer treatment service properly and in a timely manner. Table 2 and Figure 11 show the number of high-energy teletherapy units (cobalt-60 and linear accelerators) per million inhabitants. The use of cobalt-60 units continues to decline, while the use of linear accelerators keeps growing.

Table 2. Number of high-energy teletherapy units (cobalt-60 and linear accelerators) per million inhabitants

Country Clinical accelerators Co-60 Total high-energy teletherapy units Population (millions) [2015] High-energy teletherapy units per million inhabitants [2016]
Antigua and Barbuda 1 0 1 0.1 10.9
Argentina 82 36 118 42.2 2.8
Bahamas 1 0 1 0.4 2.6
Barbados 0 1 1 0.3 3.4
Belize 0 0 0 0.3 0.0
Bolivia 2 5 7 11.0 0.6
Brazil 285 61 346 203.7 1.7
Canada 275 14 289 35.9 8.1
Chile 30 8 38 17.9 2.1
Colombia 59 35 94 49.5 1.9
Costa Rica 8 3 11 5.0 2.2
Cuba 7 12 19 11.2 1.7
Dominica 0 0 0 0.1 0.0
Dominican Republic 18 3 21 10.7 2.0
Ecuador 16 5 21 16.2 1.3
El Salvador 3 4 7 6.4 1.1
Grenada 0 0 0 0.1 0.0
Guatemala 8 3 11 16.3 0.7
Guyana 1 0 1 0.8 1.2
Haiti 0 0 0 10.6 0.0
Honduras 3 4 7 8.4 0.8
Jamaica 1 2 3 2.8 1.1
Mexico 88 60 148 125.2 1.2
Nicaragua 0 2 2 6.3 0.3
Panama 8 0 8 4.0 2.0
Paraguay 4 0 4 7.0 0.6
Peru 28 11 39 31.2 1.3
Saint Lucia 0 0 0 0.2 0.0
Saint Kitts and Nevis 0 0 0 0.1 0.0
Saint Vincent and the Grenadines 0 0 0 0.1 0.0
Suriname 2 0 2 0.5 3.6
Trinidad and Tobago 3 2 5 1.3 3.7
Uruguay 15 6 21 3.4 6.1
Venezuela 56 31 87 31.3 2.8
United States of America 3818 143 3961 325.1 12.2
Latin America & the Caribbean 1023 624.665 1023 624.7 1.6

Source: IAEA/PAHO, 2016. PAHO elaborated from the International Atomic Energy Agency/World Health Organization, Directory of Radiotherapy Centres 2016. Available from: http://www-naweb.iaea.org/nahu/dirac/default.asp. Accessed 29 November 2016.

Figure 11. Number of high-energy teletherapy units (cobalt-60 and linear accelerators) per million inhabitants

Source: IAEA/PAHO, 2016. PAHO elaborated from the International Atomic Energy Agency/World Health Organization, Directory of Radiotherapy Centres 2016. Available from: http://www-naweb.iaea.org/nahu/dirac/default.asp. Accessed 29 November 2016.

Blood and blood services. Universal access to blood transfusions and safe blood products is essential to save lives and improve the health of people who need them. Blood transfusions have been identified as one of the eight key life-saving interventions in health centers that offer emergency obstetric services. Therefore, the Plan of Action for Universal Access to Safe Blood seeks to promote universal, timely access to safe blood in order to save lives and improve the health conditions of all patients who need it (). Transfusions are also necessary for the care of the following: (a) children with severe anemia; (b) patients with hemoglobin disorders such as thalassemia and sickle cell anemia; (c) people injured in accidents; (d) cancer patients; (e) people who undergo major surgery and other surgical interventions such as transplants; and (f) patients with chronic age-related diseases such as bleeding resulting from vascular problems or orthopedic surgery, among other causes. To achieve universal access to safe blood for transfusions, the following key strategies and priorities have been identified:
a) Effective and sustainable integration of national blood programs and services into the national health system to achieve blood self-sufficiency, safety, efficiency, availability, and universal access to blood and blood products;
b) Self-sufficiency in safe blood and blood products through 100% voluntary non-remunerated donations;
c) Quality management in the national blood system and screening for transfusion-transmitted infections; and
d) Health surveillance, hemovigilance, risk management, monitoring, and evaluation.

There is a marked difference in the level of access to blood between low- and high-income countries. The blood donation rate is an indicator for the general availability of blood in a country. The median blood donation rate in high-income countries is 33.1 donations per 1,000 people, compared to 11.7 donations per 1,000 people in middle-income countries and 4.6 donations per 1,000 people in low-income countries. The blood donation rates for 2015 are presented in Figure 12.

Figure 12. Blood donation rate per 1,000 people, selected countries 2015

Source: PAHO, Supply of blood for transfusion in Latin America and Caribbean countries. Washington, D.C.: PAHO; 2015.

An adequate and reliable supply of safe blood can be ensured by a stable base of regular, voluntary, and unpaid blood donors. They comprise the safest group of donors as the prevalence of blood-borne infections is lowest among this set. World Health Assembly resolution WHA63.12 urges all Member States to develop national blood systems based on voluntary unpaid donations and to work towards the goal of self-sufficiency. The percentage of blood collection in LAC by voluntary, replacement, and remunerated blood donations is illustrated in Figures 13a and 13b, respectively.

Figure 13. Percentage of blood collection in selected (a) Latin American countries and (b) Caribbean countries by voluntary, replacement, and remunerated blood donations, 2014.

(a)

(b)

PAHO/WHO recommends that all blood donations prior to use be screened for HIV, hepatitis B and C, and syphilis (Treponema pallidum). Figure 13c shows the percentage of blood units screened for HIV, hepatitis B, hepatitis C, Chagas (T. cruzi), and syphilis in Latin America in 2014. Figure 1.5.11 depicts the percentage of blood units screened for HIV, hepatitis B, hepatitis C, HTLV I-II, and syphilis in the Caribbean in 2014.

Figure 13. Percentage of blood units screened for HIV, hepatitis B, hepatitis C, Chagas, and syphilis, selected (c) Latin American countries and (d) Caribbean countries, 2014

(c)

(d)

Source: PAHO, Supply of blood for transfusion in Latin America and Caribbean countries 2014-2015 [in press].

Health financing and elimination of direct payments

Public expenditure in health

Countries in the Region agreed to increase public expenditure in health up to at least 6% of their GDP as a necessary condition to reduce inequalities and increase financial protection within the framework of universal health (). One of the most common and informative indicators to determine the sustainability of changes to health care spending is the ratio of health care spending relative to the size of the economy (GDP). Moreover, increased public investment in health is associated with reductions in mortality rates and prolonged life expectancy (). The data presented in Chapter I demonstrate that public expenditure in health is also a fundamental factor for improving health outcomes and financial protection in the Region of the Americas.

In 2014, total health spending accounted for 14.2% of GDP on average for the Region of the Americas, though Uruguay, Costa Rica, Canada, United States, and Cuba were the only countries in the Region that allocated 6% or more of their GDP to public expenditure in health (Figure 14a). Twenty-two countries in the Region witnessed growth in their public expenditure in health to GDP ratio between 2010 and 2014 (Figure 14b). Ecuador, Paraguay, Dominican Republic, Bolivia, Nicaragua, and Peru experienced the highest percentage increases during the period. Despite these improvements, percentage increases in the 22 countries were smaller compared to the 2005-2010 period, with the exception of Bolivia, Peru, and Uruguay. Many countries in the Region experienced cuts ranging from 2% to 36% in public spending in health to GDP in the 2010-2014 period. The amount that countries spent on health varied across the Region of the Americas between 2010 and 2014. Several factors explain the differences observed: income (GDP per capita), population age structure and epidemiological patterns, progress in health technologies, health systems characteristics, and the economic crisis in 2008.

Figure 14. Public expenditure in health:

(a) as a percentage of GDP, 2014

(b) percentage change from 2005–2010 to 2010–2014

Source: Figures prepared by authors based on data from WHO Global Health Expenditure Database (GHED), accessed October 2016.

Out-of-pocket health expenditure

Out-of-pocket health expenditure constitutes payments made by an individual or households at the point of service, including gratuities and in-kind payments in formal settings (clinic, hospital, pharmacy) or informal settings (complementary medicine), while deducting any refund. It is a part of private health expenditure. The burden of out-of-pocket spending in health creates barriers to access health care services in the Americas. The share of households directly financing health spending varied considerably across the Region in 2014, ranging from as little as 4% of total health spending in Cuba to as high as 64% in Venezuela (Figure 15). Between 2010 and 2014, out-of-pocket health expenditure grew by up to 172% in St. Vincent and the Grenadines, Argentina, Guyana, Venezuela, and Nicaragua, and declined by up to 36% in the Dominican Republic, Peru, Bolivia, and Paraguay. The data need to be interpreted with caution, however, as country data may differ in terms of definitions, data collection methods, population coverage, and estimation methods used.

Figure 15. Out-of-pocket health expenditure by country: (a) 2014; (b) percentage change from 2005–2010 to 2010–2014

(a)

(b)

Source: Figures prepared by authors based on data from WHO Global Health Expenditure Database (GHED), accessed October 2016.

Health care capacity and activities

Human resources for health

Achieving universal health not only requires policy efforts to ensure an appropriate density of human resources for health (HRH), but also to focus on ensuring an even geographic and social distribution. Offering better economic incentives and work conditions in remote and underserved areas, limiting transnational migration, reshaping education programs to fit the new models of care, and improving quality and performance of the health personnel are necessary conditions to meet the health needs of the population along their life course with an intersectoral, intramural, and extramural approach ().

Minimum availability of health personnel. The World Health Organization established a parameter of 25 health personnel per 10,000 population as the minimum availability of human resources required to achieve high coverage of essential public health interventions (). In 2015, the Region of the Americas met the minimum recommended availability of health personnel with an average of 70 physicians and nurses per 10,000 population and 35 countries and territories reached the target of 25 doctors and nurses per 10,000 population (Figure 16). Nevertheless, values varied widely across countries. Cuba had by far the highest number of physicians and nurses (around 158 per 10,000 population), followed by the United States, Canada, Cayman Islands, and Martinique. Meanwhile, 10 countries did not reach the target of 25 doctors and nurses per 10,000 population: Belize, Brazil, Bolivia, Guatemala, Haiti, Honduras, Jamaica, Nicaragua, Guyana, and Venezuela. Among these countries, Bolivia, Guatemala, Haiti, and Honduras had deficits of health personnel with less than 15 physicians and nurses per 10,000 population, which represents less than 60% of the minimum availability recommended.

Figure 16. Availability of physicians and nurses per 10,000 population, circa 2015

Source: PAHO, Basic indicators: health situation in the Americas, 2016. Data may be underestimated. Data refer to physicians and professional nurses. The occupational category “midwives” was not considered to ensure comparability between countries. Certified nurses do not include auxiliary and unlicensed personnel.

Distribution of health workers. Universal health also requires an adequate distribution of the health work force, especially in the first level of care and remote areas, to ensure proper access according to need (). Difficulties in recruiting and retaining health personnel are often geographical (rural areas, dispersed populations, distance from metropolitan centers) and cultural (i.e., native populations) (). Many countries in the Region are implementing programs to encourage health personnel to work in remote areas, many of which have been successful in increasing the availability of health personnel in rural and underserved locations. Examples include programs in Colombia (Mandatory Social Service [SSO for its Spanish acronym]), Brazil (Mais Médicos [More Doctors] Program), Peru (Rural and urban-marginal health service [SERUMS]), Costa Rica (Articles 10 and 19 of Costa Rica’s Law on Incentives), and Mexico (Programa de Calidad, Equidad y Desarrollo en Salud (PROCEDES) [Programme for Quality, Equity and Development in Health]) (). Despite the efforts and progress achieved, problems with the uneven distribution of health personnel persist across the Region (Figure 17). For instance, the level of physicians and nurses between subnational jurisdictions in the United States varied from 81.8 to 170.4 per 10,000 population in areas with the lowest density vs. highest density. In Canada, while the disparities in the distribution of physicians and nurses decreased from 2011 to 2015, the density of health personnel was still unequal between subnational jurisdictions with the lowest and highest density (81.5 to 142.2 per 10,000 population, respectively). In addition, countries such as Bolivia, El Salvador, Panama, Paraguay, and Peru were still facing challenges in both the availability and distribution of health personnel in 2012/2013.

Figure 17. Regional distribution of health personnel, range between geographical jurisdictions

Source: Prepared using data from Segunda Medicion de Metas Regionales en Recursos Humanos, 2013, for Bolivia, El Salvador, Paraguay, and Peru.

United States: U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. The U.S. Health Workforce – State Profiles, Rockville, Maryland; 2014; Canada: Canadian Institute for Health Information (CIHI), Physicians in Canada, 2015: Chartbook, Ottawa, ON: CIHI; 2016 & Health Workforce Database, Regulated nursing workforce by health region, 2006, 2011 and 2015, Canadian Institute for Health Information; Statistics Canada; Panama: Ministerio de Salud 2013, cited in Carpio, Carmen; Santiago Bench, Natalia. 2015. The health workforce in Latin America and the Caribbean: an analysis of Colombia, Costa Rica, Jamaica, Panama, Peru, and Uruguay. Directions in Development–Human Development. Washington, D.C.: World Bank. © World Bank. https://openknowledge.worldbank.org/handle/10986/22027.
Note: MRA: Minimum recommended availability of 25 health personnel per 10,000 population./span>

When comparing the distribution of health personnel in rural versus urban areas in some countries of the Region, the percentage of physicians is up to 80 percentage points higher in urban areas, compared to rural (or nonmetropolitan) areas (Figure 18). For instance, in the United States, while primary care physicians are more likely to practice in rural areas than nonprimary care specialists, primary care doctors still are more concentrated in urban areas (22.5% vs. 77.5%, respectively). Within the primary care work force, nurse practitioners are more likely than physicians to work in rural areas (16% vs. 11%). PAHO’s Department of Health Systems and Services has assisted in conducting two assessments of goals for human resources for health development in 24 countries in the Region (). One of the Regional targets calls for a reduction of at least 50% in disparities in the geographic distribution of health workers (physicians, nurses, and midwives). Results from the last measurement show that in 2013, only Costa Rica and Nicaragua achieved the target, while seven countries made progress in relation to the first measurement: including Bolivia, Dominican Republic, El Salvador, Guatemala, Honduras, Paraguay, and Peru (Figure 19).

Figure 18. Disparities in the distribution of physicians per 10,000 population, rural vs. urban areas and selected countries

Source: Prepared using data from Bolivia: Segunda Medicion de Metas Regionales en Recursos Humanos, 2013; United States: Primary Care Workforce Facts and Stats No. 3. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD; Canada: Scott’s Medical Database, 2015, Canadian Institute for Health Information
Note: data for the United States correspond to physicians working in primary care.

Figure 19. Percentage of progress in the reduction of regional disparities in the distribution of health personnel, selected countries, 2009-2013

Source: Prepared using data from the Regional Goals for Human Resources for Health 2007-2015: Final Report, 54th Directing Council, Washington, D.C., Sept. 2-15 (CD54/INF/1). Data refer to progress (measured in percentage) in the reduction of at least 50% in the number of health workers (physicians, nurses, and midwives) between subnational jurisdictions having a lower density of health workers than the national density. The main limitation of this indicator is the availability of reliable and valid data for the number of medical doctors, nurses, and midwives nationally and in each subnational jurisdiction.

Ratio of nurses to physicians. On average across countries in the Americas, there were 48.7 nurses per 10,000 population in 2015 (Figure 20a). North America had by far the highest density of nurses, which was more than 7 times higher than in LAC (110.9 vs. 13.6 per 10,000 population). The United States, Canada, Martinique, and Cuba had the highest density of nurses (81.3 to 111.4 per 10,000 population), while Argentina, Dominican Republic, Haiti, and Honduras had the lowest density (3.5 to 3.8 per 10,000 population). A minimum ratio of one qualified nurse for one qualified doctor is recommended to ensure proper competency of health care teams, with a higher ratio recommended in the first level of care ().

Figure 20. Status circa 2015: (a) nurses per 10,000 population; (b) ratio of nurses to physicians

(a)

In 2015, nurses outnumbered physicians in most countries in the Region with an average of 2.4 nurses per each physician, though the nurse-to-physician ratio ranged from 0.1 nurses per physician in Haiti to 6.9 nurses per physician in Montserrat (Figure 20b). While most countries reached the set minimum nurse-to-physician ratio of 1:1, Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, Uruguay, and Venezuela had more doctors than professional nurses.

(b)

Source: Prepared using data from PAHO, Basic indicators: health situation in the Americas, 2016.

The results presented here need to be interpreted within the context of each country. The dependency of the health system on health personnel not only varies according to the composition and distribution of HRH, but also the epidemiological patterns and cultural characteristics that shape and create the demand for different and new capabilities. Further, the data presented here combine the availability of physicians and professional nurses. The occupational category “midwives” was not considered to ensure comparability between countries; consequently, the total number of health personnel in each country (nurses, physicians, and midwives) can be underrepresented. Data collection varies from country to country, depending on the national planning cycle, and further limits the interpretation of the data.

Health care services capacity and utilization

Hospital beds ratio. The hospital beds ratio measures the number of hospital beds available per every 1,000 population, for a stated year, for a given country, territory, or geographic area. The indicator provides a metric of the resources available for delivering services to inpatients in hospitals. In 2014, the number of hospital beds per 1,000 population was particularly highest among English Caribbean countries in the Region, and Argentina (Figure 21a). Barbados, Montserrat, Bermuda, Cuba, and Guadalupe had the highest number of beds with more than 5 beds per 1,000 population. On the other hand, Nicaragua, Haiti, Honduras, and Turks and Caicos Islands had the lowest hospital beds ratio, with less than 1 bed per 1,000 population. The number of hospital beds slightly increased in many countries in the Region from 0.3 to 1.6 more beds per 1,000 population in 2014 compared to 2010 (Figure 21b). Antigua and Barbuda, Cayman Islands, Trinidad and Tobago, and Argentina had the largest increases (0.9 to 1.6 extra beds per 1,000 population). In contrast, Barbados and Cuba experienced the highest decreases in the number of beds per 1,000 population (0.8 and 0.7 less beds per 1,000 population, respectively). There is no standard for the necessary number of beds for hospital settings; thus, the interpretation of the data presented here needs to be further evaluated in terms of the particular context and characteristics of each health system and country. The necessary number of hospital beds depends on a variety of factors, such as changes in epidemiological patterns and the age structure of the population, which may increase the need for hospitalizations. Improvements in efficiency of diagnosis and treatment also play a role in reducing the need for hospital beds, while in some countries, cuts in health budgets lead to reductions in hospital capacity as a strategy to reduce costs. Furthermore, redefining the model of care to one that prioritizes the role of the first level of care can lead to reductions in the need of hospital capacity (). Finally, determining the number of hospital beds does not provide an indication of the necessary hospital infrastructure by itself as other factors, including the health personnel, equipment, and medicines, are also important to ensure the capacity of hospitals to deliver proper care.

Figure 21. Hospital beds ratio per 1,000 population, 2014 (or 2013)

(a) 2014 (or 2013)

(b) ratio change from 2010 to 2014 (or nearest year)

Source: Prepared using data from PAHO, Core Health Indicator Database [retrieved in October 2016]. Data for Bahamas, Chile, Ecuador, French Guiana, Guadaloupe, Haiti, Panama, Puerto Rico and United States correspond to 2013. Data in Figure 21a for Bolivia, Colombia, Grenada, and Uruguay refer to 2011 and 2014.

Hospital discharge rate. The hospital discharge rate is an estimate of the degree of utilization of in-patient health care services It measures the formal release of hospitalized individuals (per year per 1,000 population) due to death, return home, or transfer to another institution. Several factors affect the hospital discharge rate in a country, including the capacity of hospitals to treat individuals, the ability of the first level of care to prevent avoidable hospitalizations, and aging and epidemiological patterns of the population that may increase the demand for hospitalizations (). In 2014, hospital discharge rates were highest among the English Caribbean countries in the Region, and for Uruguay (Figure 22a). French Guyana, Guadeloupe, and Cayman Islands had the highest hospital discharge rates (249, 196, and 127 per 1,000 population, respectively), while Colombia, Paraguay, and Honduras had the lowest rates (33.5, 37.2, and 42 per 1,000 population, respectively). Data available from selected countries in 2010 and 2014 (or closest year) show that Uruguay had the highest increase in hospital discharge rates by about 43 hospitalizations per 1,000 population, followed by Guadeloupe and Cuba with increases of about 23 and 14 hospitalizations per 1,000 population, respectively (Figure 22b). On the other hand, Montserrat, Turks and Caicos Islands, and the British Virgin Islands experienced the highest decrease in hospitalization rates (41.3, 36.7, and 20.6 per 1,000 population, respectively). The implications of the data presented here need to be further studied in terms of the efficiency, quality, opportunity, and equity of health services delivery in each country. Indeed, the data need to be interpreted with caution. The number of hospitalizations is based on public institutions only and may exclude hospitals within the public network, which results in underestimations in the data. There also exist variations across countries in the coverage and definition of the hospitalizations affecting comparability of the data. Furthermore, other important indicators of hospital activity and efficiency, such as occupancy rate and average length of stay, are not included here (as there is no common source of information for all countries in the Region), further limiting the interpretation of findings.

Figure 22.Hospital discharge ratio per 1,000 population: (a) 2014 (or 2013); ratio change from 2010 to 2014 (or nearest year)

(a)

(b)

Source: Prepared using data from PAHO, Core Health Indicator Database. Data retrieved in October 2016. Data for Bahamas, Barbados, Bermuda, Canada, Chile, Colombia, Ecuador, French Guiana, Guadaloupe, Jamaica, Mexico, Panama, Paraguay, Puerto Rico, Saint Lucia, and Saint Vincent & the Grenadines correspond to the year 2013. Data in Figure 3.2.4 for Bahamas, Canada, Chile, Colombia, Ecuador, Guadaloupe, Mexico, and Puerto Rico compares 2011 vs. 2013.

Outpatient health care visits ratio. The outpatient health care visits ratio is defined as the number of outpatient health care visits per every 1,000 inhabitants, in a given year, for a given country, territory, or geographic area (). Outpatient visits include curative, preventive, and specialized services at emergency departments in hospitals and physicians’ offices, which may in turn include tests, procedures, and even minor surgery as long as it does not require hospitalization. Furthermore, many factors drive outpatient health care utilization, including changes in the age distribution of the population, policy initiatives and the availability of human resources, supplies, and payment methods. Consequently, the rate of outpatient visits does not fully describe what type of services are being provided and thus cannot be used as a proxy of either access to specific services or quality of care (). Nevertheless, monitoring outpatient visit trends can bring attention to areas that need to be further evaluated in terms of the quality, opportunity, and equity of specific health services.

Figure 23. Outpatient health care visits ratio per 1,000 population, 2014, 2012, and 2010 (or closest years)

Source: Prepared using data from PAHO, Core Health Indicator Database. Data retrieved in October 2016.
WHO/PAHO country offices and technical Regional programs provide the data reported by the national health authority. Data come mainly from administrative sources.

In 2013 and 2014, the number of outpatient consultations in 29 countries of the Region ranged from about 195 per 1,000 population in St. Vincent and the Grenadines to 9,657 in Cuba (Figure 23). Outpatient visits were highest in Cuba, Brazil, Chile, and Uruguay and lowest in St. Vincent and the Grenadines, St. Martin, Haiti, and Dominican Republic. Overall, the rate of outpatient visits increased for most countries studied between 2010 and 2014 (or closest year). Data available for Argentina, Brazil, Chile, Guatemala, Jamaica, and Mexico plotted by income quintile distribution for outpatient services show higher use by the rich population, although inequalities decreased over time in the countries studied (Figure 24). Compared with outpatient services, the proportion of the population receiving inpatient services in all countries was much smaller, and most hospital services were equally distributed among the rich and poor, or show a slight pro-rich inequality, with a greater pro-rich inequality in Guatemala and Jamaica. The data need to be interpreted with caution, however. There are variations across countries in the coverage and definition of these consultations, notably in outpatient departments of hospitals, which hinders comparability of the data. Figures are estimated based on public institutions only, and in some cases exclude institutions within the public network.

Figure 24. Income quintile distribution of inpatient and outpatient visits, selected countries.*

Source: Prepared using data from Dmytraczenko T, Almeida G, eds. 2015. Toward universal health coverage and equity in Latin America and the Caribbean: evidence from selected countries. Directions in Development. Washington, D.C.: World Bank and PAHO. *Inpatient visits refer to hospital services that require at least one night of hospitalization.

Highlights

Access to preventive health services improved in the Region, but further efforts are necessary to increase access to comprehensive care and address persisting inequities:

  • Nearly all countries in the Region have reached universal (or near universal) aggregate coverage for maternal and child health interventions, except for the poorest countries. While these indicators show overall improvements, inequities in wealth and other social determinants of health persist and have a significant impact on health and access to health services.
  • Data available show many countries in the Region have reached high levels of population coverage of health insurance, but that did not always translate into high levels of utilization of preventive health care services or low levels of access barriers. Levels of utilization of adult preventive health care services varied across countries studied from 21.04% to 76.3%. In most countries studied, the utilization of preventive health care services increased over time and was accompanied by improvements in wealth inequities, though with persistent gaps between the poorest and richest families. Meanwhile, the percentage of the population reporting access barriers varied greatly among countries (from 6.8% to 66%) and was highest in the poorest households.

The quality of health care has improved, but progress has been uneven in the Region:

  • Mortality amenable to health care has reduced in most countries from 2010 to 2014, reflecting improvements in the quality of health care in the Americas, but it has also risen in non-Latin Caribbean countries indicating the need for greater efforts to improve quality of health service delivery.
  • Infectious gastroenteritis, lower airway diseases, and diabetes were the main drivers of avoidable hospitalizations between 2001 and 2009.

About one-third of countries in the Americas have yet to meet the minimum recommended availability of 25 health workers of per 10,000 population:

  • The following 10 countries did not reach the target of 25 doctors and nurses per 10,000 population: Belize, Bolivia, Brazil, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, and Venezuela.
  • Despite the efforts and progress achieved by other countries, problems with the uneven distribution of health personnel persist across the Region, while other countries face challenges regarding both the availability and distribution of health personnel.

Health expenditure shows significant variations across countries in the Region with minimal progress in terms of public spending:

  • Canada, Costa Rica, Cuba, United States, and Uruguay and are the only countries in the Region that allocate more than 6% of their GDP to public expenditure in health. Twenty-two countries in the Region witnessed growth in their public expenditure in health to GDP ratio between 2010 and 2014, but at a smaller percentage increase compared to the 2005-2010 period, except for Bolivia, Peru, and Uruguay.
  • Health spending directly paid by people remains high across most countries in the Americas. More than half of the countries reduced out-of-pocket health expenditure by up to 36% between the 2010-2014 period, while others experienced an increase.
  • The total pharmaceutical expenditure is highly variable among countries studied and, in many countries it is financed through private out-of-pocket spending, increasing the risk of people incurring financial difficulties, impoverishment, and exposure to catastrophic expenditure.

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Reference/Note:

1. This value is based on data available from 38 countries that reported in 2014 and 2013 to the PAHO Health Information Platform for the Americas.

2. Refers to subnational jurisdictions (state, province, or Region) having the lowest and highest density of health workers than the national density.

3. A hospital is defined as any medical facility with an organized medical and professional staff and beds available for continuous hospitalization of patients formally admitted to it for medical observation, care, diagnosis, or surgical and nonsurgical treatment.

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