Pan American Health Organization

Socioeconomic inequalities in health

  • Social Inequalities in Health
  • Two inseparable notions: equity in health and the social determinants of health
  • A regional look at health through the window of the Millennium Development Goals: focusing on equity
  • The persistence of inequities and inequalities in the Region
  • No one left behind…? How to make good on our promise
  • References
  • Full Article
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Social Inequalities in Health

Equity in health is a cardinal expression of social justice, attained when every individual has the opportunity to reach his full health potential and no one is excluded or hindered from reaching that potential because of his social status or other socially determined circumstances. This ethical imperative is accompanied by a political imperative, since today it is recognized that social equity is a prerequisite for good governance. Thus, equity is a political objective that consists of creating equal opportunities for health and well-being. Indeed, without social equity, sustainable human development cannot be guaranteed (). In recognition of this, “Transforming our world: the 2030 Agenda for Sustainable Development,” embraced by every country in the world in 2015, has explicitly promised that no one will be left behind ().

Two inseparable notions: equity in health and the social determinants of health

Aspiring to equity in health, including universal access to health and universal health coverage, implies altering the underlying distribution and role of the social determinants of health—that is, the circumstances in which individuals are born, grow, live, work, and age and the broader array of forces and systems that affect those circumstances, such as the global, national, and local distribution of wealth, power, and resources. Transformational action that addresses the social determinants of health and promotes equity in health requires, on the one hand, abandoning public health practices based on the risk-factor paradigm, in which the individual and behavior are the focus, while, on the other hand, adopting a more comprehensive approach to public policy that empowers individuals and communities to exercise control over their circumstances—a multidisciplinary and essentially intersectoral approach under the principle of Health in All Policies.

The Americas: a vibrant region plagued by persistent inequities

Guaranteeing the universal right to health will remain simply an aspiration if the profound social inequalities behind the health gaps in the Region are not addressed. Empirical studies offer clear proof that the population groups with the worst health outcomes in the countries of our Region also are those that demonstrate the tangible expressions of socioeconomic inequality, including low income and consumption levels, poor housing, job insecurity, limited access to quality health services, fewer educational opportunities, inadequate access to water and sanitation services, marginalization, exclusion, and discrimination, among other adverse social and health situations ().

Evidence of the stubborn persistence of profound social inequalities, exclusion, and discrimination—and, thus, profound inequalities in population health and the burden of disease—is present even in Latin American countries where “post-neoliberal” political, economic and social reforms have been implemented to counteract the neoliberal model that emerged in the 1980s (). One possible explanation for this could be a certain myopia in the policies designed and implemented, even in those consistent with the universal right to health.

According to Garcia-Subirats et al., 20 years after the introduction of reforms to increase equity in access to health care, inequities (defined in terms of unequal use for equal need) are still present in both Brazil and Colombia (). According to these authors, the inequalities in the two countries illustrate the close connection between use of the health services and the design of each health system ().

For example, and delving a bit further into the matter, bridging gender gaps in health implies unmasking and addressing explicit and, especially, implicit, discrimination or bias in their various forms, which make public policies ineffective for women. The combination of gender based discrimination and the material constraints imposed by poverty and the consequences of other social discrimination (such as living in a neglected geographical area or belonging to an ethnic group subject to social discrimination), will lead to significant health service access barriers (even to services in the public sector) for certain women. In other words, the different forms of discrimination, which tend to fuel each other (intersectionality ) and, in practice, affect certain women, become real obstacles to taking advantage of public policies that, in theory, could benefit them. As a result, if the aspiration is to make the health system an effective equalizer that intervenes to improve the health of disadvantaged groups and, consequently, bridge the gaps in health, its design and implementation should be based on a paradigm that involves an analysis of the target populations’ most pertinent problem stemming from the array of inequalities, exclusion, and discrimination to which they are subject.

The causality between socioeconomic and health inequalities runs in both directions: on the one hand, conditions associated with poverty (such as economic insecurity, stress, and malnutrition) and different types of social discrimination directly affect people’s health and at the same time limit their access to health services; and on the other hand, poor health limits the potential for income generation and upward mobility by lowering school and work performance, thus reinforcing the patterns of social exclusion and discrimination.

A regional look at health through the window of the Millennium Development Goals: focusing on equity

Notwithstanding the historical structural impact of harmful colonial legacies, tremendous social injustice, and profound socioeconomic inequities (), the Region of the Americas, and Latin America in particular, enjoyed macroeconomic growth for much of the period 1990–2015, characterized by a reduction in poverty, extreme poverty, and inequality in income distribution—a period that has come to be known as the temporary window of the Millennium Development Goals (MDGs). As documented in this publication and its preceding edition (), the Region consolidated undeniable gains in health, meeting several of the targets set for MDG 4 (child mortality), MDG 6 (incidence of infection with the human immunodeficiency virus [HIV], tuberculosis), and MDG 7 (access to safe drinking water).

Despite the impressive overall improvements, a regional look at health through the window of the MDGs paints a different and more troubling picture when examined through the lens of equity. Achievement of––or progress toward––the health-related MDGs has not generally been accompanied by a systematic reduction in social inequalities in health, especially relative inequality, which tends to be the most sensitive indicator for determining the impact of policies targeting population segments at greatest social disadvantage to ensure that no one is left behind. An eloquent—and dramatic—example is illustrated for MDG 5 (maternal mortality) in Figure 1, which looks at the maternal mortality situation through the lens of equity.

Figure 1. Inequalities in maternal mortality in the Americas, by human development quartiles in the MDG period (1990–2015)

Source: SDE/PAHO, 2016. Prepared by the authors using WHO data in the public domain.

On average, the Region succeeded in halving the maternal mortality ratio between 1990 (101.8 per 100,000 live births) and 2015 (51.7 per 100,000 live births)—information that, in principle, is necessary and sufficient to determine whether or not MDG 5 (which established a 75% reduction) has been achieved. However, the histograms of human development quartiles among countries (Figure 1, left side) show that while the absolute gaps in maternal survival have been reduced—especially at the expense of a reduction in maternal mortality in the countries in the quartile with the lowest human development levels—gradients of inequality in maternal mortality persist. Both the regression curves (lower left-hand corner) and the concentration curves (lower right-hand corner) of social inequality (i.e., according to human development) for maternal mortality among countries in the Americas, which yield more sophisticated and detailed metrics of the inequality gradient (i.e., the slope index of inequality and the health concentration index, respectively), confirm this undesirable effect. In fact, 50% of maternal deaths in the Region continue to be concentrated in the 20% of countries with lower human development levels—a situation that did not change in the period 1990–2015. These women represent the people we have left behind.

There is documented evidence of health inequalities between countries—analogous to those illustrated here with maternal mortality—involving other health outcome indicators and other stages of the life course (). For example, a regional study of the burden of tuberculosis incidence in the Americas between 2000 and 2013 found that the absolute inequality gradient (measured as the slope index of inequality) was virtually constant throughout the period: around 54 excess new cases per 100,000 population in the countries with the lowest human development versus those with the highest human development; the relative inequality gradient (measured as the health inequality concentration index) grew even more steeply (shifting from –0.20 to –0.24 between 2000 and 2013): 40% of the regional tuberculosis incidence burden in 2013 was concentrated in the quintile of countries with the lowest human development (). Similarly, recent studies using double stratification have documented the presence of profound educational and gender inequalities in the risk of death () and the burden of blindness () in the countries of the Region.

More eloquent still is the available evidence on health inequalities within countries, based on microdata from population surveys. The distinguished International Center for Equity in Health of the Federal University of Pelotas in Brazil—a new PAHO/WHO Collaborating Center on Equity in Health—has produced a detailed study that, using data from demographic and health surveys (DHS) and multiple indicator cluster surveys (MICS), systematically documents the magnitude and extent of social inequalities in reproductive, maternal, newborn, infant, child, and adolescent health in many of the countries in the Region that have these surveys for the MDG window. These unjust inequalities in health outcomes, health coverage, and access to health services and programs, are reproduced in inequality gradients in income and wealth, access to education, and the urban-rural, male-female, and geographic dichotomies (). On a more positive note, this study also notes the gradual progress toward universal maternal and child health care observed in some countries, which have managed to reduce extreme absolute inequalities among social groups. Another study, conducted in 14 Latin American countries, documented the presence of profound sociogeographic inequalities in the distribution of ophthalmologists and underscored the critical implications of redistributing human resources for the gradual achievement of universal health ().

The persistence of inequities and inequalities in the Region

The Region of the Americas—and Latin America and the Caribbean in particular—continues to have the dubious distinction of being one of the regions of the world with the greatest social and health inequities (), especially in terms of inequality in income distribution (the starting point for the construction of the imaginary group on regional inequality). The social, economic, and health inequalities observed and felt in the streets and among the peoples of our Region tend to be the product of something more deeply rooted and, therefore, less evident: policies, laws, and regulations whose design and implementation reflect the persistent inequality of access to power in our countries.

In an article published in 2006, Navarro et al. () noted the scarcity of scientific research on the connection between political power, health policy, and people’s health. In order to bridge this knowledge gap to some extent, these authors developed and tested a model that linked political and power resources with two types of public policies (labor market policies and government welfare policies) and their effects on income inequality and mortality levels in the majority of the Organisation for Economic Co-operation and Development (OECD) countries from 1950 to 1998. The countries studied were grouped by the political tradition that had governed them for the longest time during the period in question.

Some of the conclusions of this study reinforce the idea of the connection between political contexts and certain health outcomes: the duration of governments headed by pro redistribution parties in the period 1950–1998 played an important role in reducing income inequality and infant mortality in the OECD countries analyzed ().

The Navarro et al. findings serve as a frame of reference for the Region’s experience in from 2000 to 2010 and the fight against poverty and its relation to the political context at that time. Contrary to the situation in the 1990s, the 2000s were characterized by economic growth, coupled with a reduction in poverty and inequality in the vast majority of countries in the Region (). While the causes of the decline in poverty and inequality in the 2000s following their increase in the 1990s are still a matter of debate, the majority of these causes can be linked to high levels of economic growth, accompanied by the growth of employment and job earnings, or with a change in the political paradigm (expressed in a greater proclivity for public policies with a redistributive impact) or both. (). In any case, there is recognition of the significant role of public interventions in social and labor policy, which need further strengthening, and the reversal of certain pro-market reforms in some countries of the Region. The recent experience in Brazil exemplifies this: some estimates indicate that around 17% of the direct decline in income inequality in that country between 2001 and 2011 was due to conditional transfer programs— specifically the Bolsa Familia and Beneficio da Prestação Continuada programs; 19% to contribution- and non-contribution-based pensions; and 58% to the growth of job earnings ().

In fact, “politics are important in designing, creating, and guaranteeing the sustainability of legitimate institutions and adopting public policies that work to the benefit of all citizens” (). However, the extreme inequality that characterizes the Region can alter the policy-making process, even in democratic contexts in countries where pro-redistribution parties are in power, for it often translates into in imbalances in the way in which the power to influence the political process is distributed in a society. As a result, the real potential of those who lack that power to overcome poverty and exclusion and thus enjoy decent and satisfactory living conditions, including robust health, will be diminished. A study that explores access to justice and the right to health in Brazil from the standpoint of equity in health is useful for exemplifying how the aforementioned asymmetry works in practice. At the time of publication (2009), the author of this study warned about the potentially negative impact of Brazil’s litigation model on equity in health:

The model is characterized by the prevalence of individual lawsuits requesting curative care (often medicines) and a high success rate for litigants. These two elements are largely the consequence of the way in which Brazilian judges have interpreted the enjoyment of the right to health recognized in Articles 6 and 196 of Brazil’s Constitution—that is, as the right of individuals to meet all their health needs with the most advanced treatments available, regardless of cost. Since resources are always scarce in relation to the health needs of the population as a whole, this interpretation can only be sustained at the expense of universality (…). Individuals and (less often) groups that can resort to the courts and exercise this right are therefore privileged over the rest of the population. This is potentially prejudicial to equity in health, because privileging litigants over the rest of the population is not based on any concept of need or justice, but rather, on their ability to resort to the courts, which only a minority of citizens can do ().

Policy-making involves the discussion, approval, and implementation of public policies. It can be understood as a negotiating or transactional process among stakeholders that unfolds in both formal and informal settings. When this process occurs in contexts of profound inequalities, the circumstances, realities, and agendas of the elites—the privileged stakeholders who hold all the power to influence the political process—tend to be reflected in the resulting policies that govern our societies, which reinforces the culture of privilege that prevails in our Region (). As the Economic Commission for Latin America and the Caribbean (ECLAC) points out, reducing the entrenched social inequalities in the Region urgently requires a “shift from a culture of privilege to a culture of equality” ().

The elites use various means to influence the political process in their favor. These range from practices that are not illegal but are a topic of growing concern and debate, such as the lack of transparency in lobbying, the private funding of electoral campaigns or political advertising, to mechanisms that are undesirable, such as “revolving doors” and the concentration of media ownership (which facilitates the dissemination of certain ideas or beliefs and stifles others that oppose the agendas of the elites), or are frankly illegal, such as threats and assaults against journalists, patronage (where public employment and the delivery of public services are considered an exchange of favors), political cronyism, or corruption ().

In any case, the Gordian knot of the issue lies in the fact that the elites and their networks, with their ideas and resources, can be synonymous with forces having great potential to shape the conditions for generating and appropriating the economic surplus in their favor and slanting the workings of government institutions against the public interest. In extreme cases, the elites can come to have a permanent influence on the different branches of government, even when there is a change in the head of the executive branch and political party represented. For example, the elites can exacerbate or take advantage of imbalances in the customary systems of checks and balances among branches of government, which exist to maintain the health of democracy, or of regulatory deficiencies or omissions in key areas. In this regard, Schneider () states that while judicial systems in the Region have become more independent and powerful with democratization, the elites have also been quick to exploit for their own benefit the prerogatives granted to these systems ().

Thus, the influence of the elites and their consequent co-opting of policies (for example, progressive taxation or policies that apply the principles of social justice to health policies) are not simply structural obstacles to combatting inequities but a violation of the basic precepts of democracy, debilitating its institutions and corrupting policy-making in general.

Today, given the sustainable development scenario promoted in the 2030 Agenda, PAHO has identified a key role in rendering policy-making more equitable in furtherance of the universal right to health at all stages of life. First, it must continue producing and disseminating specific analyses and evidence related to the social determinants of health—that is, on the close correlation between certain characteristics of the broader political, economic, and social context (structural determinants) and the social conditions of various population groups (intermediate determinants), the interaction between these groups and their physical and mental health status, and the distributive inequality imposed by the social determinants on the rest of society. These studies should reflect the magnitude of the changes in the paradigms of analysis and practical intervention, which are key to reducing health inequities.

It will also be essential to ensure that that evidence is reflected in the recommendations on public health policies (including those related to health service access, which is one of the channels for translating socioeconomic conditions into health conditions) and on social and economic policies, broadly speaking. Moreover, guaranteeing that health is not just the privilege of the few in the Region also implies the need to facilitate technical cooperation for generating political advocacy to further social equity in health and the search for the common good.

No one left behind…? How to make good on our promise

Notwithstanding its undeniable and timely emphasis on equity, the 2030 Agenda and its Sustainable Development Goals (SDGs) do not have explicit targets or specific indicators for the reduction of social inequities in health or progress toward equity in health, beyond recommending greater availability of data disaggregated by the variables that produce social stratification. We must build institutional capacity to measure, analyze, monitor, and communicate social inequalities in health; to manage statistics, data, and evidence honestly and responsibly; to inform policy-making; and to engender political advocacy to further equity in health throughout the life course. All of this is essential for creating and strengthening national capacity to make good on the promise that no one will be left behind on the road to sustainable development by the year 2030.

A recent and still unresolved debate on target setting for maternal mortality in the SDGs, published in The Lancet (), offers an eloquent example of the need for serious reflection on how to report on the impact of the 2030 Agenda on equity in health. SDG target 3.1 calls for reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Although it has yet to be determined how this target can be incorporated at the national level, one proposal (Jolivet et al.) is to convert the global target to a relative national target equivalent to a two-thirds reduction in maternal mortality between 2015 and 2030. The other proposal (Kassebaum et al.) is to convert the global target to an analogous absolute national target—that is, to reduce maternal mortality to less than 70 per 100,000 live births by 2030. Figure 2 illustrates the potential distributive impact of maternal mortality between 2015 and 2030 on the social gradient, defined by income per capita quintiles among all the countries in the world, under these two proposals.

Figure 2. Maternal mortality worldwide by 2015 and 2030 income quintiles, according to two types of SDG target

At the conclusion of the MDG period (2015), the risk of maternal death was distributed very unequally among the countries of the world, according to the distribution of their income per capita (deflated and adjusted by purchasing power): there were 610 excess maternal deaths (slope index of inequality) along the length of the income gradient among the countries and an absolute gap of 436 excess maternal deaths in the poorest quintile of countries with respect to the wealthiest quintile (in other words, the maternal mortality ratio in the poorest quintile was 46 times higher than that of the wealthiest quintile: the relative gap). And this was in 2015 (top histogram). Again, these women are the people we have left behind. Under the figure is the distribution of maternal deaths established for the year 2030 at the end of the SDG period, according to the two types of target 3.1 proposals: Jolivet’s relative target (middle histogram) and the Kassebaum’s absolute target (bottom histogram), as well as the magnitude of the reduction in absolute and relative inequality, the gap, and the gradient associated with each scenario—that is, the intensity of potential fulfillment of the promise that no one will be left behind.

This exploratory prospective analysis yields a message of the greatest importance for the success of the 2030 Agenda: only through a systematic analysis of unjust and avoidable social inequalities in health will it be possible to visualize who we are leaving behind; this implies building institutional capacity to study the distributive equity of health gains (in terms of access and outcomes) in socially determined population groups, as well as quantifying the magnitude of social inequality in health through standardized composite metrics over time and throughout the life course. Moreover, only by monitoring inequalities will it be possible to verify the impact of pro equity policies and progress toward keeping the promise that no one will be left behind. This requirement of reporting on the progress toward equity in health was clearly anticipated in 2008 in the final report of the WHO Commission on the Social Determinants of Health, whose third general recommendation invokes the need for evidence: without it, the call for equity and social justice will be reduced to mere rhetoric. Despite the complexity of a regional scenario historically marked by profound inequities, the peoples of the Americas have been taking firm and determined steps toward reducing poverty and social exclusion at the dawn of the new millennium; the primacy of the principle of equity, expressed in the commitment to ensuring that no one is left behind on the road to sustainable development by 2030, should provide reasons to build, with optimism and determination, the fairer, more inclusive, equitable, and cohesive societies that the Region needs for sustainability and health.


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Stewardship and governance toward universal health

  • Introduction
  • Conceptual dimensions of stewardship and governance
  • Stewardship and governance of health system transformation processes
  • Conclusions
  • References
  • Full Article
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Introduction and rationale

The objective of this topic is to analyze how the health authorities have led processes of change in the governance of health systems in the Region of the Americas, as they move toward universal access to health and universal health coverage. Stewardship describes the capacity of health authorities to lead and support joint action, which allows the creation, strengthening, or changes to governance structures in the health system. Governance is understood to be the institutional arrangements that regulate the actors and critical resources that influence conditions of coverage and access to health services ().

In order to make universal access to health and universal health coverage possible, health systems must overcome their institutional limitations, generally characterized by segmented coverage and fragmented services. The health authorities must exercise stewardship in order to strengthen governance of the financial model and of the health services, human resources, medicines, and technologies that constitute the sector ().

An analysis of the strategies of universal access to health and universal health coverage implemented in the countries in the Region of the Americas allows us to recognize different processes of change that address these issues. The differences lie both in the way health authorities practice stewardship and in the kinds of governance innovations proposed as engines to transform health systems.

This topic is divided into three sections. First, the various aspects of leadership capacity and governance in the health sector are discussed. Second, there is an analysis of health system transformations in the countries of the Americas, the role of stewardship by the health authorities, innovations in governance, and the main objectives and progress made. Finally, by way of conclusion, this document indicates the challenges that must be addressed in order to move toward universal health.

Conceptual dimensions of stewardship and governance

Stewardship for universal health

When the health authorities exercise stewardship, they lead the sector by formulating, organizing, and directing national health policy. This in turn allows them to improve the effectiveness, efficiency, and equity of the health system by strengthening or transforming the governance structures of the health sector. The process of transforming health systems is necessarily political, because the actors involved in this collective action are responsible for making the process both feasible and viable (). For this reason, there is a need for stewardship that is not exclusively associated solely with the influence of the health authorities, expressed by the role of the ministries of health. Rather, consideration must be given to the authorities’ role in leading collective action that also includes other actors within and outside State structures.

Agencies in other sectors or jurisdictions (housing, education, finance, trade, etc.) within the State also bear mention, as they are indispensable for sustaining intersectoral initiatives to address the social determinants of health by strengthening social protection systems (). We must also consider actors in subnational (provincial and municipal) jurisdictions that play a key role in adjusting or implementing initiatives in the local context, as well as non-State actors (organized and unorganized civil society, non-profit and for-profit private sector organizations with varying degrees of formality and visibility) that perform important roles of social oversight, advocacy, and influencing processes of change and service delivery ().

Governance for universal health

The concept of governance has been evolving from one centered on institutional attributes toward one which addresses changes to the institutional mechanisms that regulate actors and critical health sector resources (). This approach allows us to interpret those health system transformations that, in order to improve access to health and to health coverage, require related changes to health sector institutions ().

Governance of health services

The type of governance required to achieve comprehensive health service networks, with a people- and community-centered model of care, requires changes to how different relationships or processes are regulated ():

  1. value and understanding of the actors involved in the health services network;
  2. regulation of the interactions among actors involved in the organization, management, and care provided by the health services;
  3. regulation of the relationship between services and the population;
  4. intersectoral regulations for the services and other social sectors.

The values (right to health, equity, and solidarity) of the actors involved in producing health services constitute a foundation for social regulation that helps legitimize the transformation of health service delivery. Therefore, they are crosscutting for all actors involved.

Regulations within networks can be grouped into three categories: those related to organization of the health system; those related to management; and those related to care. The rules governing how the health system is organized determine where health services are delivered (outpatient care in hospitals, in specialized diagnostic centers, and primary care); how health services are coordinated among the different levels of care (referral and cross-referral systems); and how resources (financial, human, and material) are allocated and managed in the health services network. The rules governing management include service programming (centralized or decentralized programming); labor standards (record-keeping on production, working hours, extended schedules, care hours and non-care hours); the coordination of work teams at health care centers (collegial management decisions, unilateral decisions); and relationships between health centers and social organizations (mechanisms for coordination or community participation). The standards of care determine standards of production, quality of services, and models for organizing the work among both professionals (interdisciplinary) and within the health services or in different organizations or levels of care.

The regulatory mechanisms that govern the relationship between health services and the population encompass more than the standards of care that determine access and the responsibility that health teams have for the health of the population in specific territories. They also include the expectations, demands, and rights of individuals, communities, and civil society (spaces for participation and consultation) as a part of the management model.

Intersectoral regulation can be situated at different levels. At the macro- or mezzo-institutional level, there are mechanisms to connect health policies with other social policies for coordinated implementation within the territory. At a micro-institutional level, there are intersectoral initiatives that regulate the relationship between health service delivery and other sectors or services that influence the determinants of health of the population.

Human resources

Governance of human resources is a central part of the stewardship of health authorities (). Policies related to human resources range from educating future health workers to helping them enter the job market and perform well there. In order to make progress nationally toward universal health, a set of policies, regulations, and interventions must be established to organize and align the output, competencies, internal and external mobility of professionals, employment, working conditions, and needs-based distribution of personnel-just to mention some crucial aspects ().

Multiple actors intervene in these processes-with given responsibilities and objectives-from a variety of sectors, such as education and health, with dissimilar interests in the public, private, for-profit, or non-profit sectors. From the perspective of the health authorities, the goal of effective governance and leadership is to channel, organize, and motivate these various legitimate interests in order to achieve universal health. Four dimensions of governance related to human resources are recognized: (a) human resources education, (b) professionalization, (c) regulation of professional practice, and (d) regulation of the job market.

Human resources education includes undergraduate and graduate education, residencies, and the job market, as well as continuing education during professional practice. Authorities must ensure that all health workers have up-to-date and appropriate competencies to properly perform their duties and responsibilities. Ensuring competency ranges from undergraduate education with a renewed focus on primary health care (PHC), the acquisition of collaborative and interdisciplinary work skills, the establishment of competency profiles for future professionals, the establishment of single national exams, and postgraduate education with medical residencies and continuing education. It should also take into account the requirements of periodic recertification for certain professions.

Professionalization is the professional regulation of those involved in providing health services. It requires new definitions of the professions, including profiles, responsibilities, and specializations suitable for the challenges of building comprehensive and integrated models of care, centered on people and their communities ().

The regulation of professional practice entails defining standards of practice and the instruments and entities to evaluate the performance of health professionals.

Finally, regulation of the job market refers to both working conditions (work load) and hiring conditions (job security, collective bargaining, and methods of payment).

Governance of technology and medicines

The attainment of universal access to high-quality, safe, effective, and affordable medicines and health technologies is possible if policies and regulatory legal frameworks are adopted to ensure that health authorities strengthen governance at all stages of the lifecycle of these products. Such governance includes (i) supply issues, from innovation and development of new products through regulation of the quality of production and marketing; (ii) demand issues, including mechanisms to define the criteria for inclusion in health systems coverage, as well as rational prescribing; and (iii) other factors that impact effective access to these products, such as setting market prices and operation of the systems for dispensing these products ().

Regarding supply issues, the health authorities have a critical role to play in providing guidance to innovation and development in the industrial health sector, to ensure that it addresses the health needs of the population, rather than just satisfying commercial interests. If intellectual property rights are handled from a public health perspective, high-quality patents will be promoted and innovative drugs will be developed. This will also help avoid inappropriate extension of market exclusivity and facilitate the timely introduction of generic products from multiple sources. In order to achieve this objective, use can be made of the licensing flexibilities allowed under the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and included in the 2001 Doha Declaration on TRIPS and Public Health ().

These policies should align with national health policies and social development policies in the areas of science, technology, and industrial development, given the importance of these products and sectors to economic growth. Once on the market, the production and marketing of medicines and other health technologies should be subject to strict regulation and oversight (). The work of regulatory agencies is needed to help develop markets for medicines and technologies that ensure the efficacy and quality of the products offered ().

Governance of demand conditions ranges from criteria for inclusion of these products in health systems coverage, to regulation and incentives for rational prescribing and use. Inappropriate prescribing, dispensing, and use of drugs and other health technologies cause poor health outcomes (). As of 2015, only 42.9% of countries in Latin America and the Caribbean had adopted standards and procedures to prepare clinical practice guidelines.

Finally, governance of these products includes dissimilar strategies to address economic aspects related to setting relative prices and the price structure. While some countries have price regulation mechanisms, others have encouraged negotiations to leverage the purchasing power of the public sector, such as joint national or regional procurement. This is complemented by comprehensive, transparent supply chain planning, which is crucial for ensuring access to health. The planning process should start by determining the need for these products and how they should be financed, with adjustments to the coverage, reimbursement, and procurement systems (or public production), and the corresponding distribution and supply.

The information sharing, cooperation, and networking that different sectors and countries have undertaken have significantly helped to strengthen regulatory systems and stewardship and governance in the health sector. The Pan American Network for Drug Regulatory Harmonization (PANDRH), created in 1999, includes 29 of the 35 countries of the Americas and supports drug regulatory harmonization in the Region.

Governance of financing

Governance of health systems financing entails regulation of its three central dimensions: the generation of financial resources for the health sector, determined by compulsory or voluntary contribution mechanisms; insurance, determined by the mechanisms that collect the resources, which either consolidate or segment the health system; and the transfer of financial resources to the health services, which determines the incentive structure for health service delivery ().

Governance through regulation of the mechanisms to collect, insure, and transfer resources influences the rest of the critical resources (human resources, medicines and other technologies, health service delivery) that make up the health system, as well as progress made in terms of access to health services and coverage for the population. A detailed analysis of the progress made and the governance challenges of the financing model will be discussed in topic 5 of this chapter, “Health financing in the Americas.”

Regulatory mechanisms for the production and consumption of goods that impact health

The growing leadership of the health authorities is also seen in the development and improvement of systems to regulate the production and consumption of mass-produced goods (e.g., in the food industry; use of pesticides; regulation of alcohol, drug, and tobacco consumption; and environmental stewardship). These seek to act on risk factors that affect the health of the population ().

These strategies consist of mechanisms to regulate activities not controlled by the health systems, which are national in scope and affect the health of the population. However, we should note the strong role played by global governance, as defined by international agreements.

The health authorities have also made progress with their regulatory functions due to the support of social movements and organized civil society. These partnerships have made it possible to include the health authorities in economic and commercial decision-making, traditionally outside their purview and reserved for the ministries of finance and trade. A detailed analysis of the progress made and challenges faced in intersectoral governance and its relationship to the Health in all Policies approach is presented in topic 3 of this chapter, “Social determinants of health.”

Stewardship and governance of health system transformation processes

Health system transformation processes in the countries of the Region of the Americas can be analyzed in terms of governance changes brought about by the stewardship of the health authorities. These processes are institutional-because changes in governance involve changing the “rules of the game” that regulate actors and critical health sector resources-and political-because the changes in governance are led by the health authority, together with a broad range of actors working to bring about these transformations (). In order to differentiate the various types of health system transformation processes, we will look at political aspects associated with stewardship and the institutional aspects related to governance.

Along these lines, two types of health system transformation approaches () are presented below: those based on changes in health insurance, which seek to increase financial coverage of the population, and transformations based on changes to the health services organizational model, which seek to improve access to health services.

Transformations based on changes in health insurance

These processes start by changing the mechanisms that regulate financing models-particularly for the coverage of health services-with the introduction of market incentives and competition (among resource managers, service providers, and pharmaceutical companies). The main objective of these reforms is to increase the covered population, thereby providing financial protection and determining the health services included in the coverage. For this reason, innovations in governance focus on changes to insurance mechanisms as the main engine of reform. Table 1 lists the cases of Bahamas, Colombia, Honduras, Turks and Caicos, United States of America, and Uruguay. These examples show how financial coverage expansion policies can follow different strategies, with uneven progress and limitations ().

Table 1. Changes in insurance mechanisms, by country

Country Date Policy Objectives Innovations in governance Achievements and progress
Bahamas 2016 to present National Health Insurance Law Increase coverage: ensure free-of-charge health services to all residents at point of care. Cost to be fully or partially covered by government The National Health Insurance Authority was created to oversee implementation of the National Health Insurance plan Designed in stages (); stage 1 is registration of users
Colombia 1993 Law 100 of 1993 Expand coverage; Create a system of regulated competition by introducing private administrators to handle social security resources; 100% population coverage
2012 Convergence of contributory and subsidized systems with the unification of covered benefits Standardize coverage under the two subsystems
2015 Overcome access barriers Eliminated service coverage criteria and moved to a system of an exclusions-based benefits system In the process of implementation
Honduras 2015 Framework Law of the Social Protection System Achieve universal health insurance Public or private administrators of health service networks may be included in the social security funds, and, progressively, in the public sector In the process of implementation, with complementary legislative initiatives regarding social security and national health system laws
Turks and Caicos Islands 2009 to present National Health Insurance Plan Increase insurance coverage (goal of 100%), eliminate direct payment, and provide access to a comprehensive benefits plan in the public and private sectors National Health Insurance Council is established to monitor the plan, define benefits, determine contributions, and advise the minister of health; it is comprised of representatives of ministries and political parties Implemented in 2009, but starting in 2016 amendments are approved to extend coverage to unemployed people and children of migrant workers, and to allow voluntary membership
United States of America 2010 to present Patient Protection and Affordable Care Act Increase the uninsured population’s coverage and access to health services Private insurance sector: compulsory universal insurance; no applications turned down regardless of health status; same premium for all plans; subsidized premiums and copayments for those who qualify; expansion of the public sector through Medicaid (state and federal) has been optional for each state Reduction of the population without health insurance from 16.4% in 2010 to 11.4% in 2015, and lower barriers to access; Expansion of Medicaid coverage in 25 states
Uruguay 2007 to present Law 18,211 of the Integrated National Health System Increase insurance coverage through social security Changed the financing model (more public financing and insurance equity) Increase in coverage from 20% of the national population to almost 70% in 2016

The logic of introducing economic incentives as a strategy to change health insurance requires powerful stewardship and governance mechanisms to regulate all the critical resources of the health system (financing, human resources, and medicines and health technologies). Stewardship of these reforms centers on the participation of regulatory and control agencies, whose obligations usually revolve around social security. These actors are housed in new management, regulation, and control structures associated with the new financing model (). In countries where relevant changes have occurred in social security, these new structures are seen in the operation of regulatory authorities governing the organizations in charge of health services finances (e.g., the superintendencies in Chile and Colombia). Other countries focus on greater involvement of the Ministry of Health in regulation and management of contribution-funded insurance (e.g., JUNASA of Uruguay) or the agencies responsible for public insurance (e.g., FONASA of Chile and SESAL of the Dominican Republic). However, countries still need to develop the political and technical authority needed to control the direction of these transformation processes. Some countries, with the support of international financing agencies, have also created new executing units with structures in charge of implementing these reform projects.

Joint activities can also be complemented by new or traditional private actors involved in managing health insurance and providing health services. The characteristics of these for-profit or not-for-profit private actors that complement collective efforts-their local history, corporate development, vertical integration between insurers and providers, and the type of local and international partnerships involved-are elements that determine their influence on transformation processes and the strategies used to achieve them.

Governance of medicines, health technologies, and human resources for health can be influenced by the key players involved in this type of transformation process. First, there are specific structures at the ministries of health and regulatory agencies on each of these topics, with varying levels of regulatory capacity. However, private insurers and providers also have potential influence on the governance of drugs, health technologies, and human resources through partnerships and trade agreements. Examples of this include virtual integration between private insurers and companies that supply medicines and technologies, and strategies to train new professionals and recruit them to work at these companies’ own health service delivery facilities. There is a complex web of tension between different private interests and the objectives of public policies to promote universal access to health and universal health coverage, requiring active strategies to strengthen the leadership and influence of the health authorities. For this reason, drug policies must be further developed. They must include regulatory mechanisms to strike a balance between the market and incentives to promote innovation (intellectual property) and competition (generic drugs), on the one hand, and the health needs of the population and social policy objectives of equity, solidarity, and the guaranteed right to health, on the other hand. To this end, it is essential to strengthen the government’s regulatory authority and give it the political and technical power to enforce compliance with regulations and encourage the pharmaceutical industry to take an innovative, competitive, and social approach. Examples of such actors are the Food and Drug Administration (FDA) of the United States, the National Health Surveillance Agency (ANVISA) of Brazil, and the National Drug, Food, and Medical Technology Administration (ANMAT) of Argentina. With its capacity to innovate and introduce health technologies, the medicines and technology market holds great economic and political power and must therefore be counter-balanced by State power representing the interests of society. This will ensure that the market will not have undue influence on how the health systems and health services are organized, how human resources are trained, how new devices and equipment are introduced, and the opening of new units, hospital services, and new professional specialties.

Finally, these reform processes result in pressure for changes in the training and performance of human resources, brought about by the insurance market, private services, and health technologies. Agencies that purchase services can introduce innovations in the standards and dimensions of professional practice, either through economic incentives or through standards of care specifically included in job contracts. For this reason, the health authorities must exercise stewardship to strengthen the governance of human resources education, ensuring that it is aligned with the objectives of universal health. Educational programs must be consistent with PHC and people- and community-centered models of care.

Transformations based on the model of care and organization of health services

A second type of reform revolves around transformations in the governance of health systems and services, in conjunction with changes in the regulation of human resources aimed at increasing access to health services. Table 2 shows certain countries (Bolivia, Brazil, Canada, El Salvador, and Guatemala) that have health system transformation policies in place, whose main objective has been to expand access. The models they have used to organize, manage, and deliver health care have been key factors in bringing about change ().

Table 2. Changes in the organization of health services, by country

Country Date Policy Objectives Innovations in governance Achievements and progress
Bolivia 2013 to present Mi salud model Ensure that the population not covered by social insurance has access to family doctors Human resources education and changes to the model of care, with the introduction of traditional medicine Has been implemented in 306 of Bolivia’s 339 municipalities with the addition of 2,389 physicians
Brazil 2011 National PHC Policy (), National Program to Improve Access and Quality (PMAQ) Ensure the quality of care Expand health teams by paying outcome-based incentives Between 2011 and 2015, increased from 71% to 96% of all municipalities, and from 53% to 94% of family health teams
Canada 2004 to present Development of Integrated Health and Social Service Centres (CISSS) in Quebec Transform the model of care at 90 CISSS that serve specific local populations, with a focus on accessibility and continuity of care, with preventive and curative care for the most vulnerable Integration of health and social welfare services through PHC in “autonomous” family practice clinics; this has encouraged multidisciplinary work by giving the nursing staff and public health workers a more important role, and by focusing on the participation of community groups, including citizens’ committees and community representation Progress was made toward achieving an integrated network with: expansion of the duties of nursing staff at the clinic and community levels; integration of other health professionals to support family doctors; monitoring of the quality of private medical care for older persons; low level of citizen collaboration in management, but greater user participation in planning, and better integration of the curative and preventive approaches in family medicine
El Salvador 2009 Construyendo la Esperanza (Building Hope) Ensure access to health services for the rural population Organization of the health services (community family health teams and specialized teams) 7.21% increase in institutional deliveries and 13.68% increase in deliveries at regional hospitals between 2009 and 2012
Guatemala 2016 Inclusive Health Model Increase equitable access to health services for the rural indigenous population facing problems in receiving care Strengthening of the primary care model through territory-based health teams, as a complement to traditional medicine Limited progress in 10 health districts and 5 departments with trained staff and a comprehensive information system on individuals, families, and communities

These kinds of transformations are based on new understandings of health and disease in the population and, as a result, in changes to the way the health services respond to the needs of the population. They generally require changes to the governance both of services and human resources. These innovations result from the collective efforts of new groups of professionals included in health teams (family doctors and general practitioners, social workers, psychologists, and nurses) who lead the introduction of new concepts, in partnership with decision-makers, health service managers, and social movements. Their guiding principles are the social values associated with equity, social inclusion, and health as a social right.

According to this approach, changes in the governance of services involve new regulatory frameworks and organizational structures, including new ways to coordinate the organization of health services into integrated networks. Health services management thus becomes proactive and encompasses logistics for medicines and other health technologies, and the development of instruments to register, measure, and evaluate the performance of the health services. Finally, changes to the governance of health services also imply changes to the model of care, leading to a new relationship between health teams and the population. These teams take responsibility for the health of a population within a given territory, with greater resolution capacity in primary care, within a context of comprehensive care and collective compliance with integrative standards at the different levels of care.

Changes are needed in the governance of human resources primarily due to innovations in the health services. New social values must be incorporated into professional training. Mechanisms must be established to coordinate organization and care through integrated health service networks. This requires new approaches to professional practice that incorporate interdisciplinary and crosscutting work into health care. Similarly, it is necessary to make changes in the regulation of the health professions as new specialties (within general medicine and family health) facilitate changes to the models of care. Thus, the new models of care also require regulatory changes in professional working conditions, including full- or part-time work, workload, wage scales, decent working conditions, and responsibilities.

These transformation processes have implications for governance of medicines and technology. In order to ensure access to quality health services and response capacity at the primary care level, medicines and health technologies must be available. This is possible if appropriate price negotiating mechanisms are used, generally including centralized (national or regional) procurement, and with the introduction of systems to ensure that supplies are sufficient to cover health needs.

Financing mechanisms also have a big impact, such as innovations in budget formulation and execution. In this case, the establishment of comprehensive health service networks requires resource allocation mechanisms that are aligned with integrated management of the production processes, assuming that primary health care, specialized services, and hospital services are all integrated. Similarly, the development of comprehensive health service networks also requires efforts to combat or minimize segmented health systems and, as a result, to coordinate or establish different systems to finance, insure, and deliver individual and collective health services. Finally, transformations in the supply of health services to achieve universal access to comprehensive, quality services have driven policy arguments in favor of increasing public financing for health.

Stewardship of transformation processes can be seen in the new institutional and organizational frameworks responsible for managing these health service networks. One example is the emergence of new municipal health secretariats, areas, and regions that act as decentralized entities or primary health care bureaus in charge of managing health services and promoting policies of change. These structures house strategic players in the reform processes. They include health authorities and health service managers (with a strong presence in the management structures governing the health service organizations), new actors (such as groups of health professionals involved in primary care), and social movements that give political support for the expansion of health services, while exercising public oversight to ensure that the supply of health services is aligned with the demands and expectations of the population (e.g. in Bolivia, Brazil, Ecuador, and El Salvador).


Developing health systems able to achieve universal access to health and universal coverage requires changes in governance affecting the critical resources of those health systems (financial and human resources, services, medicines, and technology) (). An analysis of health system transformation processes in the Region shows that the dynamics of such reforms have not been uniform. On the contrary, we see two types of transformations, each with its own underlying logic. According to the logic of each, stewardship and governance possess unique characteristics.

Supply-centered health system transformations have been led by health authorities whose main objective was to improve access to health services. These initiatives were based on organizational structures to manage the health services network, along with the collective action of different health professionals and social movements.

These governance transformations revolved around changes to the model of care, in conjunction with new regulations for human resources. This approach assumes that changes to the framework in which health services are produced helps facilitate and structure institutional innovations (financing, intersectoral regulations, and intersectoral governance of medicines and technology) in the rest of the health system. Countries that have promoted this type of reform have achieved substantial progress in terms of access to services through more integrated and less fragmented models of care. Such changes have generally been limited to the public sector and have shown a limited ability to reduce the segmentation of health systems.

Demand-centered health system transformations have focused on increasing the financial coverage of the population by introducing economic incentives in the institutional arrangements that regulate insurance. Stewardship is exercised by agencies and structures to regulate and oversee private actors that serve as either fund administrators or health service providers. According to this approach, introducing competition-through demand for both insurance packages and for health services-will encourage innovation in the rest of the health system (in service organization and human resources). These kinds of changes have managed to expand financial coverage for a larger segment of the population, in a context of reforms that include both the public sector and social security. However, the challenges lie in ensuring that the regulatory agencies work, and showing that coverage has expanded, yielding real improvements in access for the population ().

It is also important to realize that although these two approaches to change tend to yield different kinds of health system reform, both approaches are sometimes applied simultaneously in countries. This is true of federal countries (in which national and local jurisdictions promote different approaches) and of countries that have segmented systems (in which both social security and the public sector include private initiatives) where the dual approach is part and parcel of the transformation process ().

Finally, the stewardship of the health authorities and involvement of key actors in joint activities does not end with a formal delineation of responsibilities, but with the development of critical capacity to respond to the specific context of each country. This brings us back to the concept of essential public health functions, such as the critical capacities of the health authority and an agenda to develop the health authority’s stewardship, within the framework of processes aimed at transforming and strengthening health systems ().


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1. There are various initiatives in the Region promoted by institutions that regulate service quality. Ecuador has an initiative promoted by a specialized, autonomous entity for managing the quality of health services. It is called the Agencia de Aseguramiento de la Calidad de los Servicios de Salud y Medicina Prepaga (Agency to Ensure the Quality of Health Services and Prepaid Medicine) (Access). The purpose of the agency is to ensure stewardship of the public network and comprehensive health care, and to regulate the quality of service delivery in both the public and private sectors. This process starts by qualifying, certifying, and accrediting institutions, and strives for continuous improvements in quality. Out of 44 hospitals in 2016, 28 received a Gold rating, 2 Platinum, 11 were awaiting accreditation, and 3 had not been accredited. In Mexico, the quality management model takes a people-centered approach. It measures results through indicators on the health of the population, real access, reliable and safe organizations, customer satisfaction, and reasonable costs. Finally, Peru has implemented the Dirección de Calidad en Salud (Bureau of Health Quality) based on the National Health Quality Policy adopted in 2009. It seeks to improve the quality of service at institutions delivering health care by following guidelines handed down by the national health authority. One policy is aimed at accrediting health establishments and medical support services. Between 2008 and 2012, hospitals began to conduct self-assessments. In 2013 and 2014, the accreditation process began to be transferred, in accordance with the Health System Reform Framework ().

2. The health authorities of some countries of the Region (e.g., Brazil and Cuba) play an important role in governing innovation for health. However, a lack of technological innovations that make a significant difference, along with prices that significantly exceed the marginal contributions, is still a persistent problem in many cases.

3. Some countries of the Region have used such licenses: Canada granted a compulsory license for export purposes only which authorized a generic drug manufacturer to export HIV/AIDS drugs to Rwanda in two shipments in 2008 and 2009; in 2007, Brazil granted a compulsory license for efavirenz for the treatment of HIV-1; and between 2010 and 2014, Ecuador granted compulsory licenses for ritonavir, abacavir+lamivudine, etoricoxib, mycophenolate, sunitinib, and certolizumab.

4. In 2016, 13 countries of the Region had structures to evaluate health technology and 7 had adopted legislation requiring that health technologies be evaluated before decisions are made. Furthermore, 92.9% of countries already have national selection committees and drug and treatment committees, and have prepared national lists of essential medicines. Establishment of the Caribbean Regulatory System (CRS) is an innovative subregional integration model for small states and territories. It is based on common policies that allow states to preserve sovereignty in health decision-making, while maximizing multinational cooperation to strengthen health stewardship and governance ().

5. Atlases of health care variations in different countries highlight the need to also consider the high degree of noncompliance with therapeutic positioning and clinical practice guidelines, as well numerous unjustified variations in medical practice.

6. The MERCOSUR countries (Argentina, Brazil, Paraguay, Uruguay, and Venezuela) have systematically used this mechanism to share inspection reports and report adverse events. The National Regulatory Authorities of Regional Reference and the five countries (Australia, Brazil, Canada, Japan, and United States) involved in establishing the Medical Device Single Audit Program (MDSAP) (http:/ also consider information exchange to be an essential part of their work. In order to support the secure exchange of non-public information, an IT portal was developed called the Regulatory Exchange Platform – secure (REP), which in its initial phase will include the countries participating in the MDSAP initiative. It affords a safe and dynamic environment for the exchange of regulatory documents for the authorization and control of health technologies.

7. These functions were traditionally distributed in different dimensions of stewardship, such as regulation of insurance plans (as part of regulation by the health authorities), the monitoring of insurance, and financial oversight ().

8. One example is the WHO Framework Convention on Tobacco Control (WHO FCTC), which reaffirms the right of all the people to the highest standard of health and was negotiated under the auspices of the World Health Organization ().

9. Insurance is understood to consist of mechanisms that pool financial resources to ensure that the population has access to health services when it needs them.

10. The introduction of commercial or management contracts with service delivery institutions and with professionals is an important regulatory tool. It should be designed to align incentives by determining specific prices and products with new forms of payment, and should promote standards of care and performance indicators for the services. These are the general conditions necessary for changing the way in which health services are produced.

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