Pan American Health Organization

Health financing in the Americas

  • Introduction
  • Financing and its characteristics in the Americas
  • Financing challenges for the countries
  • Summary
  • References
  • Full Article
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Introduction

Despite the economic growth and progress in health of the past decade, poverty and inequity within and among countries remain a challenge for the Region of the Americas. Some 29% of the Region’s population is still below the poverty line, and 40% receives less than 15% of total income, with marked differences among the countries (). The wealthiest 10% of the population receives 14 times the average income of the poorest 40% in Latin America and the Caribbean (LAC) (). Furthermore, an estimated 30% of the population has no access to health care for financial reasons, and 21% is kept from seeking by geographic barriers ().

At the same time, exclusion and lack of access to quality services persist for large sectors of the population. The prevailing models of care, based more on hospital care for episodes of acute illness than on disease prevention and health promotion, often with excessive use of technologies and poor distribution of medical specialists, do not necessarily meet the health needs of individuals and communities. Investments to reform and improve health systems have not always been designed to deal with new challenges related largely to the demographic and epidemiological transition or the expectations of the population.

The result is a lack of universality and equity in access to quality services and appropriate coverage, which entails a substantial social cost and impoverishes the more vulnerable population groups. The evidence shows that when there are access barriers to services (whether economic, geographic, cultural, demographic, or other), a deterioration in health implies not only greater expenditure but a loss of income as well. The absence of mechanisms to protect against the financial risk of ill health creates and perpetuates a vicious cycle of disease and poverty.

Inadequate financing and inefficient allocation and use of the available health care resources are major obstacles to progress toward equity and financial protection. Indeed, average public health expenditure in the Region of the Americas is around 4% of gross domestic product (GDP)–a very low level compared to the 8% allocated to this budget line by the countries of the Organisation for Economic Co- operation and Development (OECD) (). Direct payment (or out-of-pocket expenditure) at the point of service, the most inefficient and regressive form of financing, yields an unstable flow of financial resources and constitutes an access barrier that impedes or delays care and makes it more expensive for both patients and the system. Furthermore, it has a relatively greater impact on the poor, as even the smallest payment can represent a substantial portion of their budget. Only six countries in the Region of the Americas have direct expenditure levels of under 20% of total health expenditure, the figure that, according to the World Health Organization (WHO) (), protects their populations against the risk of impoverishing or catastrophic health expenditures.

Efficient allocation of public expenditure is a prerequisite for reducing inequities. Implementing the people- and community-centered model of care requires greater efficiency through the priority allocation of new resources to the first level of care and networks to increase the availability of quality services and speedily address unmet health needs. A series of mechanisms must be implemented simultaneously to transform the model of care and the health services structure. Particularly important are payment systems that foster integrated care and the continuity of care ().

The segmentation and fragmentation that characterize the majority of the Region’s health systems give rise to inequities and inefficiencies that compromise universal access, quality, and financing. Weak health system regulatory capacity, excessive verticality in some public health programs, lack of integrated service delivery, and, occasionally, union pressure to protect privileges and lack of political will to make the necessary changes exacerbate and perpetuate this problem.

The strategy for universal access to health and universal health coverage of the Pan American Health Organization (PAHO) redefined the concept of coverage and access to health and stressed the values of solidarity, equity, and the right to health; it also recognized financing as a necessary, though insufficient, factor in reducing inequities and increasing financial protection for the population. The core value in the strategy’s definition of “access,” embraced as a priority for society as a whole, is “the right to health,” which requires adequate, allocated, and efficiently managed financing. This vision stands in sharp contrast to the traditional view, in which access depended on an individual’s and household’s ability to pay and went hand in hand with the proposals to adopt direct payments and the promotion of policies that had led to the fragmentation of health systems in previous decades. At the same time, the strategy acknowledges the need to foster the necessary changes through political and social action that puts health squarely at the center of the policy agenda.

Strategic Line 3 of the PAHO strategy proposes “Increasing and improving financing, with equity and efficiency, and advancing toward the elimination of direct payment that constitutes barrier to access at the point of service.” Three interrelated lines of action flow from this:

  • Increase financial protection by eliminating direct payment, which constitutes an access barrier, thus preventing exposure to catastrophic expenditures or those that lead to or exacerbate poverty. The replacement of direct payment as a financial mechanism should be planned and progressively achieved through prepaid pooling mechanisms, using sources of funding that guarantee their stability and sustainability.
  • Increase public health expenditure to the benchmark of 6% of GDP, which implies a commitment by society as a whole to increase the fiscal space reserved for health in terms of new public sources of financing, with the search for equity as the main objective.
  • Boost efficiency in the health system by adopting a series of measures that specifically impact its financing and organization, such as aligning payment mechanisms with health system objectives and rationalizing the introduction of new medicines and other technologies that contribute significantly to rising health expenditures.

This chapter is a response to the need for an extensive overview of the health system financing situation in the countries of the Region and the challenges they face. Following this introduction, which outlines the theoretical framework in relation to PAHO’s current regional strategy and its financial scope, health financing in the Region will be examined in a conceptual and descriptive section, with special attention to financial protection. The third and final section completes the analysis and describes the immediate challenges facing the countries in terms of the need to equitably and efficiently increase financing.

Financing and its characteristics in the Americas

Any characterization of health financing in the Region would do well to start with the definition of the structures in which health financing functions are performed, the type of health system constructed, and its processes of development and change.

Health financing structure in the Americas

Institutional arrangements in financing decisions are critical. In securing resources and identifying and structuring funding sources, they involve decisions in the realm of tax policy that have developed over time, and in the absence of a major change or reform, are neither directly nor exclusively related to the health sector, but rather, the State and government. In the majority of the countries, operational financing decisions are made year-to-year by the ministries of finance and health as part of a planning process in which the democratic political system is involved, since in most cases, the main source of funding (or a significant part of it) – the budget – is approved by the parliament or congress. Other sources of financing are determined by the market through private expenditure.

Pooled resource arrangements, in turn, are usually long-term and have also taken shape during the historical development of the systems. The Region is largely characterized by segmented systems in which different entities exercise this function hermetically and hence with little or no solidarity (with the notable exceptions of Brazil, Canada, Costa Rica, Cuba, and Uruguay). On the other hand, the purchase of services as a resource allocation mechanism takes many forms, with payments from the historical budget in the public sector and the fee-for-service mechanism in the private sector predominating. However, some countries have made significant progress in planning or implementing payment systems designed to efficiently reaffirm health objectives by operating in networks, as seen in Brazil, Chile, Costa Rica, Ecuador, Peru, and Suriname.

In the same way that financing can be characterized by its functions, the development factor and transformation of systems can be added. In fact, the universal health strategy characterizes health system segmentation and fragmentation as a serious problem. Countries continually launch processes of transformation, reform, or change, and these efforts also determine financing strategies.

For example, when Chile began reforming its explicit health guarantees in 2005, this appeared to be a remedy for the health system’s access and fragmentation problems; however, it failed to address the segmentation of the existing funds for mitigating risk (). In Mexico, the design of the People’s Insurance created a new health care system in the attempt to cover a population group that had been excluded from access to health care; this implied greater equity () but not less segmentation. Something similar happened in Peru with the creation and gradual roll out of its Comprehensive Health Insurance, although in this case, it appears that broader coverage has led to greater equity (). The Uruguayan reform, with a single revenue collector and payer (FONASA), vigorously addresses segmentation, pools resources, and promotes solidarity in financing. However, there is still the challenge of reducing fragmentation, which could perhaps be addressed by using ways of financing the purchase of services that facilitate movement toward a comprehensive integrated system based on primary care.

Between 2010 and 2016, the United States implemented the Affordable Care Act (ACA), a substantive reform for that country’s context that has brought insurance and coverage to major population groups through a three-pronged approach: 1) compulsory universal insurance, so that all citizens are covered; 2) the regulation of group premiums and open enrollment to prevent discrimination against seniors and the rejection of beneficiaries by insurance companies; and 3) subsidies for people who meet the criteria (low income) so that they can receive coverage, along with a significant expansion of the national Medicare and Medicaid programs. Thus, whether or not segmentation predominates is reflected in the composition of health financing in the countries, as seen in Figure 1.

Figure 1. Segmentation reflected in financing

Source: WHO, Global Health Expenditure Database (accessed June 2016).

Countries with national public health systems and broad-based coverage, such as Brazil, Costa Rica, Cuba, and Ecuador, must still confront the need to boost efficiency through payment mechanisms and the creation of fiscal space (sustainable resources to finance increases in public expenditure), which will help them achieve health objectives and the sustainability of the system. In contrast, several Caribbean countries, such as Belize, the Bahamas, and Jamaica, promote the policy of establishing single-payer systems, creating a new source of funding in the form of compulsory social security contributions. In addition to the considerable effort that shifting to this new institutional arrangement implies, they will have to deal with its potential consequences in terms of equity levels.

By instituting reforms, changes, or transformations grounded in the principles of equity, solidarity, and health as a right, PAHO’s Member States have committed to moving toward the elimination of direct or out-of-pocket expenditure, the creation of the largest possible pooled funds, and more efficient public financing as the way of promoting greater individual and community access to comprehensive quality services in integrated health systems, with strengthening of the first level of care. This effort is determining the types of health systems that are being developed in the Region.

Health financing and expenditure in the Americas

This section contains a descriptive comparative analysis of health accounts in the Americas, emphasizing public health expenditure and out-of-pocket, or direct, payment. It also provides other relevant data, such as private and per capita expenditure, together with the weight of the tax burden and the fiscal priority of health in the countries. The first two variables are emphasized, since public health expenditure is the variable that is positively correlated with health outcomes and out of-pocket expenditure is one of the main obstacles to access to health.

a) Public health expenditure and its weight in total expenditure

Considering the universal health strategy’s public health expenditure benchmark of at least 6% of GDP, Figure 2 shows that only 5 of the 34 countries that provided information are above that threshold: Canada, Costa Rica, Cuba, the United States, and Uruguay. The countries below the threshold include three with public health expenditure above 5% of GDP: Colombia (5.4%), Nicaragua (5.1%), and Panama (5.9%).

Observing what happens with total health expenditure and its public-private mix, we discover that in countries that exceed the 6% benchmark, public health expenditure accounts for more than 70% of total health expenditure, except in the United States. Furthermore, in the case of Bolivia, Canada, Colombia, Costa Rica, Panama, and Uruguay, this balance is similar to the average for the OECD member countries (73%). At 17%, total health expenditure in relation to GDP in the United States is known to be the highest in the world, without proportionally better health outcomes (). This indicates the need not only for more resources but greater efficiency in their use.

At the opposite extreme, countries with lower public health expenditure are also those in which the composition of total health expenditure is more skewed toward the private component: Guatemala (private expenditure of 62%), Haiti (79%), Saint Kitts and Nevis (58%), and Venezuela (71%). However, Peru and the Dominican Republic are examples of the opposite, with low public health expenditure (3.3% and 2.9% of GDP, respectively) and a high share of public health expenditure in total health expenditure (61% and 67%, respectively). Added to this is the case of the United States, with high public health expenditure (8.3%), but health expenditure that is predominantly private (52%).

Figure 2. Health expenditure (as a percentage of GDP) and composition (public-private, as a percentage of total expenditure), 2014

Source: WHO, Global Health Expenditure Database and OECD Data (accessed June 2016).

b) Per capita expenditure and equity in expenditure

Total per capita health expenditure in the Region averages 1,320 international dollars (Intl$) per year (adjusted by purchasing power parity) and ranges from Intl$ 160 in Haiti to Intl$ 9,145 in the United States (Figure 3). This absolute level of expenditure can be compared with the average for the OECD countries, which is triple that of the Region and far less scattered. Furthermore, in each country the different segments have different amounts of per capita expenditure, which is one of the most unmistakable signs of inequity. Some countries move toward the convergence of these figures, but slowly, as seen in Colombia, Chile, and El Salvador. With the reform of 2008, Uruguay’s transition was faster in closing this gap, leading to a drop in the difference between the per capita expenditure of social security providers and the public provider from 2.3 times greater in 2007 to just 25% greater in 2012.

Figure 3. Per capita health expenditure in the Americas

Source: WHO, Global Health Expenditure Database and OECD Data (accessed June 2016).

c) Out-of-pocket health expenditure

When examining the impact of health expenditure on household well-being and access and use of the health services, out-of-pocket health expenditure (or direct payment) merits special attention. These terms refer to the payment required at the time of service and at the point of access to the health services and health products, after discounting any subsequent reimbursement. In practice, this can take different forms, such as direct payments for medicines, copayments, coinsurance rates, and deductibles. It can also involve formal or official payments, informal or “under-the-table” payments, or both at the same time ().

The fact that this type of payment may be required to receive care or access the necessary health services makes them a health care access barrier. Even among people who can cover these expenses, incurring them may adversely affect their household’s well being and the consumption of other goods and services or may even be harmful to health if the alternative is self-treatment. It also has implications for the efficiency of the health system, since by discouraging the use of the health services, it causes many users to seek care from the system at more advanced stages of an illness, requiring more complex and expensive services. Thus, out-of-pocket expenditure can result in higher costs in the medium and long term, with worse health outcomes, poorer health system response capacity, and less efficiency and effectiveness.

The indicator most commonly used to measure the burden of out-of-pocket health expenditure in a country is the proportion of total health expenditure that it represents: the higher the proportion, the greater the number of households likely to face financial difficulties as a result of using health services. Figure 4 shows the value of the indicator for the countries of the Region and, as a reference, the average value for the countries of the European Union (EU). First, it shows that while out-of-pocket health expenditure in the EU countries averages 21% of total health expenditure, 29 countries in the Region (83%) exceed that value. Furthermore, the countries with a lower proportion of out-of-pocket health expenditure are also those with higher public health expenditure (as a percentage of GDP) (Figure 1): Canada, Colombia, Cuba, the United States, and Uruguay. Some exceptions are conspicuous: Suriname has low public health expenditure (2.9% of GDP) and also a low proportion of out-of-pocket expenditure (11% of total health expenditure); and Costa Rica, with very high public health expenditure for the Region (6.8% of GDP), has a moderate proportion of out-of-pocket expenditure (25% of total health expenditure).

Low out-of-pocket expenditure is not always an indication of equitable access, since it may also be due to lack of access to the services. Also, it can sometimes increase with the desired increase in access, although the ratio with coinsurance rates or unit values of copayment remains constant.

Figure 4. Proportion of out-of-pocket health expenditure in the Region of the Americas, 2014

Source: WHO, Global Health Expenditure Database (accessed June 2016).

The weight of direct payment (out-of-pocket expenditure) by households in total health expenditure is trending downward in certain countries in the Region, among them Chile, Colombia, El Salvador, and Mexico.

Here, the case of El Salvador is worth examining. In 1995, more than 60% of its health expenditure was financed through direct payments; today, the figure is less than 30% and though still high, represents a significant decline. In Colombia, the indicator fell from 38% to 15% in that same period, and the country currently has one of the lowest percentages of out-of-pocket expenditure in the Region. Other countries show a certain stability in the indicator and remain at very high levels, as in Guatemala (above 52% throughout the period), or low levels, as in Costa Rica, although with a certain upward trend (from 21% to 25% during the period). In Ecuador, a marked increase in the indicator was observed between 1995 and 2000 (moving from 32% to 62%), subsequently shifting downward, but nevertheless remaining at very high levels (48% in 2014).

Figure 5. Trends in out-of-pocket health expenditure in the Americas, 1995–2014 (selected countries)

Source: WHO, Global Health Expenditure Database (accessed June 2016).

While out-of-pocket expenditure is generally more of a direct barrier to care for households with less purchasing power, it also is for the middle class (). Thus, having access to health services does not prevent out-of-pocket payments from undermining health equity, since “overcoming” the barrier can significantly jeopardize a household’s well-being, driving it into poverty (impoverishing expenditure) or representing a painfully high proportion of its total expenditure or ability to pay (catastrophic expenditure). Expenditure is considered impoverishing for a household when it represents the difference between being above or below the poverty line (). Expenditure is considered catastrophic when out-of-pocket health expenditure represents a substantial percentage of household expenditure–usually 30% or 40% of its ability to pay (), or 25% of total expenditure (), with “ability to pay” understood as total household income minus the expenditure necessary for meeting basic subsistence needs (). The values of catastrophic and impoverishing expenditure indicators vary with the methodology used. However, a recent PAHO study of 11 countries in the Region shows that in 7 of them, 2.5% of households have catastrophic expenditures according to any of the known methodologies. These methodologies generally vary in whether the catastrophe threshold is 30% or 40% of a household’s ability to pay or use the more recent threshold established by WHO and the World Bank for the Millennium Development Goals, which is 25% of total household expenditure.

d) Trends in public health and out-of-pocket expenditure

Observing the averages of these two key indicators in the Region in a 20-year series, we see a slight increase in public expenditure, together with a slight decrease in out-of-pocket expenditure. The point of intersection in Figure 6, which was 3.6% of GDP and 34% of total health expenditure in 2007, did not augur well. In 2012, the figures were 4.1% of GDP for public health expenditure and 32.6% for out of-pocket expenditure. In fact, since 2008, this trend has continued its moderate path without reaching sufficiency, especially in the LAC countries. However, in the non-Latin Caribbean countries, the general trend exhibited in the Region did not materialize; instead, the two indicators have remained stable. North America, which had already reached 6% of GDP at the beginning of the series (1995), was almost at 7% and 13.8% of out-of-pocket health expenditure in 2007, and in 2012 had increased the share of public expenditure in GDP to 8% and decreased out-of-pocket expenditure to 12% of total health expenditure.

Figure 6. Trends in public health expenditure and out-of-pocket health expenditure

Source: WHO, Global Health Expenditure Database (accessed June 2016).

e) Decomposing public health expenditure

The following is an intuitive way of decomposing the indicator for public health expenditure as a proportion of GDP to facilitate analysis of its determinants ():

Public health expenditure

=

Total public expenditure

×

Public health expenditure

GDP GDP Total public expenditure

Thus stated, the indicator in the formula is expressed as the product of two factors. The first of them, total public expenditure as a proportion of GDP, refers to a country’s fiscal capacity. The second, public health expenditure as a proportion of total public expenditure, represents the fiscal priority of health.

Figure 7 presents data on fiscal capacity in the Americas, as well as the simple average for EU countries. The median for the Region, around 30% of GDP (with considerable variability between countries), stands in marked contrast to the average of 48% of GDP for total public expenditure in the EU countries. Fiscal capacity (understood as total public-sector resource mobilization) should be a potential source of fiscal space for health in the Region. Furthermore, the combination of a low tax burden and weaknesses in tax collection—manifested, for example, in tax evasion and tax fraud—create a scenario not uncommon in the Region that must be considered in the specific analyses.

Figure 7. Fiscal capacity in the Region of the Americas, 2014

Source:International Monetary Fund, World Economic Outlook Database (accessed June 2016).

When analyzing the fiscal priority of health in the Region (Figure 8), the variability of the indicator is even greater. While public health expenditure in the EU member countries averages 14% of total public expenditure, almost half the countries in the Region of the Americas give higher priority to the health sector. In the case of Costa Rica and Nicaragua, for example, public health expenditure accounts for almost one quarter of total public expenditure (23% and 24%, respectively). At the opposite extreme, however, nine countries allocate less than 10% of their total budget to the health sector: Haiti (5%), Venezuela (5.8%), Brazil (6.8%), Saint Kitts and Nevis (6.9%), Argentina (6.9%), Trinidad and Tobago (7.6%), Jamaica (8.1%), Grenada (9.2%), and Guyana (9.4%). Painting a more complete picture of the countries’ health financing efforts requires at least this dual perspective in order to see how countries that prioritize health in their budget may be spending little due to their excessively low level of total public expenditure, while countries with a high level of total public expenditure may not be prioritizing the health sector, even though health expenditure figures are relatively high in absolute terms.

Figure 8. Fiscal priority of health in the Region of the Americas, 2014

Source:International Monetary Fund, World Economic Outlook Database (accessed June 2016).

Combining the data on fiscal capacity and fiscal priority reveals very unequal country performance. For example, despite its relatively low fiscal capacity (25% of GDP), public health expenditure in Nicaragua is relatively high for the Region (5.1% of GDP), thanks to the high priority of health in the national budget (24% of total public expenditure). However, in Guatemala, where the fiscal priority of health is relatively high for the Region (17.8% of total public expenditure), public health expenditure is low (2.3% of GDP), due to the country’s excessively low fiscal capacity (13.4% of GDP, the lowest in the Region). In Brazil, public health expenditure stands at 3.8% of GDP, despite a high fiscal capacity (almost 40% of GDP), since health has a low fiscal priority (6.8%). In general, the data show that in the eight countries where public health expenditure exceeds 5% of GDP (Canada, Colombia, Costa Rica, Cuba, Nicaragua, Panama, the United States, and Uruguay) the fiscal priority of health is more than 14% of public expenditure.

f) Health outcomes and expenditure

It should be pointed out that these indicators provide no information about the quality of the expenditure, which can be obtained only by comparing them with health outcomes in the population. One way to do so would be to compare health expenditure with life expectancy and mortality from diabetes, as shown in Figure 9 and Table 1.

Here, we can see a correlation between higher public health expenditure and better health outcomes. The figure shows the association between life expectancy at birth and public health expenditure as a percentage of GDP in the countries of the Americas. In Table 1, moreover, the results of a preliminary study of 34 countries, using data from 2000, 2010, and 2014, show that increased public health expenditure is highly correlated with longer life expectancy and lower mortality from diabetes mellitus, as well as lower out-of-pocket health expenditure. Thus, public health expenditure is essential for improving health outcomes and financial protection in the Americas, and increased investment in public health is expected to result in a further reduction in mortality and longer life expectancy, bringing significant economic benefits to the Region. This association has been confirmed in other regions and countries in the world (), serving as additional support for the argument to convince governments to increase resources for the health sector.

Figure 9. Relationship between public health expenditure and life expectancy

Source: WHO, Global Health Expenditure Database (accessed June 2016).

Table 1. Summary of regression analysis

Outcome variable Year Coefficient SE 95 % CI Lower 95 % CI Upper
Mortality from diabetes mellitus 2000 -32.26188 5.19368 -42.86878 -21.65498*
2010 -34.82691 7.34039 -49.81798 -19.83584*
2014 -20.66315 5.89383 -32.66849 -8.6578*
Life expectancy at birth 2000 4.58267 1.02212 2.49522 6.67013*
2010 6.88649 1.56629 3.69607 10.07691*
2014 3.10145 0.73388 1.60659 4.59631*
Out-of-pocket health expenditure 2014 -20.83396403 4.29818 -4.84715 -29.62474*

Note: * p<0.001; SE = standard error of the coefficient; CI = confidence interval. Source: PAHO/WHO from WHO Database (accessed June 2016).

g) Pharmaceutical expenditure

Total pharmaceutical expenditure accounts for a growing proportion of total health expenditure in LAC, increasing from 17% in 2010 to a projected 33% in 2017. Per capita pharmaceutical expenditure in 2015 was calculated at nominal US$176 (US$ 264, adjusted by purchasing power parity), where 25% of the expenditure is covered by the public sector and the remaining 75% by private insurance and households (the latter, through direct payments). In 2010, total expenditure on pharmaceutical products came to US$ 9.4 billion, or 1.2% of GDP, and in 2015, US$ 16.7 billion, or 1.8% of GDP. This upward trend is expected to continue and reach 2.2% in 2017. The LAC countries are net importers of pharmaceutical products. Between 2010 and 2015, the share of pharmaceutical products in the global value of trade rose by 15%, from 1.2% to 1.38% of GDP.

Financing challenges for the countries

Increasing public investment: a priority need

Health financing in the Region is far from meeting the objectives set by the countries in 2014 when they adopted the strategy for universal health. In fact, as stated earlier, only a small group of countries has achieved public health expenditure of 6% of GDP (Figure 10), and direct expenditure in the Region accounts for 33% of total health expenditure.

Figure 10. Public health expenditure and out-of-pocket health expenditure in the Americas

Source: WHO, Global Health Expenditure Database and OECD Data (accessed June 2016).

Recent calculations show that the targets are unlikely to be met unless specific planned action is taken to increase fiscal space for health. In fact, if the rate of increase in public health expenditure of the past 20 years continues, it will take an average of 80 years to meet them (Table 2).

Table 2. Estimated year for reaching the benchmark of 6% of GDP, considering only economic growth

Country Initial public health expenditure Elasticity Gap Year
Cuba 8 · 19
United States 7 · 58
Canada 7 · 40
Costa Rica 8 · 05
Uruguay 6 · 14
Ecuador 3 · 94 2 · 90 2 · 06 2024
Nicaragua 4 · 49 1 · 56 1 · 51 2026
Brazil 4 · 66 1 · 68 1 · 34 2030
Colombia 5 · 18 1 · 22 0 · 82 2032
Barbados 4 · 14 2 · 68 1 · 86 2034
El Salvador 4 · 63 1 · 49 1 · 37 2039
Honduras 4 · 28 1 · 35 1 · 72 2040
Bolivia 4 · 75 1 · 22 1 · 25 2042
Saint Kitts and Nevis 2 · 30 1 · 94 3 · 70 2050
Suriname 3 · 24 1 · 42 2 · 76 2053
Chile 3 · 66 1 · 26 2 · 34 2068
Grenada 3 · 00 1 · 41 3 · 00 2083
Paraguay 3 · 46 1 · 16 2 · 54 After 2099
Guyana 4 · 30 1 · 08 1 · 70 After 2099
Antigua and Barbuda 3 · 14 1 · 14 2 · 86 After 2099
Belize 3 · 39 1 · 01 2 · 61 After 2099
Jamaica 3 · 38 <1 2 · 62 Never
Dominican Republic 2 · 82 <1 3 · 18 Never
Panama 4 · 93 <1 1 · 07 Never
Haiti 0 · 70 <1 5 · 30 Never
Argentina 4 · 92 <1 1 · 08 Never
Trinidad and Tobago 2 · 62 <1 3 · 38 Never
Peru 3 · 12 <1 2 · 88 Never
Venezuela 0 · 98 <1 5 · 02 Never
Guatemala 2 · 42 <1 3 · 58 Never
Bahamas 3 · 20 <1 2 · 80 Never
Saint Lucia 4 · 70 <1 1 · 30 Never
Dominica 4 · 20 <1 1 · 80 Never
Mexico 3 · 23 <1 2 · 77 Never
Saint Vincent and the Grenadines 4 · 30 <1 1 · 70 Never

Source: IMF/WHO and World Bank data.

This is because the increase in per capita public expenditure has historically been moderate, with relatively low elasticities in health expenditure with respect to economic growth (below 1 in many countries). Even the peak public health expenditure of 2009 was due to the impact of the economic crisis on the GDP of the countries of the Region and not to an absolute increase in that expenditure. However, although the average GDP growth rate would recover by 2010 and continue until 2014 (), the particular situations in the Region in response to the global crisis caused the decline in public health expenditure as a percentage of GDP to continue in several countries, as seen in Figure 11.

Figure 11. Trends in public health expenditure in the Americas, 1995-2014 (selected countries)

Source: The World Bank Data (accessed June 2016).

The calculations also show that reasonable modifications in some sources of fiscal space (such as taxes and efficiency levels) would accelerate progress (). In fact, a simulation in which the fiscal priority of health was at least 15%, like the figure established in the Abuja Declaration for the African countries, and some tax rates were equalized to the LAC average finds that 8 more countries would reach the target and raise expectations about another important group of nations.

Table 3. Changes in health investment simulating changes in the tax burden (exercise with 13 Latin American and Caribbean countries)

Countries Public expenditure in
health as a percentage
of GDP (2013)
Increase scenario (1) Increase scenario (2)
Bolivia 4.8 5.6 7.6
Honduras 4.3 4.30* 5.9
Nicaragua 4.5 6.2 5.8
Paraguay 3.5 S/D 5.1
Colombia 5.2 6.4 6.7
Ecuador 3.9 4.4 5.2
Peru 3.1 3.8 4.5
Argentina 4.9 5.3 5.3
Brazil 4.5 6.0 6.0
Chile 3.7 4.1 4.0
Barbados 4.1 S/D 4.7
Guyana 4.3 S/D 4.6
Jamaica 3.4 3.7 4.3
Countries reach 6%
or nearly (5,8%)
0 3 5
Percentage 0% 23.1% 38.5%

Source: PAHO from Collecting Taxes Database 2010/2011, BID-CIAT and CEPAL.
Scenario (1): current priority fiscal levels.
Scenario (2): fiscal priority of 15% of total public expenditure.

The economic context today is complex and makes the challenge more difficult. The majority of the LAC countries are experiencing zero growth (-0.5%, on average, in 2015, with projections of -0.8% in 2016) and fiscal contraction. Especially in South America, some countries, such as Argentina, Brazil, Ecuador, and Venezuela, will experience a significant drop in GDP (2.1% on average), and in the Caribbean, GDP in Suriname and Trinidad and Tobago will fall. Despite this somber picture, however, Central America and Mexico will grow at an average of nearly 2.6% ().

Notwithstanding, according to economic theory, fiscal policy should be countercyclical. Countercyclical policies generally cool the economy down when it is growing (covering the fiscal deficit) and stimulate it when there is a downturn (increasing government expenditure to attenuate economic and financial fluctuations). One component of these programs is countercyclical social policy, which includes health and education, as well as unemployment benefits and other social transfers. Several studies hold that countercyclical government spending has been essential for meeting long term economic and human development targets () and will surely be today to meet the United Nations Sustainable Development Goals adopted in 2015 with a 2030 horizon.

In spite of this consensus, there is evidence that in the low and lower-middle income countries, protecting public health investment and maintaining expenditure during crises has not been the norm. Indeed, the contraction of public expenditure, beginning with the social sectors, has unfortunately been routine. While this procyclical practice can attenuate economic fluctuations, it adversely affects State revenues, poverty levels, long-term growth, and human capital formation. As the facts show, the more advanced countries have historically favored countercyclical policy. In fact, Europe and Central Asia exhibited countercyclical behavior during the Asian crisis of 1997-1998 and up to 2007. After that, however, their behavior was procyclical. In LAC, procyclical behavior was generally seen in both periods ().

Due to cyclical nature of the economy, the health sector must be sustainable and resilient to the economic cycle, as it must in disasters and emergencies. Countercyclical policy is key to protecting the health of the population and mitigating the risks posed to households by illness and the impoverishment that may accompany it. Thus, reacting to the global crisis of 2008, WHO proposed several lines of work to the countries to mitigate the effects of these changes in the economic cycle (): (a) raise awareness about the ways in which the drop in GDP can affect health expenditure, health services, healthy behaviors, and medium- and long-term health outcomes; (b) protect investments in health; and (c) identify action, including the monitoring of troubling signs, to mitigate the adverse impact of the economic cycle.

Fiscal space for universal health

Since the 1950s, health has gone from being a residual explanatory factor in economic growth theories to having a place of its own among the main factors that spur productivity, growth, and poverty reduction. The WHO report of 2001 () was definitive. Its recommendations leave no room for doubt about the link between health and growth and promote the economic development of the world’s poorest countries through investment in health (). The arguments of the international agencies that backed the formulation of the Millennium Development Goals in 2000 and the Sustainable Development Goals today have also been supported in these recommendations. In 2013, the Lancet Commission report, Global Health 2035, once again emphasized this link (). Finally, the 2016 UN report on investing in the health workforce, co-sponsored by the Director of WHO together with the Presidents of France and South Africa, bases its findings on the association between health and economic growth ().

There are several historical examples of countries whose development was rapidly stimulated largely by the good health of their populations. Some authors maintain that this is what happened in the United Kingdom, the United States, and Japan (). Certainly, the countries with longer life expectancy in the 1960s grew faster in the next four decades (). Furthermore, in a study of 138 countries, Barro () showed that a 5-year increase in life expectancy was responsible for annual growth of 0.3 to 0.5 points from 1965 to 1990. The Sachs Commission’s estimates also showed that each 10-percentage-point increase in life expectancy is associated with an annual growth increase of no less than 0.3-0.4 percentage points. Several studies also demonstrate the inverse: that countries with high disease rates do not develop or they grow less.

PAHO has identified the following sources of fiscal space ():

  1. Creating conducive macroeconomic conditions.
  2. Greater prioritization for health.
  3. Creating new tax revenues through a greater tax burden.
  4. Increasing the efficiency of tax collection.
  5. External aid with loans and specific donations for the health sector.
  6. Increased efficiency in existing health expenditures.

Economic growth, the most direct and generic source of all, which is based on the assumption of economic stability, consists of creating fiscal space through GDP growth and a consequent increase in State revenues. Greater prioritization of health, in turn, implies an increase in public health expenditure at the expense of other sectors, such as defense or foreign affairs. On this point, PAHO’s analytical framework presents two ways of accomplishing this: first, by increasing the proportion of health expenditure in public social expenditure or total public expenditure; and the second, by increasing public social expenditure as a whole to prevent competition between health expenditure and other complementary budget lines for an “intersectoral approach” to universal health ().

In addition to providing resources, creating new revenues through a higher tax burden and taxation is positively correlated with better health indicators, as seen in the scientific literature (). In addition to the level of taxation, the tax structure is key to meeting the objective of increasing equity: systems based on indirect taxes (as in the majority of countries in the Region) tend to be more regressive (that is, they impose a greater burden on poorer households) than those in which direct taxes (on income or inheritance) have greater weight. Related to this, “increasing the efficiency of tax collection” means preventing tax evasion and avoidance and promoting formal economies. Here, it is worth calling attention to matters such as the granting of tax reductions or special exemptions from the general tax regulations (), which occurs when the regulations are waived for an agent, sector, or type of income, resulting in lower taxes than are levied on similar activities or income. Many such exemptions were created at specific times for specific purposes, but the need for them has not been reexamined. Finally, “external aid with loans and specific donations for the health sector” refers to two mechanisms: debt and donations. Based on the scientific literature, it is important to point out the macroeconomic implications of the former and the volatility and fragmentation of the latter.

Promoting greater fiscal space requires a broader social dialogue among all stakeholders. These decisions, which involve States, tend to be political and are based primarily on technical arguments. There are several ways of fostering this type of dialogue, for which technical studies are also essential. The PAHO studies of fiscal space — a regional study covering 14 countries () and three individual studies for Peru (), Honduras (), and Bolivia () — show the following:

  • The countries generally have fiscal space for health, and economic growth is not enough to fill that space and meet financing needs.
  • Additional fiscal revenue must be collected, using better methods.
  • Tax expenditures should be reviewed to identify exemptions that are unfair or not beneficial to the countries.
  • There are arguments and space for increasing specific health taxes (primarily on alcohol and tobacco). Although revenues are low in these cases, the projected savings to the system can be substantial.
  • From a policy standpoint, loans and donations are not a viable source of revenue for governments in the medium and long term.
  • Measures to boost efficiency should accompany these efforts, promoting the principles established in the strategy for universal access to health and universal health coverage.

Boosting efficiency: necessary, but not enough

From the financing standpoint, efficiency should be an objective in itself. However, it is also important to consider that it can be an additional source of fiscal space (since making better use of existing resources or combatting waste has the same effect as injecting new resources). Efficiency in the organization of services implies, among other things, the adoption of people- and community-centered models of care and the delivery of quality services by strengthening the first level of care and building integrated networks.

a) What is “efficiency in the health sector”?

Resource allocation in a health system is efficient when it achieves an optimal combination of morbidity and mortality reduction and greater financial protection for households that permits equitable access to the health services with given resources. In this case, the efforts are designed to yield what society needs and expects in terms of health and well-being—a task that involves both the State and society. The degree of productive and technical efficiency achieved will depend on how the health services are managed—or to put it another way, on obtaining the best response capacity through better coordination and linkage between levels of care and care networks. It is necessary for resource allocation to achieve a balance among the inputs used in the health sector (technical efficiency); and for technical efficiency to be transformed into productive efficiency, it is also necessary to meet the aforementioned objectives as fully as possible, given the existing resources. Dynamic efficiency, in turn, implies guaranteeing conditions and efficiency levels over time through innovation in the health systems in the broadest sense of the word ().

b) Payment systems to boost efficiency

Payment mechanisms must be aligned with system objectives. Thus, it is important to note that territorial and population-based payment systems—keeping in mind morbidity levels and combined with mixed-level payment mechanisms—are potentially effective regulatory mechanisms for meeting these objectives (). Aligning incentives with health system objectives to promote integrated care and comprehensive services, and putting emphasis on the first level of care are initiatives that can boost the efficiency of the system as a whole. Studies coincide in recommending the adoption of payment mechanisms with circumstantial margins of flexibility and empirically contrasted macro- and micro-allocation instruments. Territorial capitation and episode-based payment (also called bundled payment or case rates, as in diagnosis-related groups) are two examples of tools that can boost the efficiency of expenditure. Thus, capitation adjusted by territorial and population risk is a powerful regulatory tool already in use in several initiatives that makes it possible to align incentives with health-system and health objectives ().

There are known mechanisms for boosting efficiency in resource utilization, among them protocols for reducing clinical variability, centralized drug procurement systems, economic evaluation, and the evaluation of other aspects, such as safety and quality in the introduction of new technologies, programs to boost workforce efficiency and productivity, and the strengthening of disease prevention and health promotion. In this context, the measures with the greatest short-term impact are related to resource allocation mechanisms, including those involving drug procurement. For example, as a result of the financial crisis of 2008, the United Kingdom recently took steps to improve productivity and cost control, with various results. For example, from 2011 to 2013 the greatest savings in resources were obtained with measures involving changes in payment mechanisms and organized drug procurement ().

From 2010 to 2015, several countries in the Region, among them Brazil, El Salvador, and Ecuador, made progress in this regard, channeling most of the growth in expenditure to the first level of care to broaden access to these services and improve their quality. For cases like those of Chile, Mexico, Peru, and Uruguay, results based payment systems were also established (). The 2008 reform in 2008 in the latter country involved the expansion of coverage and pooling of social security and State funds to finance services to the beneficiaries of FONASA, the national health insurance program that currently covers more than 70% of the population. The risk-adjusted capitation payment system used in this fund also considers four targeted areas associated with preventive measures for pregnant women and older persons and the allocation of human resources. During this period, Peru launched a results-based payment system through a project implemented at the more general level of results—based budgets. Chile, in turn, introduced targets in the per capita transfer system in primary health care and is developing a hospital payment system based on diagnosis-related groups, aspiring to be the first country in LAC to employ this tool. Suriname currently uses a capitation system for first-level providers and payment per day and bed in the hospital setting.

c) Prioritization to equitably boost efficiency

Finally, it should be noted that the countries of the Region are increasingly adopting prioritization as a way of meeting health objectives through efficient and equitable resource allocation. This process takes different forms and involves different approaches; thus, we find processes related to the definition of the services offered and the use of positive lists of standardized services, lists of generic medicines, and the preparation of clinical treatment guidelines and protocols, in addition to health promotion, disease prevention, and the prioritization of first-level services to build strong systems based on primary care. The use of economic analysis in the health sector to evaluate cost-effectiveness and cost-utility in prioritization processes is also growing in the countries. In this context, efficiently increasing expenditure implies identifying specific action to prevent losses in health (as measured by indicators such as quality-adjusted life years [QALY]) to ensure that services reach the neediest beneficiaries based on their health deficits.

Improving financial protection through pooled funding

Increasing financial protection requires greater public expenditure, adopting efficient interventions primarily at the first level of care to boost response capacity and increase linkage among service networks. Increasing financial protection will reduce inequity in access. However, the replacement of direct payments should be done gradually through collective prepayment mechanisms involving different sources of financing, such as contributions to social security, taxes, and fiscal revenues. Thus, the main components of a financing system designed to offer financial protection to the population are the elimination or minimization of direct payments by households and the pooling of funds.

Pooled funds, in which the risk of disease and the need for health services are shared by a group of people through collectively financed prepayment mechanisms, is therefore key to financial protection. Sharing risk under any institutional arrangement implies the transfer of resources or a subsidy from healthy people to patients, as well as from young people to older people — basically, from people who are not using the health services at a particular moment to those who are. Moreover, for this financing to be solidarity-based, there should also be a subsidy, grounded in redistributive policies, from households with greater contributory capacity (the wealthiest) to those with fewer resources (the poorest), whose contributions are limited but whose health care needs tend to be greater.

There is no ideal number of people who should share risks, but the larger the fund, the greater the probability that all of these population groups will be covered. The existence of numerous small and fragmented funds hinders the cross-subsidies mentioned above, since it provides an incentive for risk selection: each fund will attempt to include people who are better off economically and in better health and exclude those with limited resources and more health problems. Smaller funds are more vulnerable to specific risks, such as illnesses that require more expensive treatment. This is why funds that cover a small number of people tend not to be economically viable in the long term ().

In the extreme case of an individual fund, such as health savings accounts (), in which the risk of disease is carried almost exclusively by one person, a costly episode of illness could lead to financial ruin. Furthermore, when the members of a fund share similar characteristics in terms of the social and environmental determinants of health to which they are exposed, the risk of health problems tends to be inefficiently diluted, implying a higher cost per person to treat episodes of illness than in funds that cover people with different characteristics. This is a powerful reason for advising against segmented funds for communities with limited resources.

The existence of numerous funds with their respective mechanisms for collecting and pooling resources and contracting services compromises the efficiency of the entire health system due to the administrative costs that it entails, as well as the cumulative superimposed transaction costs. Single large funds tend to be a more efficient type of organization than competing funds, as long as organizational and institutional incentives are adequate (). Economies of scale in the operation of these funds can generally be expected—not only in the collection and pooling of resources, but in the contracting of services for large numbers of people.

Pooled funds will contribute little to meeting the objective of equity if poor individuals and households must make a greater economic effort to finance them than the non poor. Flat contributions or fixed amounts that are equal for all are a highly regressive mechanism, since they represent a higher proportion of the income of poor households than non-poor households. In order to prevent this, contributions should be tied to the contributory capacity of households and individuals and should be progressive only when poor households must contribute a small percentage of their income. Moreover, solidarity-based risk sharing among a group of people means that the contribution to the fund must not be greater for those at higher risk of disease. Financially protecting households with young children, older persons, people with chronic diseases, and other groups likely to make greater use of the health services means not penalizing them with higher contributions.

Finally, in addition to increasing access to quality health services, financial protection is an important tool for fighting inequity and poverty, as it converges with policies for development and the social and economic protection of societies. In other words, it represents a specific contribution from the health sector to human development strategies.

Summary

The health financing situation in the Region is well defined. Public expenditure rose between 2010 and 2015 but did so very slowly, and out-of-pocket expenditure fell, but not fast enough. In this context, substantial progress was made in some cases, with sharp increases in public health expenditure in Uruguay, and sustainability of the goal in Canada, Costa Rica, Cuba, and the United States, all of which had met it earlier. Considering past levels of public expenditure, substantial increases are being observed in Bolivia, Ecuador, Nicaragua, and Peru, along with a clear trend toward the reduction of direct payments, as seen in Bolivia, Brazil, Colombia, El Salvador, and Peru. Tax policies could play an important role in enabling Bolivia, Brazil, Ecuador, and Nicaragua to reach the benchmark of 6% of GDP in the near future. However, health expenditure has not been accorded sufficient priority in many countries, even in the context of economic growth. Considering only the more populous countries in each subregion, this can be seen in Argentina, the Bahamas, Guatemala, Jamaica, Mexico, Panama, and Venezuela—countries with negative health expenditure elasticities with respect to GDP growth. Still, the countries report progress in terms of efficiency in the integration of care and the strengthening of primary care through different types of initiatives—in some cases with a high degree of success in their health indicators.

References

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Reference/Note:

1. According to WHO (), health financing functions consist of raising revenue, pooling it, and allocating economic resources (that is, spending). Revenue can be raised through taxation, contributions to the social security system, voluntary premiums, and direct payments. Pooling, in turn, involves collecting and managing resources to guarantee that the financial risk of losses stemming from an episode of illness is borne by all members of the common fund. Resource allocation, or spending, is the payment to health service providers, which includes the transfer of historic budgets to mixed payment mechanisms.

2. While this indicator is very important because it is a significant measurement of country efforts in health and because of its acceptance as a prerequisite and useful benchmark in the regional strategy for universal health, it cannot be interpreted in isolation, since individual variations can reflect movements within a country’s economic cycle (variations in GDP), for example, regardless of the resources allocated to the health sector.

3. By definition, insurance premiums (or any other form of prepayment) are not considered out-of-pocket expenditure; by convention, neither are the indirect costs associated with the use of services (transportation, meals, etc.).

4. European Union parameters are used as representative of the more advanced countries, even though development levels in some EU countries are considered similar to those of several countries in the Americas.

5. There is no absolute consensus regarding this threshold. For example, Wagstaff and van Dorslaer () examine threshold differences in the case of Vietnam. Knaul et al. () define a threshold of 30% of the non-subsistence expenditure or the total expenditure of a household once the international poverty line of US$ 1 per day is discounted.

6. PAHO. Estudio de gasto catastrófico y empobrecedor en salud en la Región de las Américas (forthcoming).

7. Cuba does not appear in the figure because it is not in the World Economic Outlook Database of the International Monetary Fund (IMF).

8. Simple average of the countries.

9. PAHO. Public and private expenditures on pharmaceutical products in Latin America and the Caribbean (unpublished).

10. Cid C, Matus M, Báscolo E. Fiscal space for health. Is economic growth enough for the Americas? Washington, D.C.: PAHO; September 2016 (unpublished).

11. Grossman’s human capital model () and Shultz’s human development model () laid the foundation for including health in neoclassical economic growth theories based on Solow (). In post-Keynesian theories, moreover, institutional distributive stimuli are critical for growth, in which equity is an important factor. Many economists, among them Nobel Prize winners such as Gary Becker and Amartya Sen, have also made important contributions-the former noting the importance of health in workforce productivity and the latter giving health a value in itself as a human capability.

Building health throughout the life course

  • Introduction
  • Health throughout the life course
  • People-centered health policies
  • Building health for a lifetime
  • The importance of a good beginning
  • Health in childhood
  • Child development during early childhood
  • Transitions and critical moments of life: adolescence as a model
  • Health in middle age and beyond: a vision limited to disease?
  • Building mental health
  • Building health in old age: functional capacity as the focus of care
  • Investment in health: a long-term strategy
  • Conclusions
  • References
  • Full Article
Page 1 of 14

Introduction

Health is a component of and a key resource for human development. It results from a cumulative process of continuous interaction between exposures and experiences, which have an impact at both the individual and population levels, not only episodically but over time, and with trans-generational effects (). The increase in human life expectancy by approximately 30 years over the last century provides a compelling reason to expand health-related goals beyond simple survival ().

In the Region of the Americas, the effort to increase life expectancy has been successful; however, the increase in healthy life expectancy has not kept pace. On average, 8 of every 10 people who are born in the Region will live beyond age 60, and more than 4 in 10 will live past 80 (). One-quarter of those who live past 80 will live with poor health () . According to estimates, people in the Region live on average 9 years with functional limitations or disability (). An increased lifespan, but with longer periods of illness and dependence on care provided by others, is a great burden for States, societies, and families, and a significant challenge for public health.

Health throughout the life course

Halfon and colleagues define health throughout the life course as a dynamic process that begins before conception and continues for an entire lifetime (). This concept, even in evolution, is based on bio-psychosocial and post-genomic models, in which health is considered a process that is integral to complex systems ().

Acting upon that vision of health requires going beyond interventions targeted to specific diseases and their consequences and instead treating health as an essential resource in producing and maintaining capacities and reserves in individuals and populations, throughout the life course. Health is a dimension and a marker of sustainable development, since it reflects the combined effects of social, economic, and physical living conditions on the population. A healthy population displays greater labor and economic productivity, leading to more inclusive and sustainable growth ().

The life course approach

In the life course approach, the health of individuals and populations is conceived as the result of dynamic interaction between exposures and events throughout life, conditioned by mechanisms that embody the positive or negative influences that shape individual trajectories and the development of society as a whole. According to this conceptual framework, health is a fundamental dimension of human development and not merely an end in itself.

The life course comprises the succession of events that occur throughout the existence of individuals and populations. These events interact to influence health from preconception until death, and may extend even further to affect future generations. The life course perspective provides a basis on which to predict future scenarios in health. Trajectories, temporary conditions, transitions, critical periods, the interconnection of lives, and cumulative effects form a conceptual platform that, as part of the available scientific evidence, can be used to model scenarios in health ().

There are longstanding efforts to transcend the narrow vision of health as merely the absence of disease. However, these efforts have been limited to philosophical definitions, conceptualizations, and theoretical models of public health (). Clinical practice, the organization of services, indicators, and financing are key aspects of health that continue to revolve around disease, even though the “traditional model of disease” is less and less applicable to contemporary pathological disorders.

Building health means investing in the creation of a capacity or resource that enables individuals and populations to develop according to expectations and the demands of their environment (). It provides necessary tools not only for their development, but for their adaptation to unexpected situations such as natural disasters, infectious disease outbreaks, or violent events, or to challenges that can persist a long time, such as climate change, chronic diseases, disabilities, human rights violations, lack of job security, or violent situations ().

People-centered health policies

Under the leadership of the World Health Organization (WHO), during a 1986 conference in Ottawa, Canada, health promotion was defined as a process aimed at:

… enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living ().

Building health implies not only preventing disease, but also promoting the development and sustainability of physical, mental, and social capacity throughout life. This capacity, although it has a genetic component, is not innate, since one is not born with “maximum capacity” that is then gradually lost through an unhealthy lifestyle; rather, this capacity is actively created, subject to environmental and social determinants, enabling individuals to adapt to and modify the environmental demands in their present and future life ().

The life course concept includes the influence of the determinants of health on individuals and populations. According to this approach, these determinants not only can lead to disease and death, but also are decisive in building health. Understanding this can contribute to greater clarity about the influence of health on the model of life trajectories and on human development, and about the real impact of investments in health in the short, medium, and long term. Furthermore, it demonstrates that in health, both action and inaction have consequences. This vision of public health provides a more realistic view of the problems and sharpens the focus on the priorities and needs of the population.

In the Americas, health must be considered in an increasingly diverse population context. For the first time in history, five generations are alive at the same time (). These generations have had different life trajectories: the first was born without access to vaccines or antibiotics; another experienced the double burden of malnutrition (undernutrition along with overweight); still others started out with high levels of illiteracy and today must adapt to global connectivity and coexist with other generations that are growing up and becoming educated in this new world. Some people are born and move through their lives with certain health protections, only to lose them in later stages of life, which poses new challenges of adaptation. All this represents a challenge for public health, and any future design of universal health must take into account these generational differences. They are added to the amply documented, but largely unresolved, inequities associated with ethnicity and gender and with the different geographic and social contexts where people live.

Inequities in the Region of the Americas have been the main cause of failures related to health, and over the next decade will continue to be a barrier to progress. Efforts to reduce and eradicate inequities should be guided by a life course perspective and by a better understanding of the “inherited” nature of health as a resource and of its intergenerational transmission. Health inequities that affect some subgroups are not limited to a single health problem, nor confined to narrow, transitory environments, but exert pernicious and pervasive effects throughout the life course ().

The cycle of inequity

The health of mothers directly affects the health of their children, and this creates a cycle of inequities between the different generations. According to a study conducted in the Dominican Republic, a newborn whose mother has no formal education is 5.6 times more likely to not be registered at birth compared to the newborn of a mother with higher education. Social inequity in health continues when the child reaches adolescence and, in the case of women, childbearing age. The unmet need for family planning among women of childbearing age in the poorest quintile is almost double (1.9 times) the unmet need of women in the richest quintile. When they become pregnant, adolescents without formal education are 9.3 times more likely than adolescents from professional families to receive no prenatal care ().

The dynamic conception of health is grounded in solid theoretical and philosophical arguments. However, the aspiration to place people—and not diseases—at the center of health policies will not be realized until practical ways to carry out the life course approach are designed and implemented.

Building health for a lifetime

Building health is a continuous process, one in which interventions and results are not isolated but cumulative over time, with periods of stability and of transformation. This interaction shapes trajectories that may be regarded as health pathways, at both the individual and population levels.

Progress in health

A girl born in Chile in 1910 had a life expectancy of 30 years (); for the same child born today, this figure has almost tripled, to 84 years (). The probability of today’s child dying before her fifth birthday has declined from 36% to less than 2%. Moreover, she has less risk of dying in childbirth, contracting infections such as tuberculosis, or suffering from anemia or cancer in middle age. When she becomes an adult, she will have the opportunity to decide how many children she wishes to have; the fertility rate in the second half of the 20th century fell from 5.3 children to 2.3. If born today, that girl would likely be taller and stronger and have greater intellectual ability than if she were born a century ago. Her life would be not only longer, but healthier.

The analysis of this process reveals both the needs and the influence of protective factors, as well as their impact on the development and maintenance of the capacities of persons and populations. An understanding of trajectories is essential in order to identify and predict the “how and when” of health, making it possible to design and implement more efficient and better-organized health policies (). The health sciences, which for centuries have sought to understand the trajectories of diseases, will need to focus in the coming years on understanding life trajectories and, specifically, the health trajectories of individuals and populations.

It is important to emphasize that health is not innate; it is built over time. All individuals are born with a genetic capacity that underlies their personal potential and influences their health and longevity. However, we now know that genetic capacity accounts for only 30% of this influence, while the remaining 70% stems from the impact of positive and negative factors during the individual’s life trajectory (). Contemporary genomic medicine already has a knowledge base concerning the genetic capacity of individuals and how to influence or manipulate it. This has improved the ability to diagnose genetic errors and genetic diseases, making it possible to predict clinical symptoms long before they appear and physiological changes in individuals before they occur (). Modern genetics is capable of forecasting very early in life the diagnosis of diseases such as breast cancer or Alzheimer’s (). It is also possible to predict which patients will be sensitive, or not, to a given treatment. These discoveries and others associated with biotechnology, nanotechnology, and pharmacology are part of an important group of interventions known as precision medicine, which will influence clinical practice in the coming decade ().

Public health authorities in the countries of the Region should seek to understand the impact of these interventions and the ethical dilemmas they pose. For example, the decision of whether to intervene based on genetic risk () must take into account the high costs of such interventions and their potential effects on health coverage, as well as questions of access and financing ().

Advances in epigenetics explain how gene expression can be modulated in response to environmental signals and how these changes can persist across several generations (). A growing body of evidence makes clear that this plasticity is present not only in the early stages of life, but at other points during the life course, a finding that will have a great impact on medicine and public health (). In their adaptive response, human beings exhibit a high degree of plasticity (the capacity to modify developmental biology in response to environmental stimuli) that enables them to cope with the changes and different circumstances that they face ().

However, the greatest advances in increasing life expectancy and improving health indicators are due to interventions that influence the life trajectories of individuals. The vast majority of the actions implemented in the Americas to date that have proved highly effective and efficient are related to health promotion. They include immunization, proper nutrition, physical activity, and the crusade against tobacco use, among others. There is great scope for increasing actions aimed at promotion and prevention. The barriers imposed by poverty and, especially, inequality, as well as the high costs associated with technology, will continue to limit access to new advances in public health and medicine for the vast majority of the population. This chapter and others in this report highlight this reality and its influence on the health situation in the Americas.

The importance of a good beginning

The impact of events on the life course is not uniform. A single stimulus—negative or positive—can have different impacts, depending upon the time of life when it occurs (). During particularly sensitive periods, such as the prenatal stage, childhood, and adolescence, these stimuli can trigger adaptive responses in the individual and in populations, with long-term effects that extend to other stages of life. A reduced growth rate in utero and after birth has been associated with an increased risk of cardiovascular diseases and diabetes (). In recent decades, greater knowledge of such time-linked effects, known since the mid-20th century as the “fetal origins of adult disease,” has increased the body of evidence regarding specific and critical moments of greatest susceptibility, the mechanisms involved, and the results ().

Pregnancy and maternal health. With adolescent pregnancies in the Region at alarmingly high rates already, there is evidence of a new and troubling phenomenon: the increase in pregnancies among girls 14 years of age or younger in some countries (). There has also been a relative increase in pregnancies among women 35 years of age or older, with a consequent rise in complications and mortality associated with assisted reproductive technology practices. The current functional relationship between maternal mortality and age results in a U-shaped curve, whose upper ends correspond to girls under 15 and women over 35 (). The Region of the Americas is experiencing an obstetric transition that recalls the classical epidemiological models of demographic and epidemiological transitions. Although some less-developed countries and territories still have high rates of births and of direct maternal mortality, the predominant situation across the Region is a smaller number of births, a reduction of maternal mortality, and greater life expectancy for women. In this context, maternal mortality is linked to indirect obstetric causes and to the increased number of pregnancies that occur in complex circumstances, such as in women with noncommunicable diseases, transplants, and similar health problems. These different scenarios, shaped by economic, social, and cultural factors, will need an appropriate response from the health sector in the coming years. The goals and strategies for ending preventable maternal mortality require a specific and realistic framework to guide strategic planning. Furthermore, they should be sufficiently flexible so they can be interpreted and adapted effectively in various national contexts, and especially in the local contexts where they are applied.

Ample evidence exists that an inappropriate intergenesic space has an unfavorable effect on both the woman and her offspring. To ensure that a woman begins her pregnancy in the best circumstances, it is key to intervene with accurate information, while strictly respecting her self-determination (). This perspective, which is not yet widespread in the Region, is linked to a focus on preconception, which in the coming years should be accorded the importance it deserves, just as occurred with prenatal care in last century (). The impact of adverse conditions during pregnancy can be reduced through preconception care that is based on the provision of biomedical interventions and on the promotion of favorable habits and socio-environmental conditions, directed both to women and to their partners. The evidence suggests that births in disadvantageous conditions are often due to poor health behaviors, exposure to harmful environmental factors, and lack of access to health care ().

Newborn health. Health at birth is a factor that helps to predict long-term results, such as education, income, and disability. In the Region of the Americas, even today, 8% of all newborns have low birthweight (less than 2,500 g) and 8.6% are premature. Both low birthweight and prematurity require prenatal care, which is provided to 88.2% of pregnancies in the Americas. Regionwide, 94.1% of deliveries take place in hospitals, although these figures obscure inequalities both within and between countries ().

There is steadily increasing knowledge available about the protective effect on fetal health of various interventions, including expanded coverage of influenza vaccination—which helps prevent premature birth—as well as expansion of complementary nutrition, improvements in environmental health, reduction of violence against women, increased use of conditional cash transfers, and better understanding of maternal and fetal health (). The association between the height of the child and of the mother, or between low birthweight in girls and the body composition and intrauterine growth of their eventual offspring, demonstrates the intergenerational effect of these influences ().

High-quality care at the time of birth means achieving adequate coverage of the interventions with proven effectiveness, those that have a positive effect on maternal and newborn health. Examples of these interventions are timely clamping of the umbilical cord, early skin-to-skin contact, immediate initiation of breastfeeding, neonatal screening tests, and maternal-infant bonding to promote early development.

Breastfeeding and early childhood development

In the 21st century, breastfeeding is more relevant than ever, whether in a high- or low-income country or in a rich or poor family. The physical and emotional bond between a mother and her child is strengthened and influences epigenetic programming (). Adequate nutrition and a safe and nurturing environment favor early brain development and are essential in promoting better cognitive development, minimizing the risk of overweight, and protecting against certain chronic diseases ().

A good beginning means that the woman is attended by skilled personnel and that her delivery takes place in an appropriate institution and surroundings. Later, balancing the requirements of breastfeeding with the mother’s need to work implies extending maternity protection to provide mothers with a time, a private space, and an appropriate place to store breast milk and breastfeed safely. Society still does not provide a favorable and enabling environment to the majority of women who wish to breastfeed. Successful breastfeeding should be regarded as a collective social responsibility, involving health systems, families, communities, and workplaces. Rates of breastfeeding and indicators of adequate complementary feeding can be improved considerably in a very short time. Policies and programs to support nursing mothers in health centers, homes, and workplaces have a greater effect if they are designed and implemented as part of a package of interventions, but they require financing and political will ().

Health in childhood

The life course approach clearly identifies the most critical or sensitive periods of life, which are “windows of time” characterized by heightened susceptibility, when exposure to certain factors can change the direction of a person’s life trajectory and modify the biological programming or social trajectory of individuals and populations, with short-term and long-term effects (). According to the United Nations Convention on the Rights of the Child, all children have the right to achieve their full development potential and enjoy maximum health (). Healthy children have greater opportunity to grow and develop into adults who are healthy and productive. The child population has particular characteristics and health needs that require specific responses and actions. The recognition of factors that promote their health and growth requires an understanding of the demographic, socioeconomic, and equity conditions that shape their lives, as well as factors related to family and social cohesion, health promotion policies, nutrition, the environment, and access to and utilization of services, among others ().

Preventing disease and death is not sufficient to ensure a healthy childhood. In 2015, WHO presented the Global Strategy for Women’s, Children’s and Adolescents’ Health (), one objective of which is to enable children to achieve their full development, which in turn yields high returns throughout the life course. It has been recognized that early childhood development provides a solid basis for the formation of human capital (). Today it is known that the foundations of brain architecture are laid and consolidated in the first years of life, through a dynamic interaction of genetic, biological, psychosocial, and environmental influences. The child’s brain begins developing at conception, and during the first two or three years of life this process advances more rapidly than at any other time ().

Child development during early childhood

In 2016, Britto and colleagues () proposed three packages of effective measures aimed at creating opportunities for every child to achieve his or her maximum development potential: (a) a package of measures to support and strengthen families; (b) a package of multigenerational nurturing care measures; and (c) a package of early protection and learning measures (Figure 1). The challenge is to ensure that families and children benefit from these interventions, particularly children affected by multiple disadvantages.

Nurturing care graph

Figure 1. Domains of nurturing care necessary for children to reach their developmental potential
(Reprinted with permission from The Lancet)

The child’s environment can modify his or her genetic map, especially during a critical period of life. The environment does not change DNA, but it produces chemical changes that affect the development and neurocognitive-motor performance of the child. Moreover, these chemical signals can be transmitted from one generation to the next. The dynamic interactions between the environment and genetics place children on different trajectories that affect their health throughout life, along with their cognitive abilities, behavior, and social functioning, and those of future generations (). The current literature on early childhood development emphasizes the need to adopt a broader approach to the physical, emotional, cognitive, and social development of children (). This is a topic with intersectoral implications, encompassing health, education, nutrition, well-being, and social protection, among other areas (). The interactions between children, their parents, and other caregivers—including those who provide health and social services—constitute the most important external influence, together with the exposure to environmental risks in the home and community. Parents and caregivers, both women and men, can help offset the negative effects of possible disadvantages by providing health care, nutrition, nurturing, security, and early learning-if they receive support to help them provide an appropriate upbringing to children.

In the Region of the Americas today, we have the necessary knowledge to eliminate infant mortality due to preventable causes, as well as to greatly improve the health and well-being of children and carry out the transformations needed to ensure a more prosperous and sustainable future ().

Transitions and critical moments of life: adolescence as a model

As discussed, the life trajectories of individuals and populations contain transitions that are milestones in themselves and that constitute moments of change. These transitions can be biological, psychological, social, economic, political, or even geographic in origin, and they are not necessarily predetermined nor always foreseeable: examples include retirement, menarche, menopause, school entry, the beginning of working life, and migration. Other changes that can be mentioned include changes in social roles or, from the biological perspective, the acquisition or loss of functions that accompanies the beginning or end of physiological processes ().

Adolescence represents the most documented example of the life course concept. It is one of the life stages with the most complex transitions and also one of the most sensitive periods of human development, during which behaviors are modeled and habits and lifestyles are adopted. The development of the human brain continues throughout life through a process known as neuroplasticity. Research suggests that the brain transformations taking place in adolescence are quite different from those that occur in childhood. During childhood, the focus is on dendritic outgrowth and synaptogenesis or synaptic growth, which permits the brain to increase substantially in size and weight. The evolution of the brain during the second decade of life and into early adulthood seems to concentrate on synaptic pruning, in which the process of eliminating weak or irrelevant synapses is necessary in order to obtain greater brain efficiency. Synaptic pruning is believed to depend on the responses of neurons to environmental factors and external stimuli. As a result, this stage is regarded as a critical period in which the individual is highly receptive to environmental stimuli, which in turn has enormous consequences for the neurological development of adolescents. This explains the adaptive form of learning and the rapid acquisition of interpersonal and emotional skills during adolescence ().

An analysis of this process points to the importance of ensuring a secure and stable social environment for adolescents in order to support optimal development of the brain functions that are essential for longevity and for social and emotional well-being in adulthood () (Figure 2). Although the family can provide the primary structure of protection and security during this period, adolescents by nature are exposed to and sensitive to many other influences, such as friends, school, communications media, the community, and the world of work. This sensitivity that is so characteristic of adolescence implies that the communications media can influence the attitudes, values, and behavior of the individual more than during any other stage of life. The digital revolution has facilitated exposure to new ideas and contacts with like-minded people, but it also carries new risks, such as the marketing of unhealthy products and the promotion of fixed consumption habits.

Figure 2.Ideal model to promote healthy development in adolescence

Source: http://www.youthpower.org/positive-youth-development ()).

Young people leave the educational system and enter the world of work, where they assume steadily increasing responsibility for their own decisions, including those that influence their health. This is the time of life when the human body acquires the capacity to reproduce, and it is also the stage when young people typically encounter tobacco, alcohol, and other possible health hazards for the first time (). For this reason, parental monitoring and supervision of adolescents’ activities is indispensable in reducing health risks to adolescents. The effects of this relationship are documented: for example, the scientific evidence, although limited, suggests that communication between parents and adolescents-especially between mothers and daughters-on sexual subjects helps delay the beginning of sexual relations and promotes the use of contraceptive methods ().

Adolescent pregnancy

Giving birth at a young age is associated with greater risks to health. Unwanted early conception contributes to unsafe abortion, to mortality, and to health problems in the short and long term. Pregnancy in adolescence affects the life trajectories of the mothers and of their offspring, and has biological, social, and economic consequences. Young maternal age is associated with shorter gestation periods, low birthweight, poor nutrition, and lower educational attainment in children. Girls who become pregnant are more likely to interrupt their education, thus reducing their capacity to earn income throughout life and to support themselves and their children (). The prevention of adolescent pregnancy and the provision of support to help adolescents control their own fertility not only helps save their lives, but also allows them to complete their reproductive development, increases their chances to acquire education and income, and improves the development prospects of future generations.

 

Health in middle age and beyond: a vision limited to disease?

In the next decade, efforts to provide comprehensive care to people in midlife should be reoriented to the health needs of people, rather than to diseases. The health issues of men and women in the post-reproductive stage of life have not received the necessary attention. These middle generations are subject to major social and family pressures related to caregiving, extension of the retirement age, and the implications of being viewed by health providers as bearers of diseases or risk factors. It is urgent to evolve toward a holistic vision of the person, using a life course approach.

Building mental health

Mental health is the result of interaction between protective factors and risk factors throughout the life course, including the prenatal period and intergenerational transmission. Failure to achieve key physical, cognitive, and socioemotional competencies leads to insufficient mental health development and can cause diseases (). Cumulative exposure to stressors can have a negative effect, increasing the likelihood of the deterioration in mental health (). Being a victim of child abuse can have effects that persist into adolescence and adulthood (). Psychosis, depression, and anxiety are disorders that originate in critical periods of early development ().

A life course approach to the analysis of these trajectories and transitions provides strategic opportunities to design programs for disease prevention and promotion of mental health (). Mental health policies should treat the long-term combined effects of the biological, psychological, and environmental vulnerabilities of specific groups. By mediating or moderating the effects of exposure to risk, protective factors can have a cumulative effect on the life course (). Cumulative risk indices make it possible to more accurately evaluate mental health and estimate the probability of suffering from mental illness; this in turn can lead to greater efficacy and efficiency in prevention and treatment, as well as a reduction in the equity gap determined by the accumulation of risks and disadvantages in certain populations ().

The WHO mhGAP intervention guide is an evidence-based model with a life course perspective, geared to the prevention and treatment of mental, neurological, and substance use disorders in non-specialized health contexts (). It offers strategies tailored specifically to pregnant and lactating women, children, adolescents, and older persons. The guide also provides tools for comprehensive care of priority disorders through the use of optimized and simplified algorithms for clinical assessment, decision making, and monitoring, as well as a new module on implementation to support the proposed interventions with the necessary infrastructure and resources ().

Intersections between violence against women and violence against children from the life course perspective

Violence against children and violence against women represent a global public health problem and are serious violations of human rights. The Sustainable Development Agenda recognizes both forms of injury as barriers to countries’ progress. An increasing body of scientific evidence points to the various intersections throughout the life course between these two forms of abuse (). Violence against women during pregnancy is associated with negative outcomes for the health of women and their children (). The consequences of child abuse often persist into adulthood, leading to long-term changes in brain structure, causing physical and mental health problems, predisposing the individual to engage in risky behaviors, and even reducing life expectancy at birth (). All this suggests that violence experienced during critical periods of development—whether directly experienced or witnessed—has harmful and lasting effects on the risk factors for health.

 

Building health in old age: functional capacity as the focus of care

Every 25 years, the global population of adults aged 60 or older doubles, and it is expected that by 2050 the Region will have approximately 400 million older people (). In the Americas, a person who lives to age 60 will live on average 20 years more, and a person who turns 80 can expect to live another 7 years (). In this demographic transition, healthy aging has been defined as a process that promotes and maintains the functional capacity required to permit well-being in old age (). This functional capacity, which has various health-related dimensions, enables people to live and act according to their beliefs and values. Although this is true throughout the life course, old age is the stage where it is essential to boost efforts to prevent a deterioration in functional capacity, thus preserving a healthy life expectancy, or at the very least, freedom from disability. The overarching goal is to enable older people to lead active and independent lives and to prevent an unnecessary increase in the burden of long-term care.

The situation of older persons and patients is perhaps the clearest expression of the new needs in health, which in turn call for a substantial transformation in the model of health care at both the individual and population levels. Because of its importance for the Region, this topic is further explored in section 2.4 Aging and health.

Self-care

Many health services are organized around the care of diseases and consider the person as a secondary priority (). The appropriate treatment of chronic diseases is impossible without the participation of the individuals who suffer from them and the support of the community. A person who suffers from a chronic disease has a continuous relationship with that disease and must make decisions every day about his or her activities, diet, and prescribed medications. Meanwhile, that person’s contact with the health services is episodic and is limited to a number of hours or minutes every year. Hence, health systems should adopt programs of self-care that facilitate active autonomy, so that each person takes care of his or her own health. Such programs must help people properly monitor their own symptoms and comply with treatments in a responsible way. The goal is to promote well-being and the most active life possible, whether or not a person is living with disease (). There is a great deal of evidence on the efficacy of self-care programs, not only in terms of their effectiveness and impact on individuals, but also because they help reduce demand for and unnecessary costs of health services ().

 

Investment in health: a long-term strategy

Health is at the center of social development and economic growth. Healthy people and populations are more productive; children who enjoy good health develop better, growing into productive adults. An expanded response over the next few decades should include not only increases in financing directed to specific stages of life, but a commitment by all relevant sectors to carry out activities aimed at reducing health inequalities and inequities throughout life. To this end, it will be important to evaluate the long-term impact of investments and interventions in health, using the life course perspective.

Nutrition. Nutrition is one of the key factors that influences human health and longevity. More than for any other factor, theoretical arguments and empirical evidence support the role of nutrition in shaping the life trajectory and building health from preconception to death. Good nutrition in the first two years of life is associated with greater height and better cognitive and school performance. It has also been associated with greater economic productivity and its corresponding impact on personal income (). Nutrition and its mediating circumstances influence the socioeconomic status of women and the birthweight of children in the next generation (). However, the mechanism that links a woman’s early nutritional experiences with the nutrients transferred to her fetus is still unknown (). Malnutrition during the first years of life can negatively influence fetal and child growth in the next generation, whether through genetic, epigenetic, or physiological mechanisms. At present, obesity is one of the principal risks to longevity in the Region. Many population groups suffer from a double burden of nutritional problems, that is, undernutrition along with overweight ().

Nutrition has been shown to have a determining effect on the maintenance of muscle mass and on the intrinsic and functional capacity of older persons, which in turn has an important impact on the ability to maintain a healthy and active lifestyle for the longest period possible ().

Physical activity. The role of physical activity in building health throughout the life course must inform health strategies in the coming years. Sedentary lifestyles have favored an increase in chronic diseases associated with physical inactivity (). Individuals with less mobility suffer greater morbidity, disability, and mortality (). Several studies demonstrate that 25% of all people who engage in some type of physical activity spend less time with disability or with some type of injury, in comparison with people who do not perform any regular physical activity (). According to one study, participation in a physical activity program of moderate intensity for approximately 2.6 years can reduce mobility impairment in older persons ().

Immunization. The success of immunization strategies is perhaps one of the best arguments in favor of the life course approach. Vaccines have a lasting impact on the economy through their mediating effect on health. Bloom and Canning propose a causal chain to explain this link between health and income (). The following points illustrate these links between health and income:

  1. Education: Immunization has a significant, long-term effect on intellectual performance and on health, which is manifested in an increase in cognitive capacity.
  2. Productivity: Workers in healthy communities are less prone to absenteeism related to their own illness or the need to care for an ill family member. Bloom and Canning estimate that a one-year increase in life expectancy improves productivity by 4% ().
  3. Saving and investment: Healthy people can expect to live longer, and as a result, they are more prone to save for their retirement. They also are capable of working productively for a longer time, thereby increasing their savings. The economic consequences of immunization are not limited to the direct effects associated with the costs of health services or disease prevention, but extend much further to include indirect effects mediated by cognitive development, level of education, labor productivity, income, savings, and investment.

Sensory health. In 2015, disorders of the sensory organs were the second-ranking cause of years lived with disability (), accounting for more than 68 million disability-adjusted life years (DALYs) (). Unoperated cataracts continue to be the main cause of blindness, and uncorrected refractive errors are the main cause of visual impairment (). Retinopathy of prematurity affects newborns in low- and middle-income countries due to deficient neonatal care (). A reduction in DALYs caused by visual impairment is a feasible and high-impact strategy for the years ahead. The high effectiveness of the interventions (glasses to correct refractive errors, and curative surgery for cataracts) in relation to their costs justifies greater attention to the burden associated with vision loss ().

The Global Burden of Disease Hearing Loss Expert Group estimates that in Latin America in 2008, the prevalence of auditory disability was 1.1% in children 5 to 14 years of age and 9.6% and 12% in girls and boys over 15 years of age, respectively (). Early identification and intervention in cases of hearing loss has a significant association with better language development in children (). The early detection of auditory disability in children, the timely use of antibiotics for treatment of otitis media and meningitis, as well as the provision of hearing aids for conductive hearing loss can reduce this burden ().
Evidence supports the importance of oral health in the different stages of life, as well as its intergenerational scope. According to a prospective cohort study, the presence of caries in adults 32 years of age is related to the oral health of the mother (), and in a low-income Hispanic population an association was found between levels of cariogenic bacteria in the saliva of mothers and their children in early infancy ().

Conclusions

In the near future, public health, the organization of health services, and clinical practice will all be affected by changes in traditional patterns. The contemporary patient will have high life expectancy but also chronic illnesses that may persist for many years, increasing functional limitations, and a need to interact with the health services over a long period of time. Such patients, in spite of their diseases, can enjoy well-being and feel healthy ().

Today, we can already glimpse the beginning of the evolution toward an approach in which individuals are no longer the “objects of health interventions” but instead become increasingly active subjects in building their own health and managing their diseases. Despite profound inequalities, people tend to be more—although not necessarily better—informed, and they are making autonomous decisions earlier and more frequently, often without the involvement of the health services. Contemporary public health cannot ignore the participation of people and other actors in health promotion. Developing strategies that take account of the bidirectional influence between these new actors and health professionals in building health will pose a great challenge in the next decade.

From the standpoint of measurement and indicators, the life course approach should be integrated into health care systems as a dynamic process. Toward this end, information systems will need to be revamped, modernized, and strengthened to upgrade their coverage, quality, and analytical capacity. Impact assessment of the life course model should be enriched by reliable sources of information from multiple sectors (education, transportation, environment, finances, employment, and the legal system, among others), as well as from elements of the private sector. Information systems should be reoriented to prioritize indicators of well-being, functioning, and quality of life, as well as environmental indicators, and will need interoperability with the databases of other sectors. It will be up to regional agencies and national governments to advocate the adoption of the life course approach in order to achieve a broader understanding of population health and the delivery of health services.

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Reference/Note:

Pathway to sustainable health

  • Introduction
  • Equity: a renewed focus for sustainable development
  • Transitioning to the era of the SDGs
  • Redefinition of global priorities
  • Regional priorities
  • Health across the SDGs
  • Identifying common ground
  • Looking forward
  • Conclusions
  • References
  • Full Article
Page 1 of 10

Introduction

In 2000, the United Nations (UN) General Assembly laid out the Millennium Development Goals (MDGs), an ambitious vision for global development with a groundbreaking approach to collaborative international action (). In the Americas, an unprecedented regional response allowed many countries to reach or surpass health-related goals to reduce child mortality, control infectious diseases, reduce poverty, and increase access to improved water and sanitation.

Sustainable Development

Figure 1. The “five Ps” (people, planet, prosperity, peace, and partnership) representing the broad scope of the 2030 Agenda for Sustainable Development, 2016-2030
Source: United Nations.

Nonetheless, persistent challenges present during the MDG era remain unresolved, and new challenges in the health landscape have since emerged. As a result, in September 2015, the UN General Assembly adopted Resolution A/RES/70/1, “Transforming our world: the 2030 Agenda for Sustainable Development” (). The product of numerous consultations and deliberations, the 2030 Agenda is an aspirational plan of action for people, planet, prosperity, peace, and partnership—the “five Ps” (Figure 1)—that shifts the world onto a sustainable and resilient path for global development over the next 15 years.Through an equity-based approach that emphasizes the needs and experiences of traditionally disadvantaged groups, the Agenda has the potential to transform the public health landscape in the Region of the Americas. By recognizing the interconnectedness of factors and interventions that influence human development outcomes, the 2030 Agenda and its Sustainable Development Goals (SDGs) outline a paradigm shift in policy-making, prioritizing actions that target the complex and intersecting structural determinants of social and economic development.

The SDGs contain just one explicitly health-oriented goal—SDG 3—out of a total of 17 (Figure 2), in contrast to the MDGs, which have three out of eight. However, many, if not all, of the SDGs include targets related to health, such as poverty, hunger, education, access to sanitation, and exposure to physical violence. While not explicitly included in SDG 3, these themes are among the most immediate determinants of health and well-being. The shift in focus between the two sets of global development goals represents a more nuanced understanding of the factors that affect health, and lays the groundwork for action across different sectors whose activities have significant effects on health but fall outside the purview of the health sector. Governments, the private sector, and civil society will need to innovate and adapt to meet the challenges laid out in the 2030 Agenda, which incorporates a broader and more multifaceted vision for health and development than ever before. A strong evidence base already exists to support this approach, and this chapter topic will extend the effort by highlighting useful strategies, mechanisms, and major global agreements to ensure that countries are prepared to achieve these global goals ().

2030 SDG Breakdown Figure 2. Breakdown of the 2030 Agenda for Sustainable Development by goal (1–17), 2016–2030
Source: United Nations.

Equity: a renewed focus for sustainable development

The MDGs galvanized broad government action to achieve national targets related to specific diseases, maternal health, and child health, but in doing so frequently focused on the “low-hanging fruit” of populations already well served by services, leaving many behind. Despite many successes in reducing population averages of disease-specific incidence and maternal and child mortality, progress was not achieved equally within or between countries. As discussed extensively in “Social determinants of health in the Americas,” health outcomes in the Region are heavily influenced by income, gender, ethnicity, cultural identification, geographic location, and education, as well as access to services and infrastructure. The 2030 Agenda has the potential to address these gaps through the promotion of multisectoral programming that seeks to address the inequalities that persistently produce poor health outcomes, with particular attention paid to the social, economic, and environmental conditions in which people are born, live, work, learn, and age. This approach has profound implications for equity, a core principle of the 2030 Agenda.

In addition to the need to develop programs and interventions that promote health for vulnerable populations, monitoring their impact through data collection and analysis is crucial to ensure that the 2030 Agenda will achieve its promise of reducing health inequalities. Country capacity to measure Regional and national progress toward the SDG targets should be developed in the earliest phases of engagement with the 2030 Agenda in order for governments and policymakers to gain greater insight into which SDG-oriented activities are realizing their goal of reducing health inequalities. It will be especially important to establish equity-sensitive monitoring tools that show which populations are experiencing improvements and increased access to services while highlighting gaps that impede progress in addressing the needs of the most vulnerable and marginalized communities.

Transitioning to the era of the SDGs

While the 2030 Agenda builds on the successes of the MDGs, it also articulates a critical political and conceptual shift in the development paradigm. The 2030 Agenda recognizes many of the lessons learned from the MDGs, which includes the need to explicitly address inequalities, requiring interventions designed to address the unequal distribution of health, disease, and resources. While the MDGs provided both a focal point and framework for government policy-making, a growing evidence base developed over the past 15 years has shown the need for a broader and more holistic understanding of health and human development (). Therefore, the 2030 Agenda encourages innovative multisectoral initiatives in which the health sector partners with actors from other areas of governance to address the key determinants of health affected by actions from systems and institutions outside the traditional scope of the health sector.

2030 SDG Breakdown Figure 3. Breakdown of the Millennium Development Goal (MDG) agenda by goal (1–8), 2000&ndash2015
Source: United Nations.

The MDGs were focused on improving the health and living conditions of those in low-income countries (Figure 3 and Table 1), whereas the SDGs recognize that inequity and gaps in services, opportunities, and outcomes are present at all levels of economic development. Recognizing the limitations of the relationship between the traditional donor (high-income country) and recipient (low- or middle-income country), particularly in today’s globalized “market” of expertise, commerce, skills, and resources, the 2030 Agenda promotes innovative models for development governance, collaboration, and financing that encourage countries to engage creatively with the process of sustainable development. In this way, the SDGs are truly global in that they represent a shared commitment to address mutual challenges across the spectrum of economic development.

Beyond these key shifts, the 2030 Agenda places the 193 signatory countries at the center of SDG implementation. From the earliest stages of consultation, national and regional input has been key to defining goals, targets, and indicators. A case in point is the inclusion of noncommunicable diseases (NCDs) and universal health coverage (UHC) in the 2030 Agenda. Neither was included in the MDGs, but both were identified as major challenges for sustainable development, and ultimately became targets with associated indicators, in the final Agenda. This was an important achievement, particularly for the Region of the Americas, where UHC has long been a priority of policymakers and public health advocates.

As countries move from the MDGs to the 2030 Agenda, it is important to review progress made through 2015. As a whole, the Region achieved health-specific targets related to child mortality, the spread of HIV/AIDS, the incidence of tuberculosis and malaria, drinking water, and sanitation (Table 1). Much progress was made on several targets that were not strictly identified as part of the “health” MDGs, but have substantial implications for health, such as reducing the proportion of people living in poverty. However, some of this progress is under threat by political instability and the ongoing effects of the financial crisis of 2008. Moreover, progress achieved has tended to mask persistent inequalities while gains remain unequally distributed within and between countries.

Table 1. Outcomes for selected Millennium Development Goal (MDG) targets, 2000–2015

MDG and targets Outcome
MDG 1: Eradicate extreme poverty and hunger
1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger
This target was achieved
MDG 4: Reduce child mortality
4.A: Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate
This target was achieved
MDG 5: Improve maternal health
5.A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
This target was not achieved
5.B: Achieve, by 2015, universal access to reproductive health This target was not achieved
MDG 6: Combat HIV/AIDS, malaria and other diseases
6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
This target was achieved
6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it This target was not achieved
6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases This target was achieved for TB and malaria
MDG 7: Ensure environmental sustainability
7.C: Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation
This target was achieved in terms of safe drinking water, and virtually achieved in terms of sanitation (the proportion was reduced by 48.5%)

Source: Adapted from PAHO, Millennium Development Goals and health targets: final report().

While the progress during the MDG era should be celebrated, the underlying inequalities driving poor health and limiting sustainable development remain. Furthermore, not all health-related targets were achieved by 2015, specifically those related to maternal mortality, access to reproductive health, and access to antiretroviral treatment for eligible persons who are HIV-positive. Persistent inequalities and the unmet health targets of the MDG agenda are key challenges to achieving health for all in the Americas, and will need to form the basis of action within the post-2015 development agenda.

As the most inequitable region in the world, the Region of the Americas is faced with unique challenges as it works toward promoting health for all and achieving sustainable development. Building on the achievements of the past 15 years, the 2030 Agenda encourages governments and societies to collaborate in new and innovative ways, while acknowledging that equity is central to sustainable global progress. It also presents a challenge to the global public health community’s responsiveness to policy action, given that the 2030 Agenda should be implemented in full alignment with national priorities, national action plans, and existing global agreements, such as the World Health Organization (WHO) Framework Convention on Tobacco Control (). To do so, identifying areas where the various agendas are harmonized will be of utmost importance so that countries are equipped to tackle these challenges efficiently and coherently.

SDG 3: “Ensure healthy lives and promote well-being for all at all ages”

Health, as a key input to sustainable development and healthy populations, is fundamental to the spirit and pursuit of the 2030 Agenda. In addition to traditional health development priorities targeted by the MDGs, particularly HIV/AIDS and maternal, newborn, and child health, the new agenda identifies a broader range of health objectives. Although SDG 3 is the only explicitly health-based goal, it calls for ambitious progress by 2030 (“Ensure healthy lives and promote well-being for all at all ages”). The first three targets for SDG 3 reflect the recognition of unfinished business under MDGs 4, 5, and 6, including commitments to reduce premature mortality due to maternal complications and to end preventable deaths due to the epidemics of AIDS, tuberculosis, malaria, and other communicable diseases (Table 2). The remaining targets address issues that were not addressed in the MDGs, including NCDs; mental health; alcohol, and other substance abuse; road traffic injuries; reproductive health services; UHC; and access to safe and effective medicines and vaccines for all.

Table 2. Sustainable Development Goal (SDG) 3: targets and means of implementation, 2016–2030

SDG 3 targets
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, water-borne diseases, and other communicable diseases
3.4 By 2030, reduce by one-third premature mortality from noncommunicable diseases through prevention and treatment, and promote mental health and well-being
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents
3.7 By 2030, ensure universal access to sexual and reproductive health care services, including for family planning, information, and education, and the integration of reproductive health into national strategies and programs
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination
SDG 3 Means of implementation
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries, especially in least developed countries and small island developing States
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

Source: Adapted from United Nations, Transforming our world: the 2030 Agenda for Sustainable Development ().

Redefinition of global priorities

By widening and diversifying the global health agenda, a shift that reflects a greater understanding of the breadth and complexity of global health challenges, SDG 3 targets have the potential to significantly improve global health outcomes. The redefinition of global priorities has profound implications for health governance. The 2030 Agenda and health-related SDGs not only lay out new principles, targets, and measurements for combating global health challenges; they also reinforce the role of the state as the primary actor in global health governance, while promoting partnership with non-State partners. Along with the emphasis on engaging civil society and mobilizing domestic political leadership and financial resources, there is an overall recognition of the state’s responsibility for setting public health agendas and implementing health-related interventions.

To achieve the nine technical targets and operationalize the four key means of their implementation under SDG 3, the health sector will need to assume a leadership role at the national level. The health sector’s pivotal position will be important in promoting actions, often implemented across sectors, which target the determinants of health and support overall well-being. At the same time, SDG 3 reflects the need for an integrated approach to addressing the cross-cutting elements of the SDG framework. Thus, the health sector will need to provide support to other sectors and institutions outside their purview to ensure progress and avoid inequitable health outcomes. While this approach will need to be adapted to differing country contexts, examining successful approaches employed at the national level can facilitate interventions that other countries in the Region may find useful.

Regional priorities

While each of the SDG 3 targets and indicators are applicable to all signatories, countries have the flexibility to decide which ones to specifically pursue as part of their commitment to the wider Agenda, according to their own priorities and sovereign interests. Nonetheless, much of the Region of the Americas shares common priorities, particularly with regard to NCDs, UHC, and the elimination agenda for infectious diseases, which are discussed in further detail below. In fact, PAHO/WHO Member States had adopted several resolutions concerning these topics, and other SDG 3 targets, before the 2030 Agenda. Moving forward, these areas will serve as opportunities to not only produce further success at the national level but also generate shared achievements through joint collaborations at the Regional level.

Noncommunicable diseases

NCDs represent a large and growing burden in the Region of the Americas, posing a threat to both regional and national development. Driven by the negative effects of unhealthy and unsustainable patterns of consumption, rapid unplanned urbanization, and longer life expectancy, these diseases have a direct impact on well-being, productivity, income, and health system costs (). The negative effects of chronic disease are exacerbated by an unequal distribution of the burden of disease predicated on socioeconomic inequality and unequal access to education, health services, and healthy living conditions. Knowledge about the impact of these diseases and the factors that lead to their development is limited by underreporting and underdeveloped monitoring systems.

Whereas the MDGs did not address NCDs, the inclusion of Target 3.4 in the 2030 Agenda clearly acknowledges the growing health burden of NCDs, a category that comprises 7 of the 10 leading causes of death in the world (). The explicit delineation of two separate targets to address communicable and noncommunicable diseases, both equally integral to the sustainability of human health and development, signifies that resources may need to be reallocated. Interventions that can most efficiently and effectively reduce the burden of diseases that pose the greatest threat to national and Regional well-being should be prioritized.

NCDs represent a whole-of-government issue, accompanied by a shift in discourse from the problem of individuals to a collective challenge requiring political action. These complex health challenges will require multisectoral collaborations and innovative solutions from heads of state. Approaches like the one used in the WHO Health in All Policies Framework for Country Action () that promote integrated, multilevel, and participatory health interventions have been identified as key to decreasing NCD prevalence in the Americas by acting on the relevant social and environmental determinants of health. Much can be learned from Mexico’s strategy to reduce obesity through its National Agreement for Healthy Eating (), Suriname’s enactment of antitobacco legislation aligned with the Framework Convention on Tobacco Control (), and Costa Rica’s executive order mandating schools to sell only fresh produce and foods and beverages that meet specific nutritional criteria ().

Target 3.4 goes further than just NCDs, however. Mental, neurological, and substance use disorders, including alcohol, are among the leading causes of the global burden of disease, and are the leading cause of global disability across all disorders worldwide and in the Americas. Like NCDs, mental health and well-being are precursors to family and community wellness, as well as the broader goals of the 2030 Agenda, which foresees “a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured” ().

Mental health can be linked with 8 of the 17 SDGs, including those related to health, poverty, hunger, gender equality, sanitation, employment, inequality, and inclusiveness. Given the important role of mental health, countries may consider measuring key markers of mental health and availability of mental health services, namely, avoidance of premature deaths, including those from suicide (), and achievement of parity in access to mental and physical health services (). In addition, Goals 4, 8, 10, and 11 highlight the inclusion of people with disabilities, essential for the promotion and protection of the rights of people with mental, neurological, and substance abuse disorders, a population that has historically comprised the most marginalized, vulnerable, and neglected in society (). Despite the significant overlap between mental health and substance abuse, each issue presents unique challenges. As such, a different target is dedicated to the prevention and treatment of substance abuse, though action on either will likely have implications for both.

Universal health coverage

In a Region that has historically maintained a public-private health system, UHC is considered an essential pillar for development. It is key to achieving health-related SDGs and critical to minimizing health system fragmentation, preventing disease, achieving better health outcomes, and, ultimately, promoting well-being for all. UHC also signifies a shift from disease-specific interventions to ensuring that communities have access to well-resourced health systems that offer comprehensive health services. Although the socioeconomic and political context of each country requires flexibility when developing strategies to achieve UHC, the need for health coverage for all is truly universal. Ensuring access to comprehensive, timely, and good-quality health care without discrimination requires a society-wide commitment to expand equitable access to health services and supplies, strengthen governance, increase financing, improve information systems, invest in human resources, and support multisectoral coordination.

To make meaningful progress toward fulfilling the promise of UHC, a human rights framework must be used to support the progressive and equitable implementation of the right to health as an obligation of the state. Doing so opens the door to an array of policies to increase the scope and equity of health programs. For example, national health systems have grown increasingly more responsive in delivering affordable care for all without causing financial hardship. Public spending, population coverage, and access to health services are increasing in the Region, while out-of-pocket payments are declining ().

A long-term challenge to UHC is the development of fiscally sustainable approaches to improve revenue generation. For any health system to become sustainable, countries must balance actual revenue generation and current expenditures. Increasing revenues through taxes is only one means of doing so and can be more or less equitable depending on which taxes are raised and in what ways they are raised (). Other ways to increase revenue include anchoring inputs or expenditures, such as limiting waste, reducing administrative inefficiencies, and reducing the adoption, intensity, and volume of services that are not cost-effective. The resulting level and quality of available health care resources is a trade-off between service coverage, the public service portfolio, and costs. Middle-income countries might struggle to adapt to steep health expenditures outpacing economic growth, whereas low-income countries often face other, unique, and possibly more limiting, obstacles. In addition to sustained investments in health, an evidence base, informed by continuous progress assessments and formal mechanisms for dialogue, should be prioritized to inform policies at the national level.

The call for UHC by the 2030 Agenda also leads to increased demand for qualified health workers, which must be matched with redoubled government efforts to produce and retain the health workforce. Strategies include coping mechanisms and self-sufficiency policies to address gaps in distribution of health workers. Countries can also offer higher salary levels and financial incentives to health providers, or introduce health worker safety policies to reduce occupational diseases and work-related accidents. Though ensuring a sufficient health workforce accounts for a significant portion of health service costs in low- and middle-income countries, strategic planning and management will better prepare countries to meet international health regulations and promote global health security (). It will also trigger broader socioeconomic development in line with SDG attainment, such as gender equality and decent employment opportunities.

The explicit inclusion of UHC and the promotion of both physical and mental health is evidence that the 2030 Agenda considers access to health and overall well-being as essential not only to human health but also to sustainable development.

Elimination agenda for infectious diseases

Countries in the Americas are increasingly aware that the control and elimination of infectious diseases have far-reaching implications for health and well-being, social and economic outcomes, and the achievement of SDG 3 and broader development goals. Over the last decades, the Region has undergone a changing environment marked by an increasingly aging population (demographic transition) and socioeconomic development including successful vaccination and vector control efforts, leading to a decrease in the overall burden of communicable diseases (epidemiologic transition). For example, there has been a 30% decrease in disability-adjusted life years (DALYs) due to communicable diseases since the year 2000. This significant progress in the control of many infectious diseases has prompted the next steps in infectious disease control, namely disease elimination.

The Region set targets for the elimination of many infectious diseases, and has already achieved many of these goals. Historically, the Americas has been a global pioneer in elimination efforts. Many endemic diseases such as smallpox (1971), polio (1994), rubella (2015), and measles (2016) were eliminated through the widespread use of vaccines. Regional elimination of mother-to-child transmission of HIV, malaria, tuberculosis, viral hepatitis B and C, syphilis (including congenital syphilis), and neglected tropical diseases (onchocerciasis, schistosomiasis, Chagas disease, leprosy, and trachoma) represents a more ambitious step forward.

Disease elimination has evolved from being based on interventions relying on effective vaccines to include those cases where no vaccine or cure (in the case of HIV) exists. In this regard, the WHO has coined the term “elimination as a public health problem,” wherein the elimination threshold is a minimum value that is achievable using all current evidence-based interventions, and where continued actions will be necessary (Box 1). Strategies for the elimination of communicable diseases now comprise a wide spectrum of interventions focusing on vaccination, use of vector control strategies, diagnostics, and medications, acknowledging the need for broad multisectoral interventions for success. Currently, there is no absolute common definition of elimination for all diseases. The various criteria used for disease elimination make having one single conceptual framework and definition a pending task that experts are working to build.

Box 1. Basic definitions related to the control and elimination of infectious diseases.

Control: Reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts. Continued intervention measures are required to maintain the reduction.

Elimination as a public health problem: A term related to both infection and disease. It is defined by achievement of measurable global targets set by WHO in relation to a specific disease. When reached, continued actions are required to maintain the targets and/or to advance to the interruptions of transmission. The process of documenting elimination as a public health problem is called “validation.”

Elimination of transmission: Reduction to zero of the incidence of infection caused by a specific pathogen in a defined geographic area, with minimal risk of reintroduction, as a result of deliberate efforts; continued actions to prevent reestablishment of transmission are required. The process of documenting elimination of transmission is called “verification.”

Eradication: Permanent reduction to zero of a specific pathogen as a result of deliberate efforts with no risk of reintroduction. Intervention measures are no longer needed. The process of documenting eradication is called “certification.”

Sources: Dowdle WR. The principles of disease elimination and eradication. Bulleting of the World Health Organization 1998;76(S2):23-25.
Pan American Health Organization. Report on the Regional consultation on disease elimination in the Americas. Washington, D.C.: PAHO; 2015.

The current major components of the elimination agenda include the vaccine-preventable disease agenda, including HBV infection; the neglected tropical diseases; the big epidemics of tuberculosis, HIV, and malaria; and lastly, sexually transmitted diseases and chronic HCV infection. The decreasing burden of disease and efficacy of technology will dictate new possibilities for elimination defining the thresholds for elimination from a public health perspective. As new drugs and new technologies develop, the elimination agenda will surely broaden to include other infectious disease and may expand into NCDs, such as for cervical cancer in relation to vaccine-preventable HPV.

Past experience shows that continuing current prevention and control efforts alone are not sufficient for elimination. In addition to strong political will, adapting strategies to local contexts, capitalizing on new technologies, and accelerating translation of science into policy and implementation are required. Combining intensified traditional approaches with innovative approaches can generate new synergies and enhance the effectiveness of elimination efforts.

Current threats to the elimination agenda include the emerging drug resistance, an increasingly aging population, antivaccination movements, and shifting political priorities. High initial costs in the path towards elimination might also be deterrents, but as the health system becomes more effective, unit costs will decrease. There are also high costs to monitor its success.

The Region is moving towards a comprehensive elimination agenda that ranges from disease control to eradication, with quantifiable goals for each step along the way. Countries are striving towards greater integration of disease elimination efforts and capitalizing on synergies. This agenda symbolizes how the Region continues to work on health, human rights, and tackling inequities. To achieve these ambitious targets, along with the other targets of SDG 3, countries must exercise strong leadership to collaborate and create synergies with other sectors and ministries.

Health across the SDGs

Unlike the disease-specific focus of health sector priorities outlined by the MDGs, the 2030 Agenda establishes numerous health-related targets that would traditionally fall under the coordination of other sectors. The interdependent framing of the SDGs creates opportunities for health programming and activities across the entire 2030 Agenda, allowing countries to tailor their national plans and policies to their own needs. While all SDGs create opportunities for the health sector, or have some effect on them, WHO has identified specific SDG targets and indicators that countries should prioritize in policy-making and resource allocation for the best return on health. These include Target 2.2 (child stunting, and child wasting and overweight); Target 6.1 (drinking water); Target 6.2 (sanitation); Target 7.1 (clean household energy); Target 11.6 (ambient air pollution); Target 13.1 (natural disaster); and Target 16.1 (homicide and conflicts) (Table 3).

Table 3. Sustainable Development Goal (SDG) targets identified by the World Health Organization for policy-making/resource allocation prioritization, 2016&ndash2030

SDG health targets
3.1 Maternal mortality and births attended by skilled health personnel
3.2 Child mortality
3.3 HIV, tuberculosis, malaria, hepatitis, neglected tropical diseases
3.4 Noncommunicable diseases and suicide
3.5 Substance abuse
3.6 Road traffic injuries
3.7 Sexual and reproductive health
3.8 Universal health coverage
3.9 Mortality due to air pollution; unsafe water, unsafe sanitation and lack of hygiene; and unintentional poisoning
3.a Tobacco use
3.b Essential medicines and vaccines
3.c Health workforce
3.d National and global health risks
SDG health-related targets
2.2 Child stunting, and child wasting and overweight
6.1 Drinking water
6.2 Sanitation
7.1 Clean household energy
11.6 Ambient air pollution
13.1 Natural disaster
16.1 Homicide and conflicts

Source: Adapted from World health statistics 2016: monitoring health for the SDGs ().

Like the SDG 3 targets, the quantity and breadth of these health concerns have far-reaching implications for funding and policy implementation, particularly in low- and middle-income countries. The systemic and multifactorial interventions needed to achieve these targets have the potential to strain the human, financial, and technological resources of health sectors and health systems. For example, “achieving universal and equitable access to safe and affordable drinking water for all” and “significantly reducing all forms of violence and related death rates everywhere” pose more complex challenges than the disease-specific MDGs.

Historically, policymakers and political leaders tend to prioritize the most feasible goals and activities with the potential to produce rapid results. As countries move forward with the 2030 Agenda, the criteria for prioritizing targets should instead focus on selecting those that utilize the most appropriate principles, assumptions, and methods to maximize health outcomes per unit of resources available.

While SDG 3 offers four essential means of implementation, they must be complemented by other actions to fully achieve the 2030 Agenda’s health and health-related targets. SDG 16 and 17 fill many of those gaps. SDG 16 articulates the importance of effective and equitable governance as an essential and enabling feature of the 2030 Agenda, and sets the stage for international cooperative action and partnerships among governments, civil society, and the private sector. SDG 17 supplements each of the goal-specific approaches with cross-cutting means of implementation for the entire agenda. Framed as a revised global partnership for sustainable development, SDG 17 covers a wide range of targets for finance, technology, capacity building, trade, policy, and institutional coherence.

Finance

National budgetary constraints demand a thorough analysis to strategically select which targets will be emphasized and how they will be financed. Public-private partnerships and investments in other sectors should be considered to ensure that all are viable and can operate efficiently. Internally, countries can mobilize domestic resources by improving tax collection, reducing external debt, and tackling tax evasion. A financially feasible development agenda will require domestic public resources and traditional sources of financing for development, such as official development assistance, as well as private investment, innovative mechanisms for funding to address structural threats to health, and the use of regulations to ensure compliance with national priorities and legislation.

The UN Addis Ababa Action Agenda, adopted in July 2015, was the first step toward developing a new and innovative financing framework (). It proposes an array of mechanisms for countries and stakeholders to effectively mobilize financial resources for the achievement of the SDGs, taking into particular consideration the challenges of middle-income countries like many of those in the Americas. The first Regional consultation on financing for development took place in Santiago, Chile, in March 2015, allowing the Region’s perspective and priorities to be fully reflected in the process ().

Measurement, monitoring, and evaluation

The importance of highlighting and tackling inequalities between subpopulations is central to the 2030 Agenda and requires indicators that incorporate data disaggregated for drivers of inequality. As the most inequitable region in the world, average improvements may mask growing inequalities between population groups, particularly the most vulnerable, disadvantaged, and marginalized. As such, there is a need to refine, adapt, and scale up the measurement, monitoring, and evaluation capacity of countries, especially those with less developed or poorly equipped health information systems. The explicit goal to develop indicators that are disaggregated by income level, education, gender, and ethnicity, as well as other important determinants of health and social inclusion within the SDG agenda, represents an important shift from the MDG agenda and reflects a growing appreciation for the negative impact of inequalities on health and development.

Mobilization of stakeholders

Achieving the health-related targets will require contributions, engagement, and leadership from beyond the health sector and greater coordination between public and private stakeholders. The term “stakeholder” should be considered broadly and adapted at the country level to expand the participation of relevant actors, including sectors such as finance, trade, environment, and labor, along with government institutions, local authorities, international organizations, civil society organizations, and the private sector. The negotiation process of the 2030 Agenda is a key example of how Regional leadership is both evolving and redefining traditional approaches to health and development. There is no doubt that the changing landscape of these players will continue to have important implications for the Region through 2030.

Because the most marginalized populations often suffer most from the negative effects of unsustainable growth and development, locally led civil society organizations are an essential element to fulfill the 2030 Agenda. A people-centered, inclusive, participatory approach will strengthen mechanisms designed to advance the 2030 Agenda. Moreover, as the front line of engaging with citizens to achieve the SDGs, civil society plays a critical role in widening access to different populations, fostering advocacy, identifying development priorities, proposing practical solutions, and even providing feedback on problematic or unrealistic policies (). Often, governments and civil societies share common goals; a good example of this is the Region’s adoption and implementation of tobacco control policies, a process in which civil society has actively promoted and monitored the enforcement of new policies ().

Although Regional bodies and organizations have long been involved in health issues in differing roles and to varying degrees, their increasing influence on global health policy-making will make them key players in the implementation of the SDGs. Because of their familiarity with Regional challenges, barriers, and opportunities, these organizations have the ability to mediate between the global and national levels. They also have the unique capability to unite specific countries and harmonize specific goals and data at the regional or subregional level. Ultimately, Regional organizations can generate new opportunities for information exchange at the global level.

Think tanks and academic institutions can also help accelerate the SDG process through their engagement in policy development, identification of determinants of success, measurement of policy outcomes, and role in ensuring that the knowledge that is generated, translated, and disseminated reaches marginalized populations more quickly (). In turn, these institutions can provide direct input to high-level processes and support more effective implementation of the overall 2030 Agenda as well as specific actions, thereby ensuring greater political accountability.

Finally, business has a critical role to play in achieving the SDGs. The private sector has traditionally been the driver of scientific and technological development and strategies. Involving the private sector has immense potential to tap into that innovative capacity and deliver solutions to the barriers outlined in the 2030 Agenda (). Mobilization of the private sector will be critical to provide capital, jobs, technology, and infrastructure. Governments should coordinate with the private sector from the earliest stages of planning and implementation to ensure that businesses contribute to, and do not undermine, inclusive and sustainable development.

Table 4. Examples of Regional stakeholders in the 2030 Agenda for Sustainable Development

Type of stakeholder  
Regional organizations Southern Common Market (Mercosur), Economic Commission for Latin America and the Caribbean (ECLAC), Central American Integration System (SICA), Council of Ministers of Health of Central America (COMISCA), Organization of American States (OAS), Pan American Health Organization (PAHO), Community of Latin American and Caribbean States (CELAC), Union of South American Nations (UNASUR), Andean Health Organization (ORAS-CONHU)
Civil society Nongovernmental organizations, neighborhood associations, media, unions
Think tanks and academic institutions Universities, research institutes
Private sector Industries, businesses

Identifying common ground

The 2030 Agenda is a timely reminder of the complexity of human health and the systems designed to protect it. It is also an opportune moment to strategize, coordinate, and plan for a future in which many of the Region’s greatest health concerns will originate outside the health sector. In light of this, health experts will be required to strengthen health systems and break down artificial boundaries across sectors to address key trends in the Americas that have direct and indirect implications on the Region’s health and well-being.

Health in All Policies (HiAP) is a useful framework for policymakers and government officials to address the SDGs at the national level (). Before the Health in All Policies approach was explicitly defined, it had already been adopted and applied throughout the Region of the Americas to place health at the center of development. Specifically, the HiAP framework is designed to identify and develop common ground between the health sector and other sectors in order to build shared agendas and strong partnerships, ultimately leading to mechanisms for participation, accountability, collaboration, and dialogue among various social actors ().

HiAP is frequently seen as a country approach to tackle NCDs and the social determinants of health, including tobacco use, obesity, housing, and transportation. Focused action and alliances between the health sector and sectors involved in clean energy, chemical safety, standards for employment opportunities in the health industry, and safe food production and distribution have also proven to be win-win situations (). While the HiAP framework has been successful in these areas, it can also be effective in “hard” politics (the use of traditional political systems and mechanisms), bringing together various stakeholders in health security, foreign policy, and finance to negotiate for health among competing interests. Given that the HiAP approach requires firm, long-term political commitments from national authorities responsible for formulating policies within and beyond the health sector, the 2030 Agenda provides an effective platform for building intersectoral health-oriented policies.

Likewise, innovative health promotion strategies can result in greater capacity and empowerment to both prevent and respond to public health concerns. A robust Healthy Municipalities and Communities Network() (Red de Municipios y Comunidades Saludables) is already in place throughout much of the Region (). In line with the 2030 Agenda, health promotion and the Healthy Settings approach() provide practical models of integrated, multilevel interventions based on enabling healthy environments, engaging local governments, reorienting health services, and promoting well-being and healthy choices through political commitment, public policies, community involvement, and strengthened individual capacity to improve health.

Both of these approaches complement the biomedical services already in place, but they also foment a Regional shift from response to preparation and prevention of negative health outcomes, and from a medicalization of society to a true public health approach to solve complex challenges. In addition, they emphasize the fact that all people and all levels of government bear responsibility for controlling diseases and managing health. The approaches and principles of the health promotion and HiAP strategies mirror those of the SDGs, thus ensuring synergy with the 2030 Agenda. More specifically, the Agenda’s call for an inclusive and participatory approach, expanded resources and participation, and collaboration across sectors presents a historic opportunity to mobilize relevant sectors, local and national governments, civil society organizations, and communities in an effort to promote health and achieve HiAP goals. Both strategies will be increasingly important at the global level, for achieving the goals of the 2030 Agenda, and at the Regional level, with regard to managing the effects of mega-trends and addressing inequalities that have become so large that they contribute to instability and poor health outcomes.

Poverty eradication

Poverty reduction is inextricably linked to health and sustainable development. It is a multifaceted phenomenon that threatens the health outcomes of affected individuals and communities, denying them full enjoyment of their human rights, including the right to health. As shown in Table 1, poverty and extreme poverty rates have decreased in the Americas since 1990, culminating in the Region’s achievement of the first target of the MDGs. Thanks to improvements in employment opportunities and income levels, income inequality also fell during this period ().

Nonetheless, since the start of the economic slowdown in 2008, the downward trends for poverty and extreme poverty have slowed; in fact, the rates are projected to increase slightly in coming years, which will affect the creation of jobs and the quality and level of the available work (). Moreover, the Region remains the most unequal in the world, leaving a high proportion of the population in a highly vulnerable position defined by volatile incomes near the poverty line (). In this way, poverty eradication signifies more than the elimination of extreme poverty; it also involves efforts to close these gaps and minimize individuals’ and communities’ vulnerability to poverty.

Approaches that prioritize concerted efforts toward poverty reduction will benefit from potential synergies with other priority areas of sustainable development, including sustainable cities, employment, energy, water, and education. Previous Regional experience has demonstrated that progress toward poverty reduction will remain fragile and reversible until countries embrace the multisectoral approach presented by the 2030 Agenda. Cross-sectoral collaboration must be accompanied by concrete commitments to ensure UHC, universal access to health, and social protection mechanisms that sustainably mitigate vulnerability and eradicate poverty in all its forms.

Sustainable consumption and production

Controlling production and consumption patterns are prerequisites for achieving the 2030 Agenda objectives of true equity, inclusion, and sustainability. As the Region’s population continues to grow, so does the importance of maintaining the productivity and capacity of the planet to meet human needs and sustain economic activities. At the same time, Regional patterns of consumption are being altered by lower fertility rates and an aging population ().

In order to reduce the risks to health and the environment associated with overarching demographic dynamics, this two-pronged issue depends on the sustainable, clean, and efficient production of goods and services, as well as more efficient and responsible consumption. Natural resources key to human survival, such as water, food, energy, and habitable land, must be protected; pollution associated with human and economic activity, including greenhouse gases, toxic chemicals, emissions, and excess nutrient release, must be reduced; and current consumption patterns, as drivers of unsustainable development, poor health outcomes, and resource degradation, must be significantly altered.

Food loss, waste, and overconsumption represent part of the unsustainability of the Region’s production and consumption patterns. The overconsumption of food has led to sharp increases in obesity and detrimental effects on the environment, primarily through greenhouse gas production, overuse of arable land, and deforestation. In spite of this, growing consensus in recent years shows that the Region has not only an adequate food supply but also a network of economic and social policies that could eradicate hunger, combat malnutrition, and address obesity in the short to medium term ().

To achieve the goals of the 2030 Agenda, the Region will need to promote a combination of multisectoral policies and economic and social activities. These should serve as enablers, empowering countries, producers, and consumers to become owners and successful users of technologies and processes that will ensure resource efficiency, sustainable consumption, and, ultimately, healthier livelihoods and lifestyles.

Governance

Since the start of the global financial crisis, the Region has been undergoing an economic slowdown. The Americas will confront the challenges of the 2030 Agenda in the midst of persistent external vulnerability, long-run low growth rates, smaller financial inflows, weaker external demand, and declines in investment growth rates. The slowdown has led to consistently increasing urban unemployment rates and poor employment quality, factors that partially explain why Regional inequality reduction has slowed. These patterns of economic activity represent one of the most significant challenges for the Region in building the capacity, infrastructure, and innovation necessary to achieve the 2030 Agenda ().

Moreover, these economic trends have the potential to reverse development progress achieved over the last decade, particularly with regard to shared prosperity and poverty reduction (). Sustaining these advances and realizing the SDGs, despite the deceleration of activity and sometimes contracting economy, means the Region must change its way of doing business under conditions less favorable than those experienced during the MDG era. This will require a stronger Regional commitment to governance and regulation of the ways institutions are shaped, legitimized, and equipped. Governance structures affect growth, equity, and well-being, each of which is pivotal for realizing sustainable development.

Accountability and responsiveness are two key pillars underlying the effectiveness of government institutions and their ability to deliver on the SDGs. Neglect of these pillars can lead to social and political instability, reduced investment, poor economic performance, and direct and indirect effects on the well-being of citizens. They can be overcome by reforms that prioritize transformative leadership, citizen participation, transparency, and innovative interventions. In order to manage this transition and mitigate the associated risks, it is vital that the Region continue to bring together high-level decision-makers, researchers, experts, and civil society to engage in strategic policy discussions, build alliances, and explore innovative approaches and mechanisms for use by governments and citizens to effect positive, sustainable change.

Urban development

The Region of the Americas is the most urbanized region in the world, with nearly 80% of the population living in urban centers, a proportion expected to increase to an estimated 85% by 2030 (). These urban areas are often hubs of innovation and economic production, with populations that tend to have greater access to social and health services than their rural counterparts. While opportunities, jobs, and services are concentrated in these areas, so are health risks and hazards. The adverse effects of these conditions are increasingly concentrated among the urban poor, generating notable health inequities between the richest and poorest urban populations. Aggravated by poor strategic planning, the ability of urban centers to meet the needs of their entire population has become a persistent challenge that will inhibit truly sustainable development.

For example, unhealthy lifestyles resulting from diets that prioritize cost savings and convenience over health; sedentary behaviors; and the harmful use of alcohol, tobacco, and drugs could heighten risks related to obesity and the increase in chronic NCDs, including diabetes, heart disease, and cancer (). In addition, the potential for communicable disease outbreaks is amplified due to large numbers of people living in close proximity, oftentimes in conditions with compromised standards for sanitation and water provision. Substance abuse, poor housing conditions, road safety concerns, and a plethora of environmental hazards associated with urban centers can also have a harmful effect on the ways in which people grow, work, live, and age.

If the 2030 Agenda is to effectively foster health and well-being in a way that advances equity, the importance of urban centers to human lives and livelihoods must be fully considered. Although an increasingly urbanized world has the potential for a multitude of adverse consequences for health and well-being, it also creates opportunities. Because the trends of urbanization are highly interdependent and multilevel, a greater focus on the ways in which cities are planned, designed, developed, and managed can help policymakers recognize systemic relationships and opportunities for strategies that will generate co-benefits and long-term synergies for health. Strategies from multiple sectors must be applied to reduce inequities and influence the determinants of health associated with rapid urbanization.

Environmental sustainability

Widespread urbanization, population growth, and industrial development continue to directly affect human health and broader development goals in the Americas. The effects of these trends include increased exposure to both traditional environmental hazards, like indoor air pollution and drinking-water contamination, and newer hazards, such as toxic chemicals, pesticides, electronic waste, and phenomena related to climate change, including natural disasters and irreversible changes to ecosystems. In terms of climate change, shifting temperatures alter disease patterns and vector distributions, ambient air quality has negative effects on respiratory health, and extreme climate events increase the vulnerability of populations to morbidity and mortality. At the same time, higher population concentrations require increased reliable access to resources that are already in high demand, namely water, sanitation, infrastructure, and energy.

While the assortment of risks varies across and within countries, they all reflect potential effects of environmental shifts on the Region’s vulnerability. Moreover, they are evidence that sustainable development, environmental health, and climate change are deeply intertwined, and that improving environmental conditions is a prerequisite for achieving SDG 3. This interconnectedness is apparent in both SDG 13 of the 2030 Agenda and the Paris Agreement of the United Nations Framework Convention on Climate Change (). In the Paris Agreement, several Regional signatories have committed to strengthening responses to the threat of climate change and developing plans to urgently reduce greenhouse gases to help meet part of the Framework’s broader goals to “allow ecosystems to adapt naturally to climate change, to ensure that food production is not threatened, and to enable economic development to proceed in a sustainable manner” (). In other words, the planet and the people that inhabit it are intrinsically interdependent. Because they cannot be separated, the harms inflicted on the planet are a threat to peoples’ health and ability to thrive.

The Region’s unequal distribution of income and the fact that those in the highest income brackets make a disproportionate contribution to emissions will require considerable improvements in the diversification of renewable energies; preservation measures in agriculture; and coverage of public services, such as mass transit and waste management (). In this way, multisectoral approaches to protecting the environment and protecting people from the consequences of its degradation are increasingly accepted as key aspects of strategies for overcoming health inequities and achieving the broader 2030 Agenda.

The health and well-being of the Region, as well at its ability to achieve these global agendas, is dependent on scaled-up actions, both immediate and long-term, to address the rapidly changing nature and scope of challenges related to the environment and climate change. Those actions are also needed to ensure that all national development plans consider environmental concerns and include rigorous safeguards and sustainability measures that also benefit and synchronize with the aims of the health sector, such as actions related to chemical safety (). Throughout this process, the greatest challenge will be to reconcile the demands of growth with the need to protect and manage natural habitats and resources and the importance of ensuring that environmental policies do not generate additional burdens for the poor. Nonetheless, the Region has many opportunities to address the topic of health and many facets of environmental sustainability in national and regional policies, which can subsequently contribute to an enabling environment for achieving many of the SDGs.

Building resilience and improving adaptive capacity is critical to continued development and achievement of the 2030 Agenda across the Americas. Adaptive efforts include increasing engagement with other sectors to improve environmental consciousness; reducing carbon footprints; and developing innovative solutions in renewable energy, transportation, water supply, forestry, agriculture, and urban development. In addition, countries must improve the reliable production of environmental statistics, promote research, build regional capacity, and develop platforms for dialogue and shared learning among relevant stakeholders. This will support the development of evidence-based prevention policies; generate income opportunities; mainstream environmental health and climate change in broader development initiatives; and ultimately strengthen the Region’s capacity to adapt to an ever-changing world.

Looking forward

The world has entered a new era of sustainable development, building on the successes of the MDGs. To continue advancing on social, economic, and environmental fronts, the Region must advocate, implement, and practice innovative public policies that close persistent inequities and address the increasing complexity and interconnectedness of health and development. Although only one of the 17 SDGs explicitly names health as a priority, many SDGs and their targets are related to health and thus highlight the health sector as one that not only is inherent to achieving the overall 2030 Agenda but also provides many opportunities for cooperation. In this way, health is central to the development of an equitable and sustainable future.

In the midst of rapid urbanization, threats to the climate and environment, and the emergence of new challenges, such as the growing burden of NCDs, it is crucial to adopt the 2030 Agenda core principles of equity and multesectoriality to harness complementary efforts and deliver shared gains. National plans and global agreements that are already in place, such as the WHO Framework Convention on Tobacco Control, the Minamata Convention, and the Paris Agreement, are prime examples of how the 2030 Agenda can be used to integrate priorities, innovations, and inputs from a variety of partners and stakeholders (). The public, private, and civil society sectors all have a role to play in strengthening the implementation of these policies and ensuring that new policies and interventions are not only equitable but also efficient.

Health is politicized at all levels of governance—locally, regionally, and globally—in governments, international institutions, the private sector, and civil society organizations. In addition, health itself is inherently political, because it is unevenly distributed, with many determinants that are dependent on political action, and inherently related to human rights (). Thus, only when the political nature of health is explicitly acknowledged will countries be enabled to develop more realistic, evidence-based public health strategy and policy.

Given the central importance of equity to the 2030 Agenda, it is clear that persistent inequities are not likely to dissipate unless health-related issues are discussed and addressed at the highest political levels. Because health affects economic and social conditions, and thus also has an impact on political legitimacy, the consequences of not embracing this strategic shift may be significant. At the same time, the effective use of politics in public health is already generating positive outcomes in areas such as NCDs and climate change. In order to gain political influence, countries and public health organizations must be equipped to analyze political contexts and complexities, frame arguments, and act effectively in the political arena ().

The 2030 Agenda has redefined public health in a fundamental way by demonstrating that public health challenges can no longer be addressed merely through technical actions but must be accompanied by political action within and beyond the health sector. The implementation of such an ambitious agenda simultaneously () creates opportunities to apply an ecological perspective, and systems thinking, and () requires that health be considered in government policies. Regional bodies, civil society groups, and global health institutions will be essential in accelerating the 2030 Agenda at all levels of governance, and the Region of the Americas must be prepared to embrace a more political approach to health in the context of sustainable human development and the SDGs.

Conclusions

The 2030 Agenda represents a fascinating point in public health history in which health is a driving force for a new quality of life and well-being, and challenges in the health sector extend beyond traditional health boundaries. The health sector thus becomes intertwined not only with development but also with politics and political processes. Health challenges require complex solutions and should thus have policy potential to take advantage of windows of opportunity and produce mutual gain across different sectors. Moreover, the co-production and co-benefits of health must be shared across society as a whole. The 2030 Agenda establishes a framework in which successful outcomes in health can have a positive impact on other aspects of development-advances that will in turn reciprocally benefit health.

Despite the complex interplay of the SDGs, the 2030 Agenda’s call is straightforward: in order to create a more equitable world for future generations, countries must identify their most vulnerable populations, develop innovative strategies to reach those populations, and monitor progress toward that end. Achieving these objectives should not be solely the responsibility of government, however. The aspirational goals and targets of the 2030 Agenda must be translated into relatable, practical, and implementable actions that individuals, families, and communities can take. These everyday actions will make sustainable development tangible, enhance effectiveness, involve new actors, and foster ownership of the Agenda across and within borders. Now, more than ever, it is of paramount importance to collectively transform the 2030 Agenda into a reality for the benefit of all.

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Healthy Municipalities and Communities Network: A strategy that integrates actions across public health, popular education and community development to address the economic, social, and political determinants of health. More information can be found at https://www.paho.org/hq/index.php?option=com_content&view=article&id=10706&Itemid=41981&lang=en; http://www.who.int/healthy_settings/types/hmc/en/.

The settings-based approach to health promotion involves holistic and multidisciplinary action across risk factors to maximize disease prevention via a “whole system” approach. More information is available at http://www.who.int/healthy_settings/en/.

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Reference/Note:

Inequities and barriers in health systems

  • Equity in the context of Regional transformation processes in health
  • Inequities and barriers in health systems: defining the problem
  • Health systems–generated inequities and barriers
  • Barriers in access to services and inequities in coverage
  • The critical role of human resources for health
  • Access to medication and appropriate health technologies
  • Social determinants: barriers to equitable health and well-being
  • Measuring equity in health systems performance: the paucity of information
  • References
  • Full Article
Page 1 of 9

Equity in the context of Regional transformation processes in health

The quest for equity is a persistent challenge for health systems in the Region of the Americas. Significant advances have been achieved in health in part as a result of the economic and social development of countries, the consolidation and strengthening of health systems, and the ability to incorporate and apply emerging technologies to improve health and well-being. The political commitment of countries to respond to the health needs of their populations has been an essential contributing factor to these achievements ().

Despite the advances, poverty and inequities remain a challenge in the Region. Recent data suggest that Latin America and the Caribbean (LAC) remains the most inequitable region in the world, with 29% of the population below the poverty line and the poorest 40% of the population receiving less than 15% of total income. Such inequities are reflected in health outcomes: for example, the Region of the Americas did not achieve the Millennium Development Goal (MDG) target for the reduction of maternal mortality by 2015, and despite significant reductions in infant mortality, very sharp differences exist between countries. Without specific interventions to transform health systems, economic growth is not sufficient to reduce inequities ().

In October 2014, PAHO Member States approved the Strategy for Universal Access to Health and Universal Health Coverage (from here on, referred to as “universal health”) (). The strategy emphasizes the need to strengthen health systems to achieve universal access and coverage, namely by reducing health inequities; expanding access to comprehensive, quality care; and improving the health and well-being of the population. The strategy underscores the need for more and better investments in health, in particular to strengthen the first level of care, and for moving decisively toward integrated health services. In addition, it calls for strengthening intersectoral approaches to the social determinants of health in order to reduce social inequalities and inequities in access and health outcomes.

Achieving equitable, comprehensive, and integrated health services will require important transformations in the model of care and in the organization of health care delivery. The countries of the Region agree that models of care based on the values and principles of the primary health care strategy should govern health care organizations or networks to provide integrated, quality, people- and community-centered services (). Certain changes will be essential, including more equitable health financing, new or adjusted regulatory frameworks, innovative approaches to human resources education and allocation, and strong leadership by the national health authorities.

Most health systems in the Region of the Americas struggle with the dichotomy of a declared policy intention to move toward universal health and people- and community-centered models of care based on the values and principles of primary health care and the reality of maintaining structures and practices of the old biomedical model. In curative services–oriented systems, a preponderance of funds is allocated to inpatient care. Evidence of this can be found in the way in which most ministries of health in the Region allocate the larger portions of their budgets to hospital services that are inequitably distributed nationwide.

In light of the above, countries urgently need to accelerate the transformation of their health systems—with universal health as a deliberate goal. Comprehensive strategic actions implemented in a progressive and sustained manner are required to build health services that are responsive to the needs of all populations. As democratic processes in the Region are consolidated and greater decision-making power is transferred to people and their communities, the social demand for universal health can be expected to grow, supported by increasingly well organized advocacy efforts.

Inequities and barriers in health systems: defining the problem

It is important to differentiate inequality from inequity. Inequalities, as defined by WHO (), are differences in health status or in the distribution of health determinants between different population groups. Inequities are those inequalities that are considered avoidable, unnecessary, and unfair ().

This means that not all inequalities are avoidable or unfair. Differences in life expectancy between men and women are a good example. When variances are due to intrinsic biologic differences, they are not considered unfair; however, when they are caused by social policies or barriers to the exercise of essential rights, they become inequalities that are unfair, unnecessary, and avoidable—thus, inequitable ().

The current debate on inequities in health introduces new terms and definitions that are useful in characterizing important aspects of the problem. One such term, structural inequities, refers to “how policies and practices embedded in systems such as social welfare, economic, justice and health care operate to produce inequitable distribution of the determinants of health” (). As such, “inequities are structural because they are entrenched in the political and economic organizations and they are violent because they cause injury to people” ().

Health systems–generated inequities and barriers

The health system is an important cause of inequity in health. As stated by Barbara Starfield, “Inequity is built into health systems—especially western health systems that are based on a view of health needs disease-by-disease” ().

Due to certain conditions of their historical development, the traditional organizational structure of health systems in the Americas was in most countries characterized by uncoordinated subsystems providing care to different strata of the population. This led to a high level of segmentation and fragmentation, profoundly affecting the systems’ performance, efficiency, solidarity, and equity. Indeed, health systems with these characteristics do not adapt to the needs of populations with present-day epidemiological profiles, in which aging and noncommunicable chronic conditions are increasingly important challenges.

The segmentation and fragmentation observed in the majority of health systems in the Region result in inequity and inefficiency that compromise universal access, quality, and financing. Segmentation and fragmentation are perpetuated by poor governance and weak regulatory capacity of health systems (). Fragmentation, on its own or with other factors, generates difficulties in access to services, delivery of services of poor technical quality, irrational and inefficient use of available resources, unnecessary increases in production costs, and great user dissatisfaction. Moreover, the evidence indicates that in insufficient coverage schemes, the focus on disease rather than meeting the health needs of people and communities results in not only greater costs but also loss of income, creating a vicious cycle of disease and poverty in families.

Although health services in the majority of the Region’s countries are fragmented, the degree of fragmentation and the underlying causes vary from country to country. The literature reviewed and consultations in countries suggest multiple causal factors, including institutional segmentation, decentralization, suboptimal funding, predominance of vertical programs, separation of public health services from curative services, disease-centered models, weak steering capacity, and human resources in health that are numerically insufficient, inadequately trained, and poorly distributed ().

Fragmented health services, which are predominantly based on the model of inpatient hospital care, undermine the capacity to respond to the overall health needs of the population. In most health systems, the current delivery model centers on episodic care of acute conditions in hospital centers, with intensive use of technology and specialist physicians. Health system investments and reforms have not always been targeted to meet new challenges, and new technology and innovation have not been sufficiently incorporated into the management and delivery of services. In many of the Region’s countries, this creates an unbalanced investment in urban hospital-based services and new technologies, to the detriment of health promotion and preventive interventions at the first level of care. Meanwhile, services in rural communities or for populations in conditions of vulnerability are neglected or under-resourced.

Fragmentation is not simply a problem of referral mechanisms. More importantly, it affects comprehensiveness, coordination, and continuity of care between different health facilities, levels of care, and clinical specialist/teams throughout the life course. It therefore demands more complex approaches and solutions. Lack of coordinated care is further compounded by limited resolution capacity. This is particularly true at the first level of care, which affects the capacity to respond to emerging health needs, especially the growing needs of aging populations and the growing burden of chronic conditions throughout the Region.

On the other hand, in many countries of the Region, health care services do not respond appropriately to the differential health needs of people and communities. Populations in conditions of vulnerability (extremes of life, women and children, ethnic minorities, patients with chronic and/or incapacitating diseases, etc.) are the most affected by this problem. For example, women’s health issues are a combination of health risks and disorders that they have in common with men, and issues that exclusively affect women because they relate to biology. Both are strongly affected by gender, ideology, and politics.

The changing scope of the worldwide burden of disease shows important advances in some of women’s foremost health priorities (), but considerable challenges and inequalities exist. While the achievement of sexual and reproductive health rights is still an unmet goal, noncommunicable diseases such as cardiovascular disorders, stroke, cancer, diabetes, chronic obstructive pulmonary disease, and mental health disorders are now the leading causes of death and disability for women of almost all countries (). On the other hand, in the Americas, men die from external causes four times more often than women. The lack of appropriate coverage of these groups affects their right to health and well-being and has negative effects on the social and economic development of countries. The same is true for populations subject to structural racism (especially indigenous and Afro-descendant populations). Structural racism describes the confluence of institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups. In the United States, “structural racism, the systems-level factors related to, yet distinct from, interpersonal racism, leads to increased rates of premature death and reduced levels of overall health and well-being” ().

Problems of exclusion and lack of access to quality services persist for large sectors of the population. The lack of appropriate coverage and access has a considerable social cost, with catastrophic effects on population groups in conditions of greatest vulnerability. In the Region, 30% of the population does not have access to health care for financial reasons and 21% does not seek care due to geographical barriers. Populations in conditions of vulnerability are among the groups most affected by this problem ().

Barriers in access to services and inequities in coverage

Classically, access to health has been defined in three dimensions. The first is physical access, understood as the availability of good health services in different parts of a country, of reasonable scope, with opening hours as well as other amenities that make it possible for users to obtain services when needed. The second dimension is financial access, which consists of monetary arrangements that affect the capacity to make use of services and that include not only fees but also indirect costs (e.g., transportation). The third is sociocultural acceptability, which represents the will to request services and is understood as the capacity of the services to adapt and respond to the realities and social and cultural requirements of the population. Acceptability is lowest when people perceive that services are ineffective or when, for reasons of language, age, sex, sexual orientation, ethnic origin, or religion, the service provider dissuades them from seeking care. Inequalities exist in girls’ and women’s access to health care for their comprehensive needs across the life course. The reproductive health services that are most unequally distributed among women by socioeconomic status, ethnicity, and age are prenatal care, skilled birth attendance for delivery, and family planning. These disparities have many complex sources, including poverty, poor education, disempowerment, weak health systems, and gender discrimination. The poor technical and interpersonal quality of care for all women has also been highlighted as a frequent problem. Improving health services coverage demands analyzing and selecting actions to modify and eliminate the barriers to access in each of these dimensions. For communities seeking to achieve universal health, services should be physically accessible, financially attainable, and socioculturally acceptable for individuals.

PAHO defines access as the availability of comprehensive, appropriate, timely, quality health services when they are needed. But more specifically, access takes into account cultural and ethnic preferences, is linguistically appropriate and gender-sensitive, and bases actions and interventions on the identified needs of the populations. Further, such services promote health, prevent diseases, and throughout the life course, provide quality care that includes diagnosis, treatment, rehabilitation, and palliative end-of-life care. Quality health service encompasses intersectoral approaches to the social determinants of health and encourages active participation of individuals and social and community organizations.

Analysis of health infrastructure distribution in the Region reveals significant inequities in the concentration of service facilities, particularly hospitals, in large urban centers. Likewise, the farther removed health facilities are from cities or urban areas, the greater the shortage of competent personnel and inputs. This affects access and aggravates inequities. At the first level of care, the lack of adequate infrastructure (in number, geographical distribution, and response capacity) generates, among other adverse phenomena, excessive use of emergency services. This drives up costs, hampers efficiency, negatively affects both the continuity and quality of care, and increases the level of dissatisfaction among users and health care workers.

Poor quality care, provided by models that are inappropriate for the needs and health priorities of the population, also negatively impact health equity. Poor quality and warmth in the delivery of services—such as, courteous indifference, crowded waiting rooms, poor or lack of information, long wait times for surgery or other procedures or treatments, opening days and hours that do not accommodate people’s preferences and needs, refusal to provide care or treat patients who cannot pay, and poor maintenance of ancillary facilities (e.g., restrooms that lack soap and water or that are unclean or out of order, and a general absence of commodities such as seating in the waiting area) are unfortunate characteristics of many health services in countries of the Region. These situations are further compounded by frequent cancellation of long-awaited appointments due to the absence or shortage of personnel, malfunctioning diagnostic and treatment equipment, or unavailability of essential supplies, particularly medications.

The critical role of human resources for health

Serious imbalances and gaps persist in the availability, distribution, composition, competency, and productivity of human resources for health, particularly at the first level of care. Worldwide, evidence indicates that a threshold of 25 health workers/10,000 population (physicians, nurses, and certified midwives) is a useful benchmark for achieving adequate coverage (i.e., 80% of the target population) for programs or basic health interventions such as immunization and deliveries attended by skilled personnel (). However, this threshold does not account for the broader offering of health services made necessary by changes in the burden of disease, particularly by the growing prevalence of chronic conditions. The regional variation ranges from 3.6 health workers per 10,000 people in Haiti to 135 per 10,000 people in Cuba. In total, 16 countries of the Region demonstrate a critical shortage of health workers. The situation is even more serious if one considers the availability of health workers at the first level of care ().

The shortage of human resources for health care constitutes one of the main challenges or stumbling blocks in achieving universal health. The first challenge is relevant to all countries of the Region regardless of income level: providing care to dispersed populations in rural or remote areas and to communities in conditions of vulnerability. The second challenge is the profound historical imbalances in many countries; there are significant differences in the availability, distribution, composition, competencies, and productivity of the health care work force, which to a great extent is determined by segmented and asymmetrical work markets. In turn, training institutions play a critical role in the quality of training for health workers but respond to an educational market that is mostly unregulated. Finally, depending on the leadership and managerial capacity of the health system and the strategies implemented, health care workers and their organizations may either contribute to creating more equitable health systems or may become an impediment.

The available data suggest that by 2030, the majority of the countries in the Region will have surpassed the minimum level of 25 health care workers per 10,000 population, although a small number will still have critical deficits. However, in light of present commitments in countries of the Region, changing epidemiological and demographic profiles, and the ongoing transformation of the model of care, the relevance of this indicator needs to be reassessed in relation to the challenge posed by universal health.

The availability of health workers nationally does not reflect the profound imbalances in how they are distributed relative to health needs. One indication is the high concentration of health care workers in large cities to the detriment of the most remote, rural areas. For example, a study conducted in Brazil documents a doctor shortage in 1,280 non-metropolitan municipalities, (primarily in the northern and northeastern regions of the country) that affects more than 28 million people ().

The composition of the health care work force is another critical element that affects access to skilled health workers, consistent with the health needs of the population and the transformation of the model of care. In many countries, medical professionals, particularly specialized physicians, often serve as patients’ first point of contact in the health care system. There are only five countries in which primary care physicians constitute more than 40% of the total medical work force. Regarding the ratio of nurses to physicians, with the exception of the English-speaking Caribbean (where a majority of countries have a ratio of 3–5 nurses per doctor), there are significant nurse-to-doctor imbalances; only five countries in Latin America register a ratio close to one nurse per physician ().

Another relevant challenge is the availability of personnel with the right competencies; this is related to cooperation among educational institutions and with health authorities. Important gaps persist in the ability of countries to institute undergraduate curricula oriented toward primary health care, and to ensure that students from underserved populations have access to educational opportunities in the health professions. Only two countries in the Region reported that at least 80% of the health science schools have reoriented their curricula toward primary health care and have incorporated strategies for interprofessional training. Thus, building a health care work force trained and aligned to the current objectives and goals of primary health care and universal health has emerged as the great pending challenge in the area of human resources for health education and training.

Access to medication and appropriate health technologies

Access to and rational use of safe, effective, quality medicines and other health technologies, as well as respect for traditional medicine, continue to present challenges for most countries of the Region and affect quality of care. Supply problems, the underuse of generic drugs, higher-than-expected drug prices, and inappropriate and ineffective use of medicine all constitute additional barriers to universal health coverage affecting equity in health (). The regulatory capacity for medicines and health technologies is improving Region-wide, but it remains a challenge, particularly for the newer and more complex health technologies required by health systems.

For significant sectors of society, expenditures on drugs remain the most important component of out-of-pocket expenditure due to absent or inadequate health care coverage. Per capita, the average out-of-pocket expenditure for drugs in LAC reached US$ 97; it ranged from US$ 7 in Bolivia to US$ 160 or more in Argentina and Brazil. Additionally, compared to men, women pay 16–40% more for health care, they live longer, provide more unpaid health care more, and have more unmet health needs.

In the majority of countries of LAC, expenditures on medications are among the most significant items in health budgets (along with human resources); the costs constitute 25% to 65% of a country’s health-related expenditures. In comparison, in developed countries, expenditures for pharmaceuticals range from 7% to 30% of their total health-related expenditures.

Accordingly, increases in the cost of medications (and the lack of financial protection to cover those costs) limit individuals’ access and impact the sustainability of health systems and the attainment of universal health.

A similar challenge is posed by the dizzying development of health technologies in diagnostic imaging and radiation therapy; often there is a gap in access to these services. Additionally, the often rapid incorporation and use of these technologies create important inefficiencies.

Social determinants: barriers to equitable health and well-being

In the Americas, efforts to achieve universal access to health and universal health coverage began as early as the 1970s. Over the past three decades, several countries in the Region have implemented health system reforms that fostered inclusion, citizen participation, and equitable access to health care. Despite this progress, however, most countries in the Region still experience great inequities in health status and coverage of health interventions, with the result that there are major differences in health outcomes based on people’s wealth, education, geographic location, gender, ethnicity, and/or age ().

In LAC, for example, affordability is one of the most important determinants of access to and coverage of health care, and populations from poor communities are less likely to seek or attain care due to the direct and/or indirect cost of treatment (). Although many countries throughout LAC have made substantial efforts to expand health services to poor populations, health inequities caused by economic factors remain widespread in the region, especially for women, infants, and children (). In the United States, health inequity is a persistent problem, despite attempts to address it. United States government reports show that since 2007, “inpatient care for people with heart failure has actually grown worse for Hispanics or Latinos, Native Americans, and Alaska Natives. These minorities…are younger than their white counterparts. They also encounter socioeconomic, language, and cultural barriers to care that lead to higher rates of re-admission to hospitals and to poorer outcomes” ().

On the other hand, in Haiti and Nicaragua, the gap between the poorest and wealthiest women who have had at least four prenatal visits is more than 30%. Also, women from the poorest quintile in El Salvador, Guatemala, Bolivia, and Panama have unmet needs for contraception that is four times higher than the women from the wealthiest quintile ().

For populations living in poor settings, a range of different interventions has proven effective in overcoming financial barriers to health care. For example, by redistributing tasks to trained community health workers at the health facility level, a “task shifting” intervention, which was originally piloted in Haiti and later validated by WHO, has improved access to health services at the facility level by decreasing indirect costs (such as for transportation and lodging) for populations living in these settings ().

Education is another factor that significantly impacts access to health care. According to a systematic review of health literacy and health outcomes, individuals with lower levels of health literacy consistently had poorer health-related knowledge and comprehension, were less able to demonstrate taking medications properly, and were less likely to understand medication labels and health messages. They also had more hospitalizations and emergency care, received less preventive care and, among the elderly, had poorer overall health status and higher mortality ().

Furthermore, a recent study showed that low education levels affect women’s abilities to access basic health commodities (). This is evident in Costa Rica, El Salvador, Guatemala, Panama, Peru, and Suriname, where women with no education have an unmet need for contraception that is at least twice as high as that of women with secondary education or higher ().

In order to respond to the low levels of literacy, countries must improve access to effective school education, including providing adult education for those who missed out. The WHO Commission Report concludes that “removing the numerous barriers to achievement of primary education will be a crucial part of action on the social determinants of health” (). Thus, achieving high literacy levels in the population is not only a vital development goal, but will also produce substantial public health benefits (). The education of girls, expansion of social protection, and protection of the environment can have substantial health benefits. Less well established but equally important is how these investments affect women’s roles as health care providers and producers. Gender-responsive policies that recognize health as more than a sectoral outcome, and multisectoral programs that involve women in an enabling environment can empower them to achieve their full potential at home, in their communities, and in the health care work force.

Geographic residency is a third factor that significantly impacts access to health care. In LAC, people who live in rural and/or geographically marginalized areas often encounter barriers that limit their ability to get the health services they need. For instance, in many countries there is often a shortage of health care professionals in certain areas; this limits the supply of available services and in turn reduces access to care. Further, people in rural and/or geographically marginalized areas are more likely to have to travel long distances for health services, which can impose significant burdens on health, money, and time. In addition, there is often a lack of reliable public transportation, making it even more difficult to access needed care (). Other barriers to health services in these remote areas include social stigma and privacy concerns, poor health literacy, facility overcrowding, inability to take time off work, and lack of alternate childcare (). Such barriers to services result in unmet health care needs, which ultimately threaten the well-being and optimal health of populations.

There are many different strategies that can improve access to health care among populations living in rural and/or geographically marginalized areas. Establishing equity-based interventions have proven effective in reaching remote populations. For example, casas maternas (maternity waiting houses) are community-run health facilities that host pregnant women for days or weeks before their scheduled delivery. The objective is to increase access to maternal health services, including births attended by skilled health staff, for populations living in rural and/or geographically marginalized areas (). Several studies indicate that this community-based strategy has been effective in increasing the number of assisted births in geographically remote areas, which consequently decreased the probability of complications during delivery ().

In spite of the vast progress made in the Americas, inequities in vaccine coverage within countries have often been masked by high estimates of vaccine coverage nationally. However, population groups that are unvaccinated or that are vaccinated at lower than the national level are among the most underserved and poorest municipalities or areas. In 2015, in 56% of 15,000 municipalities in Latin America and the Caribbean (8,456 in all), fewer than 95% of children received three doses of diphtheria, pertussis, and tetanus vaccine (DPT3), missing the target level (). The proportion of children under 1 year living in municipalities with suboptimal coverage for DPT3 is almost 20% higher in countries in the lowest income quartile compared with countries in the highest income quartile. The high risk of exposure for diseases that can be prevented with a vaccine is attributable to the prevailing economic inequality between countries in the Region ().

In order to ensure equitable access to vaccines, it is essential to maintain efforts and to further analyze, at both the Regional and national levels, the causes of inequity, including those related to the social determinants of health. Immunization coverage should be a key indicator for achieving universal health given that immunization has the potential to be directly integrated with other services, including prenatal care, adolescent sexual and reproductive health, elderly care, and prevention and control of chronic conditions.

Measuring equity in health systems performance: the paucity of information

Measuring inequalities and equity in health systems is a challenging task for many countries in the Region. As is often said, if it is not measured there is no way to know where we are, where are we going, and whether we are making progress. On the other hand, there is still much debate on some of the basic definitions—for example, what we mean by “unfair” inequalities.

Many measurement frameworks for inequity in health have been proposed and discussed, and there is no shortage of approaches in the specialized literature (). This continues to be a complex issue that “requires consideration of ethics (e.g., defining unfair inequalities), methods (e.g., quantifying health inequities), and policy (e.g., offering policy relevant information)” ().

Aside from methodological difficulties, countries often lack capacity for generating and sharing quality data to inform assessments of inequalities and inequities. PAHO Member States will require purposeful interventions and investments in health information and statistical systems to build competencies that will provide effective capacity to measure and report on health inequities on a regular basis.

In the interim, PAHO has proposed including proxy indicators for measuring equity in health care services in the assessment framework of PAHO’s Strategic Plan 2014–2019 (). Technical cooperation with Member States will be key to building capacity to achieve this goal and to further develop a Regional framework for measuring and monitoring inequalities and inequities in health.

References

1. Pan American Health Organization. Strategy for universal access to health and universal health coverage, 53rd Directing Council, 66th Session of the Regional Committee, Washington, D.C., 2014 Sept 29–Oct 3 (CD53/5 Rev. 2).

2. Byanyima W, Barcenas Ibarra A. Latin America is the world’s most unequal region. Here is how to fix it [Internet]; 2016. Available from: https://www.weforum.org/agenda/2016/01/inequality-is-getting-worse-in-latin-america-here-s-how-to-fix-it/.

3. Lustig N. Most unequal on Earth [Internet]. Finance & Development 52(3). Washington, D.C.: International Monetary Fund; 2015. Available from: http://www.imf.org/external/pubs/ft/fandd/2015/09/lustig.htm.

4. Pan American Health Organization. Regional declaration on the new orientation for primary health care (Declaration of Montevideo), 46th Directing Council, 57th Session of the Regional Committee, Washington, D.C., 2005 Sept. 26–30 (CD46/13).

5. World Health Organization. Health impact assessment, glossary of terms used [Internet]. Available from: http://www.who.int/hia/about/glos/en/.

6. Asada Y, Hurley J, Norheim OF, Johri M. Unexplained health inequality – is it unfair? International Journal for Equity in Health 2015;14:11.

7. Whitehead M. The concepts and principles of equity and health. International Journal of Health Services 1992;22:429–445.

8. Esteves RJF. The quest for equity in Latin America: a comparative analysis of the health care reforms in Brazil and Colombia. International Journal for Equity in Health 2012;11:6.

9. Browne AJ, Varcoe CM, Wong ST, Smye VL, Lavoie J, Littlejohn D, et al. Closing the health equity gap: evidence-based strategies for primary health care organizations. International Journal for Equity in Health 2012;11:59.

10. Starfield B. The hidden inequity in health care. International Journal for Equity in Health 2011;10:15.

11. Pan American Health Organization. Integrated health services delivery networks: concepts, policy options and a road map for implementation in the Americas. Washington, D.C.: PAHO; 2011.

12. Pan American Health Organization. Gender equity policy. Washington, D.C.: PAHO; 2005. Available from: https://www.paho.org/hq/dmdocuments/2009/PAHOGenderEqualityPolicy2005.pdf.

13. Langer A, Meleis A, Knaul FM, Atun R, Aran M, Arreola-Ornelas H, et al. Women and health: the key to sustainable development. The Lancet 2015;386(9999):1165–1210.

14. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives – the role of health professionals. New England Journal of Medicine 2016;375:2113–2115.

15. World Health Organization. The World Health Report 2006: working together for health. Geneva: WHO; 2006.

16. Pan American Health Organization. Regional goals for human resources for health 2007–2015. Washington, D.C.: PAHO; 2007 (CSP27/10). Available from: http://iris.paho.org/xmlui/handle/123456789/4157.

17. Girardi SN, de Sousa Stralen AC, Cella JN, Wan Der Maas L, Carvalho CL, de Oliveira Faria E. Impact of Mais Medicos (More Doctors) Program in reducing physician shortage in Brazilian primary healthcare. Ciência & Saúde Coletiva 2016;21(9):2675–2684.

18. A Promise Renewed for the Americas, Tulane University, United Nations International Children’s Emergency Fund. Health equity report 2016: analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking. Panama City: UNICEF; 2016.

19. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Annals of the New York Academy of Sciences 2008;1136:161–171.

20. Bahls C. Health policy brief: achieving equity in health. Health Affairs October 6, 2011 [Internet]; 2011. Available from: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=53.

21. World Health Organization, United Nations International Children’s Emergency Fund. Integrated community case management (ICCM): an equity-focused strategy to improve access to essential treatment services for children. Geneva: WHO; 2012.

22. Zimmerman E, Woolf SH. Understanding the relationship between education and health: discussion paper. Washington, D.C.: National Academy of Medicine; 2014.

23. World Health Organization. Commission on Social Determinants of Health – final report. Geneva: WHO; 2008; Available from: http://www.who.int/social_determinants/thecommission/finalreport/en/.

24. Nutbeam D. The evolving concept of health literacy. Social Science & Medicine 2008;67(12):2072–2078.

25. Rural Health Information Hub. Healthcare access in rural communities [Internet]. Available from: https://www.ruralhealthinfo.org/topics/healthcare-access#barriers.

26. Pearson CA, Stevens MP, Sanogo K, Bearman GM. Access and barriers to healthcare vary among three neighboring communities in northern Honduras. International Journal of Family Medicine 2012;2012:298472.

27. World Health Organization, Department of Reproductive Health and Research. Maternity waiting homes: a review of experiences. Geneva: WHO; 1996. Available from: http://whqlibdoc.who.int/hq/1996/WHO_RHT_MSM_96.21.pdf?ua=1.

28. Stollak I, Valdez M, Rivas K, Perry H. Casas maternas in the rural highlands of Guatemala: a mixed-methods case study of the introduction and utilization of birthing facilities by an indigenous population. Global Health: Science and Practice 2016;114–131.

29. Cortez R, Garcia Prado A, Kok H, Largaespada C. Las casas maternas en Nicaragua. Washington, D.C.: World Bank and Inter-American Development Bank; 2008.

30. World Health Organization. Global vaccine action plan: Regional vaccine action plans 2016 progress reports. Geneva: WHO; 2016. Available from http://www.who.int/immunization/sage/meetings/2016/october/3_Regional_vaccine_action_plans_2016_progress_reports.pdf.

31. Wagstaff A, Van Doorslaer E, Paci P. On the measurement of horizontal inequity in the delivery of health care. Journal of Health Economics 1991;10(2):169–205.

32. Gakidou E, Murray CJL, Frenk J. A framework for measuring health inequality. Geneva: World Health Organization; 1996.

33. Braveman P, Gruskin S. Defining equity in health. Journal of Epidemiology & Community Health 2003;57(4):254–258.

34. Asada Y, Hurley J, Norheim OF, Johri M. A three-stage approach to measuring health inequalities and inequities. International Journal for Equity in Health 2014;13:98.

35. Pan American Health Organization. Strategic plan of the Pan American Health Organization 2014–2019. Championing health: sustainable development and equity. 52nd Directing Council, 65th Session of the Regional Committee, Washington, D.C., 2013 Sept. 30–Oct. 4 (OD345). Available from: http://iris.paho.org/xmlui/handle/123456789/4031.

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Reference/Note:

1. Resolution capacity in this context is defined as the ability of health services to provide health care responses adapted to people’s needs and demands, in line with current scientific and technical knowledge, resulting in an improvement in health status.

2. The PAHO Gender equality policy recognizes that there are differences between men and women with regard to health needs, and to the access and control of resources, and that these differences should be addressed in order to correct the imbalance between men and women ().

3. As of 2010, 36 million people in the Region did not have access to drinking water fit for human consumption. Some 120 million lacked improved services for the disposal of waste water and sewerage, and almost 25 million people in Latin America and the Caribbean defecate in the open ().

4. Behavior displayed by service personnel (not only in health services) who speak to clients or users using courteous language but whose demeanor, body language, and attitude displays lack of warmth, poor interest, or indifference and even aggressiveness.

Values and principles of universal health

  • Introduction - Brief History
  • Guaranteeing the right to health: an unfinished agenda in the Region of the Americas
  • Progress and challenges to achieving health equity in the Region of the Americas
  • Progress toward solidarity-based health systems
  • Conclusions
  • References
  • Full Article
Page 1 of 6

Introduction

The Strategy for Universal Access to Health and Universal Health Coverage is based on the core values of the right to health, equity, and solidarity (). Throughout the world, embracing these values has been a lengthy process—one that has had a very positive reception in the Region of the Americas in the context of the human rights and social justice movement. The right to health is recognized in the constitution of 19 countries in the Region, guiding the development of strategies, plans, and policies in health and social protection. Nevertheless, differences in the limited information on health access and outcomes (disaggregated by the characteristics of population groups) reveal marked disparities in people’s ability to exercise this right. This is why equity is a value that forms part of the right to health. Solidarity can be considered a guiding value of social protection—society’s effort to ensure that the situation of people in conditions of greater vulnerability can be improved by redistributing the wealth of the more privileged. This implies that the healthy make common cause with the sick, the young, and the elderly, as well as the rich with the poor. Solidarity becomes a reality through financing mechanisms that distribute risk and prevent impoverishment from unanticipated health expenditures.

This section presents an overview of these values and examines the progress made in the Region during the period. It also identifies and analyzes the challenges to steady progress in a complex situation of political, social, and economic change; technology development; and growing social engagement.

Brief historical outline

The public’s participation in different types of organizations, coupled with social policy trends, particularly in labor and health, explain how these values have been embraced in terms of social development in Latin America and the Caribbean. Health coverage was originally conceived in association with terms of employment, giving rise to a segmentation that still affects the health system’s performance. In retrospect, the segmentation of the health system was a negative design externality of the modalities for expanding health coverage. At the same time, the criteria for social security eligibility led to the exclusion of people who were not in the workforce, as well as informal workers and their families, creating inequity in access and outcomes.

Health systems have since evolved, sometimes increasing segmentation and creating fragmentation with the well-intentioned goal of improving the access and coverage of specific population groups. Nevertheless, in the process, the notion and value of health as a social right began to gain ground. Some authors have identified four stages in this process:

  1. The period prior to the creation of national health institutions (from independence to the creation of a ministry of health or similar agency).
  2. The creation of modern national health institutions (ministries of public health and social security institutions).
  3. The growing delivery of health benefits to the nonsalaried poor, in tandem with further segmentation of the health system.
  4. The search for equity, characterized by reforms aimed at equalizing the health benefits received by different population groups and offering financial protection against catastrophic and impoverishing expenditure. Two experiences that marked the beginning of this stage were the creation of Chile’s National Health Services in the early 1950s and the full integration of Cuba’s health system in the 1960s ().

Guaranteeing the right to health: an unfinished agenda in the Region of the Americas

The right to health is a value enshrined in the Universal Declaration of Human Rights () and explicitly stated in the Constitution of the World Health Organization (WHO) of 1946: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political ideology, or economic or social condition” (). Subsequently, the International Covenant on Economic, Social, and Cultural Rights, adopted in 1966, represented progress, with Article 12 on the right to health specifying the steps to be taken by the States Parties to achieve full realization of this right—steps that included the creation of conditions that would ensure medical services and medical attention to all in the event of sickness, thus making the social protection of health one of the hallmarks of a system that honors the right to health (). In 2000, Article 12 (“The right to the highest attainable standard of health”) of General Comment No. 14 of the Committee on Economic, Social, and Cultural Rights highlighted other characteristics in addressing the substantive issues related to application of the International Covenant on Economic, Social, and Cultural Rights ().

The right to health should be understood as the right to the enjoyment of a wide range of facilities, goods, services, and conditions necessary for achieving the highest attainable standard of health. It should not be understood as the right to be healthy, since that depends on a series of personal factors, both genetic and behavioral.

General Comment No. 14 indicates two areas that contribute to the enjoyment of the right to health. First, it states that the health system is expected to provide services that are accessible (understood as nondiscriminatory, physically accessible, affordable, and with access to information), acceptable, and of good quality. Second, it recognizes the need for intersectoral efforts to guarantee other rights that complement health system efforts to meet the health needs of the population. The Comment notes that population health outcomes depend on the existence of a series of underlying determinants and the manner in which they are approached, including water and sanitation conditions, diet, nutrition, housing, occupational and environmental health, education, and infrastructure. Thus, guaranteeing the right to health requires States to address these rights, which not only have intrinsic value but directly affect the health of the population.

In terms of social development, recognizing the complementarity of the Millennium Development Goals (MDGs), the Economic Commission for Latin America and the Caribbean (ECLAC) has indicated that poverty, malnutrition, and hunger are determinants of the health of the population that hinder the enjoyment of health as a civil right ().

The committees charged with monitoring human rights conventions periodically visit their member countries. During these visits, they consult with public and private entities working in this area to learn about the situation, progress, and constraints to strict fulfillment of government commitments. The guarantee of the right to health is affected by other related rights. Thus, a review of the reports from these visits yields an overview of the progress made and areas that need strengthening in health and other sectors. It is critical that the national health authority be familiar with the reports of the committees that review and inform on progress in fulfilling the commitments made by its government in human rights instruments and treaties. These committees provide important information for improving the health system response and strengthening intersectoral action for progress toward universal health. Table 1 lists entities that monitor and observe fulfillment of the guarantee of health-related rights in the Region.

Table 1. Relevant reports on the guarantee of the right to health

Report Responsible body
International Covenant on Civil and Political Rights Committee on Human Rights
International Convention on the Elimination of All Forms of Racial Discrimination Committee for the Elimination of Racial Discrimination
Convention on the Elimination of All Forms of Discrimination against Women Committee for the Elimination of Discrimination against Women
Economic and Social Council Committee on Economic, Social, and Cultural Rights
Convention on the Rights of the Child Committee on the Rights of the Child
Convention on the Rights of Persons with Disabilities Committee on the Rights of Persons with Disabilities

The advocacy of the past five years has been accompanied by significant progress in public policy-making and legislation to guarantee the right to health in the Region. The Information System on Early Childhood (SIPI) in Latin America, sponsored by the United Nations Children’s Fund (UNICEF), monitors enforcement of the rights of young children in Latin America. With regard to health, SIPI monitors compliance with the articles of the Convention on the Rights of the Child () concerning the health conditions of young children; maternal and newborn health care; nutrition and breastfeeding; access to timely, quality health services; the right to family planning services; and children with HIV/AIDS. The following events in the period 2010–2015 should be noted:

  • Chile. Law No. 20595 (2012), creating the Ethical Household Income program, establishes conditional subsidies and transfers to extremely poor households and creates a subsidy for women’s employment. Within this framework, the Healthy Child Checkup Subsidy was created as a conditional monetary transfer initiative under the Ethical Household Income program. Its purpose is to guarantee access to health services for children under 6 from extremely poor households through an economic incentive. The subsidy is conditional to the verification of scheduled health checkups ().
  • Dominican Republic. Decree No. 102 (2013), which declares the protection and comprehensive care of all people aged 0-5 years residing in the nation’s territory to be a matter of high national interest ().
  • Paraguay. Law No. 4698, the Early Childhood Nutrition Guarantee Act (2012). The purpose of this legislation is to guarantee prevention, care, and control of malnutrition in all children under 5 and pregnant women (from the third month of pregnancy to six months postdelivery) who are poor, underweight, and suffering from malnutrition or any nutritional vulnerability ().
  • Peru. Law No. 30021, Law Promoting a Healthy Diet for Children and Adolescents (2013). The purpose of this legislation is to promote and protect the population’s right to public health and adequate growth and development through education, the promotion of greater physical activity, the creation of healthy food stands and lunch rooms in regular basic education institutions, and the supervision of advertising, information, and other practices connected with the sale of food and nonalcoholic beverages for children and adolescents to reduce and eliminate overweight- and obesity-related conditions and chronic noncommunicable diseases ().

Other countries that have legislated to protect the right to health in the past 5 years include the following:

  • Colombia. This country enacted Statutory Law No. 1751/2015, which guarantees the basic right to health and establishes regulations and measures to protect it (). It also enacted Law 1804/2016, establishing the Government policy of “integrated early childhood development from age 0 onward,” aimed at strengthening the institutional framework for recognizing, protecting, and guaranteeing the rights of both pregnant women and children aged 0-6 years, as well as establishing the Social Welfare State ().
  • Mexico. In December 2014, Mexico published the General Law on the Rights of Children and Adolescents, which recognizes that children and adolescents have rights. It includes a section on the right to health protection and social security, indicating that children and adolescents have the right to the enjoyment of the highest attainable standard of health and to receive free, quality health services to prevent disease and protect and restore their health, together with the right to social security. This piece of legislation will make this priority right a reality for children and adolescents, work in their best interests, and guarantee substantial equality and nondiscrimination ().
  • Puerto Rico. The Right to Health in Puerto Rico Act was amended in May 2016 to create the Fund for Services for Remediable Catastrophic illnesses ().

PAHO’s collaboration with the Member States to guarantee the right to health for different population groups is reflected in both the development of strategies based on the right to health and the recommendation to draft national legislation consistent with the international legal framework in health. Prior to adopting Resolution CD50.R8 (“Health and Human Rights”) in 2010, in which the Member States of PAHO committed to intensifying efforts to make the right to health a reality, the Member States had already referred specifically in their mandates to the connection between the exercise of human rights and the enjoyment of health by the following groups in vulnerable situations: (a) persons with mental illness; (b) older persons; (c) persons with disabilities; (d) women and adolescent girls, in the context of maternal mortality and morbidity, gender equality, and the prevention of violence against women; (e) persons living with HIV; (f) indigenous populations; and (g) adolescents and young adults of either sex (). In 2013, lesbians, homosexuals, bisexuals, and trans people were also included ().

Within the framework of the United Nations’ Global Strategy for Women’s and Children’s Health () and implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health (CoIA) () in the Region of the Americas (), the lawmakers of the human rights, family, health, and education commissions, together with ministry authorities in the social sector, agencies charged with safeguarding the exercise of human rights, civil society, academics, and international agencies, engaged in a dialogue to develop collaboration strategies, considering the technical guidelines for the development and implementation of policies and programs for reducing maternal mortality and morbidity consistent with human rights standards. In 2013, a document was published describing progress in the conditions for guaranteeing the right to reproductive health and healthy motherhood ().

In September 2015, the Member States approved the Strategy on Health-Related Law, whose purpose is to “provide guidance that the Member States can consider and use, as appropriate, based on the respective national context, in order to strengthen: (a) greater coordination between the health authority, the legislative branch of government, and other State authorities, and other stakeholders, as appropriate, in the formulation, implementation, or review of health-related law; (b) legislative and regulatory measures to protect health and address the determinants of health; (c) the harmonization or implementation of the recommendations of the Governing Bodies of PAHO/WHO related to the formulation, implementation, or review of health-related law, taking into account national contexts and priorities” ().

Finally, the Strategy for Universal Access to Health and Universal Health Coverage incorporates the recommendations of General Comment No. 14 on the availability, access, acceptability, and quality of health systems, offering explicit guidance to enable the Member States to make the necessary decisions to guarantee the right to health for their peoples.

Despite the progress toward recognition of the right to health and other related human rights and the efforts to guarantee them, the reports of the various United Nations commissions reveal gaps and deficiencies that should be the object of intersectoral dialogue. Table 2 summarizes the main comments from a series of reports on 11 countries in the Region on aspects that pose challenges that should be addressed in the intersectoral dialogue on health determinants.

Table 2. Summary of comments from 11 Latin American and Caribbean countries

On young children
  • Difficulties registering children at birth, which have a long-term impact on access to social protection programs
  • Violations of the marketing code for breast-milk substitutes
  • Permanent institutionalization of children with different mental or intellectual abilities
  • Malnutrition rates
On education
  • Lack of access to differentiated education programs and curricula, when appropriate, for children with disabilities
  • Lack of access by indigenous communities to intercultural bilingual education
  • Banning of pregnant girls or adolescent mothers from the school system
  • Presence of bullying and sexual violence in schools
On socioeconomic status
  • Limited financial protection for the health of disabled children
  • Legal and political barriers to family planning, sex education, and emergency contraceptives
  • Trafficking of adolescent girls for sex work and sexual exploitation
On access to work and employment conditions
  • Discrimination against migrant workers in access to social protection programs and the social security system
  • Child labor
  • High accident and occupational death rates
  • In some cases, the civil code requires women to obtain their husband’s permission to participate in the workforce
On housing and living conditions
  • Forcible eviction of people and households from marginalized or underprivileged populations, especially migrant, Afro-descendant, and indigenous groups
  • Declaring “mental illness” affects a person’s right to a home
  • Intensive and disproportionate use of water by the mining industry, limiting access to safe drinking water and sanitation
On disease prevention systems
  • Absence of legal mechanisms and policies to ensure that women, adolescents, older persons, and persons with disabilities can give their free and informed consent for medical treatment (legal capacity)
  • Lack of comprehensive strategies to replace institutional care with community-based services

Source: PAHO. The social determinants of health in selected countries in Latin America and the Caribbean [unpublished report].
Note: The review included Argentina, Belize, Brazil, Chile, Costa Rica, Cuba, El Salvador, Jamaica, Mexico, Peru, and Suriname.

Experience with explicit use of the human rights approach in the Region has made a difference, revealing the existence of systematic discrimination against populations in vulnerable situations. It has also provided the rationale for reallocating resources from the health budget to increase equity, improve the quality of care, improve surveillance, and, in the long term, increase the recognition that access to quality services is a political and legal right ().

Progress and challenges to achieving health equity in the Region of the Americas

The term “health equity” refers to the absence of unfair avoidable differences in health status, access to health care and healthy environments, and the treatment received in the health system and other social services (). The inequities in the Region have been abundantly documented, revealing it to be one of the most inequitable regions in the world. Inequity is seen in both income distribution and access to the benefits of economic growth, expressed in the indicators of social progress (i.e., education, health, access to drinking water and sanitation systems, and housing conditions). Clearly, over the past 25 years, concern has become more explicit regarding equity in public policies, with the concept of justice adding value to the analysis of inequalities and the response to them. To put this into context, it should be recalled that in 1991, following the “lost decade” and consequent structural adjustment programs, the Economic Commission for Latin America and the Caribbean (ECLAC) reported that the region’s economies were characterized by an overall loss of buoyancy and a marked deterioration in equity. In historical terms, the 1980s were a turning point in development patterns in Latin America and the Caribbean. ECLAC subsequently issued a proposal for the development of Latin America and the Caribbean, promoting “the transformation of the region’s productive structures within the framework of progressive social equity” (). Given these circumstances, ECLAC and other partners in development have promoted public policies that result in better distribution of the benefits of economic growth and are reflected in better social indicators among the groups most impacted by inequity.

The call for such policies has persisted and grown louder, particularly within the framework of the Millennium Development Goals. In 2008, ECLAC stated that progress toward equity in health promotes economic development, since investments in this area help stimulate productivity and prosperity insofar as the benefits of economic development are distributed with a reasonable degree of justice ().

A review of some indicators shows the progress made in the direction of more equitable societies. Differences in ethnicity, income level, and education have been identified as representative variables in the analysis of health equity for women and children. The Region of the Americas has made great strides in maternal and child health over the past two decades. For example, the maternal mortality ratio (MMR) in Latin America and the Caribbean fell from 117 to 68 maternal deaths per 100,000 live births between 1995 and 2015. Despite this progress, however, the Region did not reach the MDG target of a 75% reduction, and serious inequalities are seen among and within the countries of the Region. For example, the five countries in the Region with the lowest MMR in 2015 were Canada (7), United States (14), Puerto Rico (14), Uruguay (15), and Chile (22), while the five with the highest MMR were Haiti (359), Guyana (229), Bolivia (206), Suriname (155), and Nicaragua (150) (Figure 1).

Figure 1. Maternal mortality ratio in the Region of the Americas, 1995 and 2015

Source: PAHO Health Information Platform for the Americas (Plataforma de Información en Salud de las Américas, PLISA), from data gathered in August 2017, https://www.paho.org/data/index.php/en/.

Furthermore, although mortality in children under 5 in the Region fell substantially between 1990 and 2015, from 54 to 17 deaths per 1,000 live births, for a 69% reduction (), the available data from household surveys show that the rate of progress between 2000 and 2012 was not the same for every household in the Region. The mortality rate in children under 5 of the poorest households is generally more than double that of the wealthiest households (Figure 2). In addition, the mother’s education is still one of the greatest determinants of inequality in infant mortality (Figure 3). Moreover, the probability of dying before the age of 5 is higher in rural areas than urban areas, and among boys than girls (). It should be noted, however, that mortality rates have fallen faster among the poorest families, indicating growing equity.

Figure 2. Mortality in children under 5 by income level

Source: Prepared by author from the database of the WHO Health Equity Monitor, based on data from the Demographic and Health Surveys (DHS/EDS).

Figure 3. Mortality in children under 5 by maternal educational level

Source: Prepared by author from the database of the WHO Health Equity Monitor, based on data from the Demographic and Health Surveys (DHS/EDS).

The probability of dying from cardiovascular disease, cancer, diabetes, or chronic respiratory disease between the ages of 30 and 70 is 15% in the Region of the Americas (). In fact, chronic diseases represent more than 79% of all causes of death in the Americas. There is strong evidence in the literature to suggest that the poor and people with an informal education or living in marginalized groups are more likely to die from chronic diseases than are members of other groups (). Furthermore, low socioeconomic status or living in middle- or low-income countries increases the risk of developing cardiovascular disease, stomach and lung cancer, type 2 diabetes, and chronic obstructive pulmonary disease (). Surprisingly, survey data from Argentina, Brazil, Chile, Costa Rica, Jamaica, and Mexico on the diagnosis of asthma, depression, diabetes, and heart disease do not show a clear socioeconomic gradient for these chronic diseases (Figure 4). For example, visible inequalities are not found for asthma, and a definite socioeconomic gradient is not observed for diabetes and heart disease. The data from Brazil show no differences in depression. In Mexico, more depression is reported by wealthy people than poor people, while in other countries, the opposite is true.

Figure 4. Averages and distribution of chronic diseases by income level, 2000–2012 (or nearest year)

Source: Dmytraczenko T, Almeida G, eds. 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; 2015.

Tackling inequities is a priority in the Region of the Americas, since there are vast social inequalities between rich and poor, people with different levels of education, urban and rural populations, and majorities and ethnic minorities.

The 2016 World Bank report on poverty and shared prosperity shows that, based on the trend in the Gini coefficient by region, the highest levels of inequality are found in Latin America and the Caribbean (). Inequality is the main obstacle to regional progress toward inclusive human development, poverty reduction, strengthening of the social unit, and better health.

With respect to health exclusively, despite economic progress in the majority of the countries, substantial numbers of people remain without effective access to comprehensive health services that serve their needs in a timely manner. Regarding the concentration of income and differences in health outcomes, when the average data are disaggregated by income, educational level, ethnicity, gender, and rurality, health inequities are revealed. Health outcomes have improved asymmetrically when considering the dimensions of gender, ethnicity, rurality, age, and educational level—all of which have health impacts that are not only different but unfair.

Some Member States have instituted changes in organization and management to provide a better response for vulnerable groups with low health indicators that are often preventable and unacceptable from the moral standpoint:

  • Argentina. In 2016, the Health Program for Indigenous Populations was created under the Ministry of Health’s National Directorate for Community Care through Resolution 1036-E/2016. The aim of this program is to improve countrywide health coverage and indigenous communities’ access to the public health system through an intercultural approach. The program’s functions include formulating plans to reduce inequities in the health conditions of the target populations; supporting the reduction of morbidity and mortality in the indigenous population through health promotion and disease prevention programs; and training people from indigenous communities to facilitate access to the public health services, using an intercultural approach ().
  • Venezuela. In 2015, Venezuela created the General Directorate for Intercultural Indigenous Health and Complementary Therapies under the office of the Vice Minister of Health. The General Directorate’s functions, established in the Organic Regulation of the Ministry of People’s Power for Health through Decree No. 1887 of 16 July 2015, are as follows: (a) to create mechanisms for linking the offices of the vice ministers, the Integrated Health Network, and health services and programs to strengthen and optimize the Ministry’s strategic policies; (b) to forge ties, develop strategies, and conduct activities with other public health service providers for the purpose of integrating and consolidating the Comprehensive Unified National Public Health System; (c) to develop and disseminate a management model that includes proactive engagement of the population and addresses social needs through the Joint Communal Health System, in order to strengthen communal social monitoring, comanagement, and self-governance in health; (d) to define, propose, and execute policies for monitoring and oversight of health management in national, state, and local entities, and to monitor due compliance with the regulations governing the public health structure in the Integrated Health Network; (e) to establish mechanisms for the creation of comprehensive community health areas (ASIC) as population-based technical and administrative health management units through the state health directorates, in conjunction with the office of the vice minister of the Outpatient Health Network; (f) to design mechanisms, in coordination with the offices of the vice ministers, to comprehensively examine the health profiles of the population, considering the social determinants and territory of residence; and (g) based on the policies of the competent agency for indigenous affairs, to establish and disseminate strategies for health promotion, disease prevention, treatment, and recovery of indigenous people and communities in the facilities of the Integrated Network, with due respect for traditional medicine and their culture () (see topic 2 of this chapter, “Access to Comprehensive, Equitable, and Quality Health Services”).

Progress toward solidarity-based health systems

The concept of solidarity describes support for a cause or project of third parties (Royal Spanish Academy). Its etymology refers to in solidum conduct, meaning that the destinies of two or more people are linked. Thus, someone who exhibits solidarity not only offers assistance but makes a commitment to the person he or she is attempting to help. Embracing solidarity as a core health value has the potential to transform society, since it implies that people will stop making decisions to maximize their own personal (or family) well-being and instead, consider the effect of those decisions on the well-being of other community members. Solidarity is a value that promotes a culture of appreciation for and commitment to social justice; hence, it is critical for guaranteeing the right to health and reducing inequities. Solidarity is realized through a planned effort to redistribute wealth through social development and social protection policies.

The Strategy for Universal Access to Health and Universal Health Coverage is based on solidarity as the underlying value for policies on financing. It also expresses a vision that contrasts with the traditional argument that based access on an individual’s and household’s ability to pay, asserting that: “Health strategies that ensure timely, quality access for all people, within the framework of universal access to health and universal health coverage, require solidarity in order to promote and provide financial protection. To this end it is necessary to pool resources and to advance toward the elimination of direct payments that constitute a barrier at the point of service.” The Strategy indicates that those direct payments should be replaced with pooling mechanisms: “Pooling resources means combining all sources of financing (social security, government budget, individual contributions, and other funds) in a single, pooled fund; i.e., all contribute according to their means and receive services according to their needs. In such a scheme, the public budget covers contributions for those individuals who do not have the means to contribute (poor and homeless people)” ().

Topic 5 of this chapter (“Health Financing in the Americas”) offers an extensive look at health financing in the Region and the rationale for a strategy centered on pooled resources. Here, we would simply emphasize that some countries have created pooled funds to supplement other sources of financing.

One of the expressions of solidarity in health is care for migrants, an effort consistent with recognition of the health-related rights of all people, including migrants, refugees, and other foreigners. Heavy migration flows in the Region have made it necessary to conduct a situation analysis of health access and coverage for these people. In 2016, the Member States of PAHO decided to bring the issue of migrants’ health issue before the Governing Bodies, which adopted a resolution in this regard (). According to that resolution, the Ministers made a commitment to lead “the effort to modify or improve regulatory and legal frameworks in order to address the specific health needs of migrant individuals, families, and groups [ … ] and advance towards providing migrants with access to the same level of financial protection and of comprehensive, quality, and progressively expanded health services that other people living in the same territory enjoy, regardless of their migratory status, as appropriate to national context, priorities, and institutional and legal frameworks” ().

Conclusions

The values of human rights, equity, and solidarity underpinning the Strategy for Universal Access to Health and Universal Health Coverage are leading to a more just society in which the search for the common good takes precedence over the search for individual benefit. Embracing these values and implementing the strategy can potentially influence not only health outcomes but human development outcomes as well.

Guaranteeing the right to health calls for greater equity, which can be attained only through public policies built on reliable information and social dialogue on areas that affect individual and community well-being. The information on different and unfair health outcomes is the point of departure for an analysis of their causes, which can then be used by the relevant decision-making bodies. The availability of information to establish baselines for the different variants of the inequity situation is key to obtaining relevant information to characterize the situation and lay the foundations for monitoring and evaluation systems for pro-equity initiatives.

Monitoring inequities and their determinants is a challenge for information systems, since it requires changes in the types of data collected and the way they are obtained and analyzed to inform public policy design. This means selecting a base of health indicators, appropriate stratification criteria, and good indicators of inequities and inequalities ().

The information produced by sound equity-monitoring systems, as well as the evaluation of initiatives to improve them, is essential for social participation and accountability to individuals and communities and for the design and implementation of pro-equity public policies.

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Reference/Note:

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