Pan American Health Organization

Stewardship and governance toward universal health

  • Introduction
  • Conceptual dimensions of stewardship and governance
  • Stewardship and governance of health system transformation processes
  • Conclusions
  • References
  • Full Article
Page 1 of 5

Introduction and rationale

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

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

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

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

Conceptual dimensions of stewardship and governance

Stewardship for universal health

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

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

Governance for universal health

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

Governance of health services

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

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

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

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

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

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

Human resources

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

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

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

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

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

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

Governance of technology and medicines

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

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

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

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

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

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

Governance of financing

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

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

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

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

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

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

Stewardship and governance of health system transformation processes

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

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

Transformations based on changes in health insurance

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

Table 1. Changes in insurance mechanisms, by country

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusions

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

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

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

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

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

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

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22. Pan American Health Organization. Health technology assessment and incorporation into health systems. 28th Pan American Sanitary Conference, 64th Session of the Regional Committee, Washington, D.C., 2012 Sept. 17–21 (CSP28.R9). Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=26539&lang=en.

23. World Health Organization. Equitable access to essential medicines: a framework for collective action. WHO Policy Perspectives on Medicines, No. 8. Geneva: WHO; March 2004. Available from: http://apps.who.int/medicinedocs/en/d/Js4962e/.

24. Pan American Health Organization. PAHO Sub-Regional Regulatory Framework for Medicines and Health Technologies: concept paper and roadmap [unpublished report]. Washington, D.C.: PAHO; 2013.

25. Mercado Común del Sur. Resolución 34/12. Procedimientos comunes para las inspecciones en los establecimientos farmacéuticos en los Estados Partes y contenido mínimo de actas/informes de inspección en los establecimientos farmacéuticos en los Estados Partes (repeal of RES.GMC n.o 16/09. Foreign Trade Information System) [Internet]; 2012. Available from: http://www.sice.oas.org/trade/mrcsrs/resolutions/RES_034-2012_PT.pdf.

26. Hurtado M. La cuestión del aseguramiento y el nuevo papel de los ministerios de salud en el contexto de la reforma. Organization and Management of Health Systems and Services Series, No. 8. Washington, D.C.: PAHO; 1998.

27. Pan American Health Organization. Report on tobacco control for the Region of the Americas. WHO Framework Convention on Tobacco Control: 10 years later. Washington, D.C.: PAHO; 2016. Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/28393/9789275118863_eng.pdf?sequence=1&isAllowed=y.

28. Dmytraczenko T, Almeida G, eds.Toward universal health coverage and equity in Latin America and the Caribbean: evidence from selected countries. Washington, D.C.: World Bank; 2015.

29. Pan American Health Organization. Report of the Regional Forum on Universal Health: an indispensable investment for sustainable human development [unpublished report]. Washington, D.C.: PAHO; 2015.

30. Ferreiro Yazigi A, Sierra LA. El papel de las superintendencias en la regulación de seguros de salud: los casos de Chile, Argentina, Perú y Colombia. Washington, D.C.: PAHO; 2000.

31. Reveiz L, Chapman E, Torres R, Fitzgerald J, Mendoza A, Bolis M, et al. Litigios por derecho a la salud en tres países de América Latina: revisión sistemática de la literatura. [Right-to-health litigation in three Latin American countries; a systematic literature review]. Pan American Journal of Public Health 2013;34(1):213–222.

32. Gotlieb V, Yavich N, Báscolo E. Litigation and the right to health in Argentina. Cadernos de Saúde Pública 2016;32(1):e00121114.

33. Yavich N, Báscolo EP, Haggerty J. Comparing the performance of the public, social security and private health subsystems in Argentina by core dimensions of primary health care. Family Practice 2016;33(3):249–260.

34. Pan American Health Organization. Essential public health functions. 42nd Directing Council of PAHO, 52nd Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2000 Sept. 25–29 (CD42.R14). Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/1423/CD42.R14en.pdf?sequence=1&isAllowed=y.

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Reference/Note:

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

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

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

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

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

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

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

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

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

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

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:

Regional Office for the Americas of the World Health Organization
525 Twenty-third Street, N.W., Washington, D.C. 20037, United States of America