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.

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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.

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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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.

Access to comprehensive, equitable, and quality health services

  • Introduction
  • Expanding equitable access to comprehensive, quality services
  • Transforming the organization and management of health services through the development of health care models that focus on people and communities
  • Moving towards the design of comprehensive, quality, universal, and progressively expanded health services
  • Prioritizing investment in the first level of care
  • Increasing employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas
  • Improving the availability and rational use of the medicines (including vaccines) and other health technologies
  • Facilitating the empowerment of people and communities so that they are more knowledgeable about their health situation and their rights and obligations and can make informed decisions about their health
  • Conclusions
  • References
  • Full Article
Page 1 of 10

Introduction

The Region of the Americas remains one of the most inequitable regions in the world, with millions of people lacking access to comprehensive health services ().

The data for the Region indicate that between 2013 and 2014 more than 1.2 million deaths could have been prevented if health systems had offered accessible and timely services of good quality. Moreover, data for Argentina, Brazil, Colombia, and Peru show limited use of preventive health services, with only 15% to 21% of the population reporting at least one preventive care visit per year. The percentage is even smaller among the populations in the lowest income quintiles ().

The people most affected by lack of universal access to health and universal health coverage are those who live in conditions of greatest vulnerability. There continue to be differences between the poorest and richest populations in access to the health services needed to reduce maternal and child mortality and morbidity, and these inequalities have slowed the Region’s progress (). Data on economic inequalities in the coverage of maternal and child health services for Bolivia, Colombia, the Dominican Republic, Haiti, and Peru show that sizeable gaps continue to exist. In Peru, for example, the coverage rate for these services remains much lower for the poorest women, among whom the percentage who give birth in a health care institution is 69%, compared with 99% among the wealthiest women ().

Health care models in the countries of the Region often fail to adequately address the differentiated health needs of individuals and communities. Segmentation and fragmentation of health services, which exist in the majority of the countries of the Region, exacerbate difficulties in access to comprehensive, quality services, and low response capacity at the first level of care and result in inefficiencies. The available data indicate that only half of persons with noncommunicable chronic diseases are diagnosed and that only half of those who are diagnosed receive treatment, which is effective in only 1 of 10 cases (). The rate of hospitalization for conditions that could be managed in an outpatient setting is an indicator that reflects response capacity at the first level of care. Between 2001 and 2009, the hospitalization rate for such conditions in countries of the Region, including Argentina, Colombia, Costa Rica, Ecuador, Mexico, and Paraguay, ranged from 10.8% to 21.6%. Of these conditions, gastrointestinal infections accounted for the largest proportion of hospitalizations in Argentina, Ecuador, and Paraguay (33%, 27%, and 22%, respectively, of all reported cases of avoidable hospitalization). Most maternal deaths in the Region could also be prevented by delivering quality maternal health care services during pregnancy, childbirth, and the postpartum period. Approximately 81% of the maternal deaths in the Americas are attributable to direct causes, including hypertension, hemorrhage, abortion, and sepsis ().

The possibilities for expanding access by strengthening the first level through a primary health care (PHC) approach are hindered by differences in the availability and quality of human resources for health and the composition of the health workforce. For example, 10 countries of the Region have an absolute health worker deficit (fewer than 25 physicians and nurses per 10,000 population) or show severe inequalities between urban and rural areas in availability, which compounds access problems (). Countries such as Bolivia, El Salvador, Panama, Paraguay, and Peru continued to face challenges in both the availability and the distribution of health personnel in 2012 and 2013. Data from some countries in the Region, including Bolivia, Canada, Panama, and the United States, indicate that the availability of physicians in urban areas is as much as 80 percentage points greater than in rural areas ().

Other key challenges that the Region faces in expanding equitable access to health services are related to access to and rational use of medicines and health technologies. Progress in this area is very much influenced by lack of adequate financing and inefficient use of resources. Insufficient access to care and the existence of financial barriers are among the main causes of this problem ().

Barriers to access, exclusion, and changing needs are major challenges for health systems, which the reform and transformation processes undertaken in recent decades have not yet been able to fully surmount. In response to these problems, the Strategy for Universal Access to Health and Universal Health Coverage highlights the urgent need to expand equitable access to comprehensive, quality services in the Region (). Its first strategic line identifies the following key elements to guide the changes needed in the organization and management of health services in order to move towards universal health:

  • Strengthen or transform the organization and management of health services through integrated health services networks.
  • Move toward designing comprehensive, quality, universal, and progressively expanded health services.
  • Increase investment in the first level of care, as appropriate, in order to improve response capacity.
  • Increase employment options, especially at the first level of care.
  • Improve the availability and rational use of medicines (including vaccines) and other health technologies.
  • Facilitate the empowerment of people and communities.

This section describes the basic elements and orientations of each key area, as well as the progress made and the challenges for implementation.

Expanding equitable access to comprehensive, quality services

The available data show some significant improvements, although results vary from country to country. A comparison of data on health insurance coverage, use of preventive services, and barriers to access to health services for Chile, Colombia, Mexico, Peru, and the United States reveals gains in health service coverage and access in most of these countries of the Region, together with reductions in inequalities between income quintiles. Between 2014 and 2015, the level of health insurance coverage was quite high for these countries, with averages of approximately 98% in Chile, 95% in Colombia, 86% in the United States, 80% in Mexico, and 73% in Peru. Despite these high average percentages, however, insurance coverage among the poorest households was much lower than among the wealthiest ones, especially in the United States (–14 points) and Peru (-12 points). More importantly, these high insurance coverage levels did not always coincide with levels of health service use or with the percentage of households reporting access barriers, which demonstrates once again that coverage, particularly insurance coverage, does not in and of itself ensure access to services. For example, data on use of preventive care services between 2011 and 2015 show varying percentages of use among the five countries, with national averages of 98% in the United States, 75% in Colombia, 76% in Mexico, 24% in Chile, and 15% in Peru. Colombia and Mexico showed the greatest progress, with increases, respectively, from 60% to 75% between 2010 and 2015 and from 73% to 76% between 2012 and 2014. In Colombia, Mexico, and Peru, the use of preventive services was lower among the population in the lowest income quintiles. These inequalities were even more evident in Colombia, where the gap between the richest and the poorest households was almost 20 percentage points in 2015. In Chile, an inverse relationship was observed, while in the United States there was no clear pattern of disaggregation. The data for Canada, Colombia, and Peru also show marked geographic inequalities in the use of preventive services, with no noticeable improvements between 2005 to 2015. In 2015, the use of preventive services varied between 44.4% and 81.3% across the geographic subdivisions of Canada, between 17.45% and 83.49% in Colombia, and between 0.4% and 6.5% in Peru. With regard to the percentage of households that reported access barriers, the average between 2014 and 2015 was 37% in Peru, 19.9% in Mexico, 6.8% in Chile, 2.3% in Colombia, and 1.9% in the United States. The proportion of households that reported barriers was markedly higher among poorer households than among richer ones in Peru and Mexico, in particular. It is worth noting that inequalities have declined in the majority of these countries for all the indicators analyzed.

In contrast with the situation of preventive care, the majority of the countries in the Region have achieved universal coverage (100%) or near universal coverage (≥93%) of maternal and child health services (). Data disaggregated by income quintile for Bolivia, Colombia, the Dominican Republic, Haiti, and Peru show a downward trend in inequalities, although differences between the poor and the rich persist. For example, in Peru the difference in maternal care coverage among women in the highest income quintile and those in the lowest income quintile shrank from 60 to 12.8 percentage points for prenatal visits and from 80 to 30 percentage points for institutional births (). Nevertheless, the coverage of these services continues to be much lower among the poorest women. In Peru in the period 2005–2015, 69% of the poorest women gave birth in a health care institution, compared with 99% of the wealthiest women ().

As for access to immunization, major improvements have been recorded. The majority of countries have vaccination coverage rates of 93% to 100% for the diphtheria/pertussis/tetanus triple vaccine (DPT), with the exception of Ecuador, Guatemala, Haiti, and Panama, which have less than 80% coverage. Data on inequalities for Bolivia, the Dominican Republic, and Haiti show not only an increase in overall DPT vaccination coverage per year, but an even larger taking place in the poorest segments of the population, which is indicative of an improvement in equity of access ().

Data on the percentage of the population reporting barriers to health service access show marked geographic inequalities and limited improvements over time. In 2013, 16.9% of the population in Canada reported barriers to health service access, compared with 16% in 2005. The variation between geographic subdivisions was 11.48% to 20.6%. In Peru, it was 1.9% to 29.8% in 2015, while in Colombia, 11.5% of the population reported economic access barriers in 2011, compared with 42.3% in 2007. Data from the United States indicate that from 2010 to 2014 there was a reduction of 10% to 20% in the number of adults (19-64 years of age) who reported not having access to medical care because of its cost (). Data for the Region of the Americas indicate that avoidable mortality declined between 2010 and 2014 in Anguilla, Belize, Brazil, Costa Rica, Ecuador, Monserrat, Paraguay, Peru, and Suriname, although there were significant differences between countries.

Transforming the organization and management of health services through the development of health care models that focus on people and communities

The model of care provides the strategic orientation and general features of the organization of a health system, the purpose of which is to meet the needs of individuals, families, and communities. The model of care finds expression in several dimensions: the specification of what health services and benefits are guaranteed (the what), the way in which services are organized and managed in order to provide care (the how and where), and how the resources to finance the services are allocated. Accordingly, the model of care brings together the functions of the health system (Figure 1). It also incorporates the life-course, gender, human-rights, ethnic, and intercultural perspectives, and it promotes active social participation and extramural and intersectoral action.

Figure 1.Functions of the health system and the model of care

Source: Pan American Health Organization. Versión preliminar del informe Expandiendo el Acceso Equitativo a los Servicios de Salud: recomendaciones para la implementación y la acción. Washington, D.C.: PAHO; 2015.

The countries of the Region have moved forward in the development of a model of care with these characteristics (Table 1) and are in various stages of implementing the model. Nevertheless, the majority of countries continued to a biomedical model that should be no longer used.

Table 1. Overview of health care models with ethnic and intercultural perspectives

Country Structure Model of care or of program Standards and technical guides Reported experiences
Bolivia Vice-Ministry within the Ministry of Health and Sports SAFCI Program – family, community, and intercultural health model Strategic guidelines for traditional medicine and interculturalism in health Experience of Potosí
Chile Indigenous Health Care and Interculturalism Unit Comprehensive family and community health care model with an intercultural component Standards that include appropriate equipment, architectural modifications, protocols for referral and coordination between traditional and conventional medicine practitioners Makewe and Nueva Imperial hospitals, Boroa Filulawen center
Ecuador National Directorate for Intercultural Health within the Ministry of Health Comprehensive family, community, and intercultural health care model Guidelines that encourage health promotion from the perspective of diverse world views, culturally appropriate services, and coordination between the health system and traditional and ancestral wisdom Guamaní health area
Guatemala Indigenous care unit within the Ministry of Health Inclusive health model Standards developed in keeping with the inclusive model, including referral and counter-referral between different practices Municipal district of Nahuala
Mexico Directorate of Traditional Medicine and Intercultural Development Health and Nutrition for Indigenous Populations national action program Intercultural integration policies, use of traditional medicine Program for comprehensive hospitals with traditional medicine in the State of Puebla, health units under the national program
Peru National Center for Intercultural Health (CENSI), National Institute of Health/ Ministry of Health Comprehensive family- and community-based health care model Guidelines for intercultural action, including cultural diversity, traditional medicine, and integration into the system Culturally sensitive maternity care experience in in Ayacucho

In order to move towards a people- and community-centered care model, the strategy calls for an increase in the response capacity of the first level of care within an integrated health services network (IHSN) based on the primary health care strategy ().

PAHO has outlined the essential attributes and the domains that should be taken into account when designing and implementing such a network. Moving to an IHSN means that the work of health service providers must be guided by health priorities. Regulation and governance mechanisms are also needed to ensure coordination among the providers in the network and balance and linkage among national and local authorities, civil society organizations active in the area in question, and the population served by the network (see Chapter 1, Topic 4, Stewardship and Governance) ().

If a network of services is to operate efficiently, the services must be organized in a particular way. Disease prevention and health promotion services should be emphasized and ambulatory health care services should be given preference over hospital services. The first level of care should include groups of service providers who work in interdisciplinary teams and are linked to other institutions that provide specialized hospital-based and ambulatory care services. The first level should also have the capacity to coordinate care for users of the network of services. Evidence indicates that services are increasingly being transferred from hospitals to specialized ambulatory care or community-based services. It will not be possible to set up efficient networks without making changes in how health care processes are designed and delivered. Special attention should be paid to changes in the organization and management of hospitals so that they contribute efficiently to the objectives of the network, since hospitals, although they serve small segments of the population, are necessary for the delivery of highly complex and specialized services. Hospitals also account for the highest proportion of spending within health systems and are the focus of public attention and political concern. Current trends suggest that hospitals that function within an integrated network tend to need fewer beds, will make more intensive use of technologies and human capacities, and will orient their activities more towards ambulatory care. At the same time, efficiency and clinical outcomes will improve if high-complexity centers are developed ().

The problems currently besetting hospitals (such as excess demand in emergency rooms and long waits for elective procedures) will only worsen if changes are not made in the design and operation of the network as a whole, especially if the response capacity of the first level of care is not increased. In other words, it is impossible to have an IHSN without hospitals, but hospitals will not be sustainable if they are not part of an IHSN.

Higher priority must be attached to health promotion and disease prevention services that are oriented towards the coproduction of health, with a strong focus on ambulatory care and the incorporation of intercultural and gender features. It is also necessary to create opportunities for intersectoral action in the community and, sometimes, to seek opportunities for synergy between public and private actors ().

In order to put in place an efficient network, it is necessary to ensure the availability of human resources, medicines and health technologies, financing and incentives aligned with the objectives of the network, and capacities for leadership and governance. These elements will be examined in this and the following sections.

Internationally, there is evidence of the importance of reorienting health care services as described above (). In the Region, the key strategies being applied in the transformation of health care models include: investing in primary health care centers, establishing family health, developing the workforce for primary and community-based health care, developing multidisciplinary teams in the community, establishing community outreach services, investing in specialized care for older persons (including support for home care), integrating mental health care into primary care, and promoting the use of new technologies to provide treatment and manage care in remote communities.

The extent to which care models have been reoriented and transformed varies, however, ranging from reorganization of the entire network of services (Box 1) to a shift designed to address specific problems or diseases (for example, care for persons with chronic diseases and older adults and mental health care – see Box 2) or strengthen the first level of care without an IHSN approach ().

Box 1. Development of Integrated Health and Social Service Centers in Quebec, Canada ()

The Province of Quebec, Canada, has been applying a long-term strategy to overcome fragmentation in the way health care is organized and provided across its 17 administrative regions. To that end, it has established a modality of care that formally integrates the financing and delivery of health and social services. In 2004, health sector reforms reorganized the model of care into 90 integrated health and social services centers (CISSS, from the French Centres intégrés de santé et de services sociaux) that provide services to specific local populations. The emphasis has been placed on accessibility and continuity of preventive care, as well as on curative services for groups in more vulnerable conditions.

CISSSs provide PHC-based health and social assistance services through “autonomous” family medicine groups. They encourage a multidisciplinary approach, enhancing the role of nurses and public health workers and empowering community groups, including citizens committees and representatives of the community. Among the principal interventions carried out are the following:

  • Partnerships of community nurses with hospital emergency rooms to monitor and manage frequent users in community environments in order to reduce hospital readmissions;
  • Investment in education and training in comprehensive care to support joint action and serve vulnerable groups in the community; and
  • Interdisciplinary teams comprising health and municipal government personnel to support older persons in their homes through an approach emphasizing independent living and adapted dwellings.

The key challenges identified for the development of new approaches to care in Quebec included population aging and related new health problems, increased inequalities between social classes, difficulties in controlling expenses, and political issues related to financing of long-term public health care. Integration proved problematic because of competition among professional groups and autonomous service providers. Lack of preventive care remains a deficiency in the way in which care is provided.

Key lessons for the future of integrated health and social services centers in Quebec include:

  • Expand the functions of nurses at the clinical and community levels.
  • Integrate other health professionals to support family doctors in the clinical environment.
  • Ensure monitoring of the delivery and quality of private medical care, especially for the elderly.
  • Increase citizen participation in the management and organization of first-level care centers, and the participation of users in planning.
  • Improve the integration of curative and preventive approaches in the practice of family medicine.

Box 2. Improving the quality of care for chronic diseases in the Caribbean (Anguilla, Antigua and Barbuda, Barbados, Belize, Grenada, Guyana, Jamaica, Saint Lucia, Suriname, and Trinidad and Tobago) ()

Demonstration projects using the chronic care model have been carried out across the Caribbean in 142 health centers, with the participation of 40,000 patients. The goal of these projects is to boost the capacity and skills of local health teams to better manage care for people with diabetes. The specific focus of these projects is to encourage the participation of patients, their families, and the community through the introduction of the PAHO Chronic Care Passport. The aim is to support education on the disease itself and on self-management. The preliminary results show reductions in glycosylated hemoglobin (HbA1c) levels, a substantial increase in the number of people who receive preventive care (for example, nutritional counseling and examination of feet and vision), and improvements in quality-of-care indicators.

One of the non-delegable responsibilities of the network of services is to ensure the quality of services. Quality is an inherent attribute of–and a requirement for–universal health. In order to achieve equitable access to comprehensive quality services, a systemic approach is required, spearheaded by the health authority in the exercise of health system stewardship (see Chapter 1, Topic 4, Stewardship and Governance). At the health services network level, interventions are aimed at ensuring responsive care that meets people’s needs and expectations. Numerous initiatives have been launched In the Region to ensure quality in the delivery of services (Table 2).

Table 2.Summary of initiatives to address quality in health systems

Country Support structure National policy Experience reported
Ecuador National Department for Quality Assurance of Health Services, National Agency for Quality of Health Services and Prepaid Medicine (ACESS) Development of a culture of quality; quality control of services; support for users of the system and assurance of effective operation of health services Plan for accreditation of 44 hospitals
El Salvador National Quality Management Unit of the Comprehensive and Integrated Health Services Networks (RIISS) RIISS quality management system Specialized pharmacy project
Honduras Quality management unit of the Ministry of Health Saving Lives with Quality program Reduction of neonatal deaths at Mario Catarino Rivas Hospital Implementation of safe surgery
Mexico General Directorate for Health Quality and Education National Strategy for the Consolidation of Quality in Health Care Establishments and Services Evaluation of the implementation of the Comprehensive Health Quality System (SICALIDAD)
Peru General Directorate for Quality in Health, National Health Authority Health quality management system Protection of health rights in Peru: experiences arising from the oversight role of the National Health Authority

Moving towards the design of comprehensive, quality, universal, and progressively expanded health services

Health systems should be capable of defining the benefits that are going to be made available to the populations they serve. In so doing, they should seek to build in a dynamic process of progressive expansion aimed at ensuring that an increasing number of health problems can be resolved through the incorporation of new knowledge and resources, involving and making more innovative and creative use of public, private, and social security resources to reduce fragmentation, facilitate economies of scale and ensure an integrated response. This definition of benefits is key in order to realize the aspiration of ensuring equitable access to comprehensive, quality, people- and community-centered health services ().

In order to move forward in this area, one of the most essential tasks is to decide on a method for prioritizing services and benefits. The objective is to offer communities and populations a specific set of services designed to improve their health and well-being ().

The question of how to prioritize services, and thus design basic national packages of health services and benefits, has been widely debated for many years in the Region of the Americas (). Historically, the debate has centered around the strategic purchase of health services through a continuous search for the best interventions. The countries of the Region are currently at different stages of the process of specifying health services and benefits; they also differ in terms of the way the right to health is formulated (see Table 3 and Boxes 3 and 4).

Table 3. Specification of services and benefits in selected countries of the Region of the Americas ()

Country Name of benefit package Year implemented Population covered (%) Relevant legislation Regulatory entity Quantity and type of services
Argentina Compulsory Medical Program (PMO) 1995 52% Acts 23660 and 23661 Department of Health Services, Ministry of Health All levels of care

Broad and explicit list

Some criteria for coverage

Brazil National List of Health Services and Activities (RENASES) 2011 100% Act 8080
Act 8142 on the Unified Health System (SUS)
Ministry of Health, Health councils (national, state, and municipal) Primary care services

Urgent and emergency services

Psychosocial services

Specialized health care services

Public health surveillance services

Chile Explicit Health Guarantees (GES) 2005 100% Act 19966
Act 18933
Health authority, Ministry of Health Free first-level services

Secondary and tertiary level services for 80 health problems to date

Coverage guides and medicines list

Guyana Guaranteed Package of Public Health Services 2008 100% Ministry of Health All levels of care Includes medicines list
Peru Essential Health Insurance Plan (PEAS) 2009 Workers covered by Social Security and by public insurance Act 29344 on Universal Insurance Health authority, Ministry of Health First, second, and third level with care for 50 health problems selected on the basis of the burden of disease
Uruguay Comprehensive Health Care Plan (PIAS) 2008 100% Decree 465/008 of 10/2008 National Health Board (JUNASA), Ministry of Public Health Comprehensive health programs and catalog of benefits:

  1. Medical care modalities
  2. Medical specialties, other professionals, and technical personnel for the management and the recovery of health
  3. Diagnostic procedures
  4. Therapeutic and rehabilitative procedures
  5. Oral health
  6. Medicines and vaccines
  7. Medical transportation

Adapted from: Leguiza Fondos J, et al. Análisis comparativo de conjuntos de prestaciones que brindan los sistemas de salud en las Américas y el Caribe. (Comparative analysis of packages of services provided by health systems in the Americas and the Caribbean). Washington, D.C.: PAHO; June 2012 (unpublished document).

Box 3. Development of a Comprehensive Health Services Plan in Uruguay ()

Uruguay’s Comprehensive Health Care Plan establishes overall guarantees for an integrated national health system and has sought to strengthen governance and the regulatory process. Launched in 2007, the Plan’s key innovation was the creation of a catalog that sets out an exhaustive list of benefits, including 1,600 technical procedures related to diagnosis and nearly 3,000 procedures related to therapy and rehabilitation, oral health, vaccines, medicines, and means of transportation. In 2008, the Plan was expanded through the addition of a set of existing public health programs, such as support for self-care.

The list is updated on the basis of scientific evidence and changes in prevailing epidemiological conditions, with support from a group of experts. A rigorous process is followed that involves examining a set of impact criteria and the evidence base and determining whether improvements are justified in terms of healing and better quality of life. After the list is developed, a working group classifies and considers the efficacy of treatment and places the interventions in priority categories.

The catalog laid a foundation for establishing contracts for management of the model of care with public and private providers (a first round in 2008 and a second in 2012), including sanctions in the event of non-performance. The National Fund (which is income tax-based) negotiates rates and incentives with a view to promoting universality of access and quality of care, with professional incentives linked to changes in the model of care and quality. Payments are results-oriented, which allows for greater technical and administrative autonomy and flexibility for providers.

The main challenge to the Plan’s success has been to ensure sustainable care that is distributed in a fair and ethical manner. The strategy for communicating with citizens has been essential in order to help people understand that a country has limited resources and has demonstrated transparency in the development of its system of guarantees. The main principles guiding implementation include: transparency in decision-making, promotion and communication of results, management of public and professional opinion, and social participation.

Box 4. Implementation of Explicit Health Guarantees (AUGE) in Chile ()

The AUGE reforms in the Chilean health system have sought to support the development of a more integrated health system and to overcome problems related to financing, in particular high levels of private financing, and segmentation in the delivery of services. The reforms include new insurance schemes for low-income people (FONASA, which covers 7%, and ISAPRE). FONASA is geared towards reducing premiums and developing healthier populations among the poorest groups, while ISAPRE focuses on the higher-income brackets.

The basic principle guiding AUGE has been the integration of public and private financing in order to create a service with explicit guarantees, comprehensive regulation, and stronger management that promotes integrated models of care through integrated public and private networks. It includes 56 guarantees aimed at addressing chronic diseases and population aging, with a focus on strengthening primary health care, in terms of access, equity, quality, and financial protection. The latter is important in order to prevent the package of benefits from becoming a regressive tax.

The process of developing the AUGE reforms was reportedly highly political, but it took account of external consultation processes by the Ministry of Health aimed at reaching agreement on the basis for guarantees and implementation to be applied progressively. As a result, there was a large increase in financial coverage for people with insurance.

Curiously, AUGE has been insufficiently utilized, as people have maintained dual coverage, and prices of the previous coverage have declined. AUGE has improved diagnosis and treatment times, but has also been associated with an increase in administrative bureaucracy. The successes reported include more timely care and some progress in changing the model of care to promote public health and address chronic diseases. Unexpected negative impacts include “patient poaching” by providers prompted by payment system incentives. These problems should be addressed by switching to payment of incentives based on episodes of care, perhaps in the form of bundled payments. Chile continues to grapple with problems of segmentation and inequality, but has made important progress in promoting citizens’ health rights.

Prioritizing investment in the first level of care

In order to expand access to health services, it is necessary to prioritize investment in services at the first level of care in order to boost their response capacity. To do this, new resources are needed in the majority of the countries of the Region. Funding for such investment cannot be obtained only by seeking efficiencies or reallocating resources from hospitals to the first level of care, since, generally speaking, spending on public health remains insufficient (see Chapter 1, Topic 5, Health Financing in the Americas). Although most countries lack information systems that would make it possible to measure the increase in investment at the first level in financial terms, in recent years several countries have made significant progress in the development of their first level of care, as is evident from the information in Table 4.

Table 4. Experiences in primary health care as a means of moving towards universal health

Country Model of care and management Composition of the health team Functions Levels of system management
Bolivia “My Health” program within the framework of the government policy on family, community, and intercultural health (SAFCI). Operates through local health centers and higher-complexity centers that come under the responsibility of municipal governments Physician, nurse, nursing auxiliary Medical care at the local health center, family visits, and social management Ministry of Health-regulation and oversight of the entire system
 
Departmental governments and health services and municipal governments, which are responsible for the first and second levels of care
Brazil The Unified Health System (SUS) of Brazil includes health activities and services provided by public federal, state and municipal agencies or institutions. Territorial teams serving 800 to 1,000 families: general practitioner or family medicine specialist, nurse and nursing auxiliary, community health workers, dentist and oral health assistant Prevent and control diseases, injuries, and health risks; expand access to health services and health promotion and disease prevention interventions; management of health determinants; and strengthening management of the SUS at all levels of government Three levels of government (federal, state and municipal)
 
Complementary participation by private enterprise recognized
Costa Rica Costa Rican Social Security Fund (CCSS), public health insurance that includes comprehensive medical care, cash benefits and social services provided by decentralized institutions. The Ministry of Health oversees the performance of the essential public health functions and exercises sectoral leadership. National Council of the Health Sector. Basic comprehensive health care teams, distributed across 103 health areas (3,500-7,000 inhabitants): general practitioner, nursing auxiliary, medical records assistant, and comprehensive health service technician Disease prevention and health promotion, recovery, and maintenance; care for prevalent and emerging health conditions Ministry of Health, Costa Rican Social Security Fund, and decentralized institutions: National Insurance Institute, Costa Rican Institute of Water Supply Systems and Sewerage Systems, Alcoholism and Drug Dependency Institute, Costa Rican Institute for Research and Teaching on Nutrition and Health, National Health Council
Cuba Family Doctor and Nurse model, oriented towards health promotion, prevention and curing of disease, and rehabilitation at all health care levels Basic health teams: physician and nurse responsible for the health of the population they serve Comprehensive health care; educational research, managerial, and environmental activities Centralized system under the Ministry of Health, linked with government entities at the national and local level: National Assembly, Council of State, Council of Ministers, assemblies at the municipal and provincial level
Ecuador Comprehensive care model of the National Family, Community, and Intercultural Health System (MAIS-FCI) Basic health care teams: physician, nurse, psychologist, dentist, and auxiliary Promotion, prevention, treatment, rehabilitation, and home visits Integrated, decentralized, territorial, and participatory management, with transfer of competencies and resources according to MAIS-FCI requirements
 
Intersectoral coordination, integrated action at territorial level
 
Government results-based management (RBM) tool
El Salvador Comprehensive Basic Health Systems (SIBASIs), with interventions by public and private providers Health promotion, disease prevention and cure, and rehabilitation, focused on the individual, the family, the community and the environment 380 community family health teams and 28 specialized teams in 53% of low-income municipalities Comprehensive health care, decentralized management, delivery, and financing of health services and social participation Three levels:

  • Highest: Ministry, regulatory entity
  • Regional: regional directorates (SIBASI technical and administrative level), resource management
  • Local: SIBASI operational network and hospitals
Nicaragua Family and Community Health Model (MOSAFC), with three components: service delivery, management, and financing
 
Health networks include three levels of care and comprise community, public, and private establishments
Family and community health teams: physician, nurse, nursing auxiliary, basic sanitation technicians, and community health workers Comprehensive and integrated approach to education, promotion, prevention, treatment, and rehabilitation with emphasis on vulnerable groups and a life-course approach to care These actions are carried out through a network approach, actively involving community agents such as midwives, community health workers, and family, community, and life councils

Increasing employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas

The expansion of equitable access to comprehensive, quality services in order to advance towards universal health requires significant changes in the management of human resources for health. A key element, as is noted in the strategy, is the expansion of employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas. This intervention should be accompanied by the development of interdisciplinary teams at the first level of care. Interdisciplinary teams are needed to promote innovation, community participation and the empowerment of people with regard to health, intersectoral work, and the adaptation of specific work contexts to the health needs and preferences of communities.

An overall shared mission is imperative, with broad common goals and responsibilities, regulations for quality and safety of care, a mechanism for merit-based recruiting and hiring, and comparable labor conditions. Part of this mission should be to ensure the delivery of a set of services and programs and the existence of standards, work processes, treatment protocols, a management and coordination model, and accountability mechanisms.

Various countries have launched initiatives aimed at addressing the challenge of human resources for universal health. For example, in Peru, candidates for public positions, admission to second professional specialization programs, and government fellowships for basic or advanced studies are required to serve in rural or marginalized urban areas under a Ministry of Health initiative known as SERUMS (Servicio Rural y Urbano Marginal de la Salud). The initiative has boosted the number of physicians working in rural areas from 2,500 in 1999 to almost 9,000 in 2013 (). In Brazil, the Mais Médicos program is an initiative designed to improve the coverage of physicians at the first level of care, especially in rural and other underserved areas. The program includes medium- and long-term planning policies aimed at reorienting undergraduate education, a compensation policy with special incentives (for both Brazilian and foreign physicians), and an international collaboration agreement with the Government of Cuba. Thanks to an influx of 14,000 additional physicians at the first level of care during 2013, the program has improved the availability of medical professionals in the most underserved areas, especially rural areas. In Chile, the Health Careers System for physicians includes a training phase of up to 9 years in which the professionals are required to work at the first level of care in order to qualify for later specialization. Chile also has a remuneration policy that encourages health workers to work in rural and underserved areas. This policy provides special supplements for personnel who work in isolated areas or areas with high cost of living, with hardship pay for personnel working in very isolated or remote locations or performing difficult jobs at the first level of care in vulnerable or geographically isolated areas (). Uruguay is implementing its National Rural Health Program, which addresses three critical needs: better access to health services for rural populations, access to comprehensive health services (provided by a highly trained and committed interdisciplinary team), and assurance of continuity of care throughout the health care process. This program has made it possible to improve access to health care for residents of rural areas through interdisciplinary care teams ().

Improving the availability and rational use of medicines (including vaccines) and other health technologies

The aim in seeking to improve equitable and sustainable access to medicines and other safe, effective, high-quality, and cost-effective essential health technologies is to prevent, alleviate, diagnose, and treat health disorders, all of which are vital to progress towards access to universal health in the Region.

Access to medicines can be facilitated through solid and holistic management of the supply chain. Such management should ensure the integrity of the chain and the timely availability of products. A critical area is demand forecasting. Efficient supply management should include good procurement mechanisms, since such mechanisms have a significant impact on price. Procurement methods that favor competition and concentrate the purchasing power of public funds tend to reduce prices. By pooling demand across the public sector, national joint purchasing mechanisms are improving the ability of the public sector to negotiate and secure better prices. Similar results have been observed when demand is pooled at the international level. The most noteworthy examples are PAHO’s Revolving Fund for Vaccine Procurement and Regional Revolving Fund for Strategic Public Health Supplies, also known as the Strategic Fund. In 2016, 30 countries of the Region signed the agreement to participate in the PAHO Strategic Fund, through which they can access more than 150 essential and strategic products for their health programs. In 2015, purchasing through the fund exceeded US$ 70 million and yielded savings of 30% to 80% in drug costs to countries, thanks to procurement through international competitive bidding and economies of scale made possible by pooling demand from many countries. With regard to joint negotiating schemes, a noteworthy experience is the one being spearheaded by the MERCOSUR and UNASUR countries, which in 2015 formed a joint committee to negotiate with multinational pharmaceutical companies on the prices of a group of high-cost drugs. Through a transparent and collective mechanism shared among countries, and with technical support from PAHO and the use of the mechanism of the fund, countries have sought to improve the availability of essential medicines for the treatment of HIV/AIDS and hepatitis C. Sizeable reductions in the price of insert (for HIV/AIDS) have been achieved, as much as 83% in some countries. Countries continue to work jointly with PAHO to obtain better terms for the purchase of inputs for the management of hepatitis C.

With regard to the general availability of blood in a country, the rate of whole blood donation per 1,000 population is a good indicator. This rate is 32.1 donations per 1,000 population in high-income countries, 7.8 in middle-income countries, and 4.1 in low-income countries (). In 2014, the average donation rate in Latin America and the Caribbean was approximately 14.84 per 1,000 population; 45.39% of those donations came from unpaid volunteer donors, while 54.52% came from replacement donors. Although the donation rate per 1,000 population has fallen slightly in recent years (15.25 donations per 1,000 population in 2010, for example), the percentage of voluntary donations has risen steadily, climbing from 41.4% in 2010 to 45.39% in 2014. However, the high percentage of replacement donors represents an inequality that continues to affect blood availability.

Access to medical radiology services depends not only on the availability of appropriate, quality medical devices. It also depends on the effective integration of such services into the health services network and on their rational use.

Rapid technological progress is enabling the development of innovations in health care planning and delivery methods. There has been significant progress in the use of remote monitoring applications for the management of diseases such as diabetes and chronic obstructive pulmonary disease (COPD). This progress has been possible thanks to the availability of a growing number of mobile health applications. When effectively deployed, these approaches have shown that they can facilitate self-care and support continuous monitoring of symptoms in order to facilitate early intervention. E-health technology is now widely used in the Region as a means of increasing access to services, especially in rural and remote localities, and it can also be used by health care providers to facilitate coordination of care () (Box 5).

Box 5. Strengthening the first level of care through the use of new technologies in Panama ()

New technologies have been used strategically to strengthen the first level of care in Panama through the development of electronic health care records. These records serve as tools for decision-making about diagnosis, management of symptoms, and follow-up as part of the disease treatment and management process (Ministry of Health program). The synchronization of health records has helped to improve communication among health care professionals and providers. Information systems and the exchange of data facilitate clinical management, evaluation, and follow-up have helped to improve the allocation of limited resources in places where human resources or physical infrastructure were limited.

The development of telemedicine has also permitted remote management of patients (development of virtual hospitals in local communities), support for better management of symptoms, and promotion of self-care. Potential obstacles to their application include availability of human and financial resources to support the development of telemedicine, as well as cost and availability of the technological infrastructure itself. Both health professionals and service users have shown resistance to such changes. New skills are required, which means that new education and certification programs may be needed.

Facilitating the empowerment of people and communities so that they are more knowledgeable about their health situation and their rights and obligations and can make informed decisions about their health

The active participation of individuals and communities has been a fundamental principle in the successive strategies of WHO and PAHO, which have long emphasized people-centered care. The Alma-Ata Declaration, for example, recognized community participation as a key ingredient for strengthening health systems based on primary health care ().

In order to advance towards universal health, health systems must develop programs, interventions, and strategies to support both processes that empower people and processes that strengthen community participation in health.

A review of the evidence suggests the following four key strategies for involving individuals, their families, and caregivers:

  1. Self-management of health and health conditions: Includes support for the development of knowledge, abilities, and confidence to manage one’s own health (self-care), care for specific disorders, and recovery from an episode of ill health.
  2. Shared decision-making: Includes support to enable individuals to make decisions about their health, so that they can weigh various options (including the option not to take any action), think about risks and benefits, and consider how the available options mesh with their values and preferences.
  3. Actions among equals: Support for people in giving and receiving assistance from other people in similar circumstances, on a basis of mutual and shared understanding.
  4. Support for families and caregivers. The aim is to develop knowledge, skills, and actions so that people can take care of themselves and others (). Caregivers play a fundamental role in community health. Caregiving is considered a capacity for service and a human ability to care for the health of the community. It is therefore work that should be socially recognized and measured and valued in the health system. It should also be well paid if it is to cease to be considered an inescapable duty to be performed by women ().

Community participation in planning and goal-setting can help communities examine the factors underlying health problems and raise community awareness and can lead to community-led approaches to key challenges. For example, in Peru, community awareness-raising has been used as a strategy for promoting multisectoral collaboration and involving marginalized communities in decision-making about their health care ().

Community awareness-raising through education and participation in learning encounters and activities can help build stronger social networks and foster greater integration. Such measures work well when they focus on a specific health problem of mutual interest and when conversations and activities are culturally sensitive, as in the example described in Box 6.

Box 6. Promotion of health education and community participation in the city of Tunia, Colombia ()

In Colombia, 50% of families with young children live in the country’s poorest areas. Living in poverty generates a negative cycle of illness, poor mental health, lack of educational achievement, and reduced ability to work. Investing in early childhood development was therefore essential. However, traditional assistance programs tended to be paternalistic, charity-based, and ultimately unsustainable.

The city of Tunia, Colombia, has introduced a public policy on child health that aims to create a culture of care and protection for children from the moment of conception to the age of 5 years, upholding their rights and nurturing their development in order to assure them of a better future. A key part of the approach is promotion of community engagement and involvement, health education, and a new approach to health care among the residents of the city.

The approach includes the training of administrators to support activities relating to health education and nutritional counseling, family life, parenting, and promotion of community leadership. The approach to families and family life has encouraged the development of work skills, continued learning, and wise use of family finances. Approximately 355 family leaders have received training from 710 agents, which has had an impact on 4,289 vulnerable families with young children. The results have made a real difference, as can be seen from the changes reported between 2012 and 2014:

  • The proportion of pregnant women with appropriate weight and health rose from 33% to 86%.
  • The proportion of children weighing 3,000 g or more at birth increased from 60% to 65%.
  • The proportion of young children with chronic malnutrition decreased from 15% to 5%.
  • The proportion of fathers present at the birth of their children rose from 92% to 96%.

Care provided by the community through the collaboration of volunteers or community health workers as partners in care can achieve numerous objectives, including enhancing the legitimacy of and fostering trust in health care services, helping to strengthen the first level of care, encouraging learning among equals, and bolstering access to care and local support. For example, the development of “customer ownership” in the health system of Nuka, Alaska, led to investments that promoted universal access to community health associations and to the development of community partnerships that have had a profound and lasting impact on the improvement of population health ().

Organized groups of people who represent the opinions of people at the local or national level offer the opportunity to develop democratic responsibility among health services and the local communities, strengthening governance and promoting advocacy. For example, in Colombia the New Paradigm project encouraged people with spinal cord injuries to get together regularly to discuss their health care issues in collaboration with health professionals. This approach has enabled learning among peers and helped to encourage and build trust ().

The development of community empowerment strategies helps protect people’s right to health and promotes responsibility-sharing between the population and health care providers. Through the creation of transparent, respectful, and responsible relationships among communities, providers, and decision-makers, this approach helps to generate the necessary conditions for people to take more responsibility for their health and lifestyle decisions and better address the social determinants of health. This contributes to informed decision-making, better knowledge of health, promotion of self-determination, and greater involvement by people in decision-making and in influencing matters that affect their lives and the lives of their communities ().

Conclusions

This topic has explored various necessary and complementary elements for advancing towards access to comprehensive, equitable, and good quality health services. The agreements adopted by PAHO, the volume of available evidence, and technical cooperation tools constitute a solid support for the efforts of the health systems in our countries to achieve their objectives. In the preceding pages, we have endeavored to summarize each of these elements and to highlight some examples of progress in the countries of the Americas in recent years. While progress has been made, numerous challenges remain, and not all countries are advancing at the same rate. PAHO is convinced that access to comprehensive, equitable, quality health services can be achieved by following the recommendations in the universal health strategy and the technical documents that complement it.

References

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Reference/Note:

1 Estimate by the authors on the basis of available information from 38 countries of the Region that submitted reports in 2013 and 2014 to PAHO’s Health Information Platform for the Americas (PLISA).

2 Sources: Bolivia: Segunda Medición de Metas Regionales en Recursos Humanos, 2013; United States: Primary Care Workforce Facts and Stats No. 3, content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD; Canada: Scott’s Medical Database, 2015, Canadian Institute for Health Information. Note: the data for the United States are for physicians working at the primary care level.

3 Authors’ calculations based on data from Chile’s Ministerio de Desarrollo Social, Encuesta de Caracterización Socioeconómica Nacional, 2013 and 2015, data file and documentation: http://observatorio.ministeriodesarrollosocial.gob.cl/casen/basededatos_historico.php; Colombia’s Departamento Administrativo Nacional de Estadística (DANE), Encuesta Nacional de Calidad de Vida, 2010-2015, data file and documentation: http://formularios.dane.gov.co/Anda_4_1/index.php/catalog; Mexico’s Instituto Nacional de Estadística y Geografía (INEGI), Encuesta Nacional de Ingresos y Gastos de los Hogares, 2012 and 2014, data file and documentation: http://www.inegi.org.mx/est/contenidos/espanol/proyectos/metadatos/encuestas/enigh_211.asp?c=10748; Peru’s Instituto Nacional de Estadística e Informática del Perú, Encuesta Nacional de Hogares, 2010-2015, data file and documentation: http://iinei.inei.gob.pe/microdatos/; and the United States’ Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2014, data file and documentation: https://meps.ahrq.gov/mepsweb/data_stats/MEPS_topics.jsp?topicid=1Z-1. Data retrieved 21 Nov. 2016.

4 Based on calculations by the authors using data from Colombia’s Departamento Administrativo Nacional de Estadística (DANE), Encuesta Nacional de Calidad de Vida, 2012, 2014, and 2015, data file and documentation: http://formularios.dane.gov.co/Anda_4_1/index.php/catalog; Canada’s Statistics Canada, Canadian Community Health Survey, 2006-2013, data file and documentation: http://www.statcan.gc.ca/eng/survey/household/3226; and Peru’s Instituto Nacional de Estadística e Informática, Encuesta Nacional de Hogares, 2006, 2010, and 2011, data file and documentation: http://iinei.inei.gob.pe/microdatos.

5 Refers to the percentage of the population that had health problems and did not receive medical care due to lack of money, distance, time, difficulty in getting a medical appointment, or preference. Cultural, economic, geographical, and availability barriers are considered barriers to access.

6 Based on calculations by the authors using data from Statistics Canada, Canadian Community Health Survey (CCHS), 2005-2013.

7 Based on calculations by the authors using data from Colombia’s Encuesta Nacional de Calidad de Vida (ECD, 2012, 2014, 2015) and Peru’s Encuesta Nacional de Hogares, 2006, 2010, and 2011.

8 Calculations by the authors on the basis of available information for 38 countries and territories of the Region that reported data to the Health Information Platform for the Americas (PLISA) in 2010 and 2014.

9 Specialized ambulatory care services concentrate cost-effective technology and trained health personnel in specific areas for the management of complex cases and highly complex diagnostic and therapeutic procedures, such as imaging, endoscopy and laparoscopy, major outpatient surgery, dialysis, chemotherapy, etc. They also provide services for long-stay rehabilitation patients and services for community-based management of specific situations, such as care for mental health patients, care for dependent elderly persons, and initiatives for the care of other populations in conditions of vulnerability.

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