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.

Pathway to sustainable health

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

Introduction

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

Sustainable Development

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

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

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

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

Equity: a renewed focus for sustainable development

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

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

Transitioning to the era of the SDGs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Redefinition of global priorities

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

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

Regional priorities

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

Noncommunicable diseases

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

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

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

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

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

Universal health coverage

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

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

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

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

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

Elimination agenda for infectious diseases

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

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

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

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

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

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

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

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

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

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

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

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

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

Health across the SDGs

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

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

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

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

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

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

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

Finance

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

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

Measurement, monitoring, and evaluation

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

Mobilization of stakeholders

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

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

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

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

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

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

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

Identifying common ground

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

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

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

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

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

Poverty eradication

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

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

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

Sustainable consumption and production

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

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

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

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

Governance

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

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

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

Urban development

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

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

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

Environmental sustainability

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

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

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

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

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

Looking forward

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

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

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

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

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

Conclusions

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

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

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

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

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Reference/Note:

Aging and demographic changes

  • Introduction
  • The Americas Are Aging: a Window of Opportunity
  • Aging Beyond Demographics: the Search for Equity
  • Aging, Health, and Functional Capacity
  • The Public Health Response to Aging
  • Conclusion
  • References
  • Full Article
Page 1 of 7

Introduction

Between 2000 and 2050, the proportion of the world’s population aged 60 years and older will double, from about 11% to 22%. The absolute number of people 60 years and older is projected to increase from 900 million in 2015 to 1.4 billion by 2030, to 2.1 billion by 2050, and to 3.2 billion in 2100 (). Between 2025 and 2030, life expectancy in Latin America and the Caribbean (LAC) will increase to a projected 80.7 years for women and 74.9 years for men; in Canada and the United States of America, those numbers are projected to be even higher: 83.3 years for women and 79.3 years for men ().

The increase in life expectancy is due to several factors, including a decline in fertility rates and success in reducing fatal childhood diseases, maternal mortality, and mortality in older ages (). However, longer life expectancy is also a source of concern for policymakers; income growth may become harder to realize in countries with large populations of older people, and meeting the needs of a large elderly population will be especially difficult in low- and middle-income countries. It will be necessary to create economic and social institutions that provide income security, adequate health care, and other needs for the aging population (). An additional issue that policymakers are facing today is how to best define an older person. Terms used to define an older people include “the aged,” “the elderly,” “the third age,” and, in some cultures, “the fourth age” (). However, being “old” comes at different times to different people (). How to define older persons will remain a challenge because “the elderly, despite being a class, consist of individuals with unique life experiences, goals, and needs,” and because becoming older involves a change in capacity, social involvement, and physical and mental health ().

In response to these demographic transitions and concerns, the the Pan American Health Organization (PAHO) and the World Health Organization (WHO) have approved strategies and guidelines related to aging and health. In 2002, for the first time, PAHO Member States approved a resolution on health and aging (CSP26.R20). The Region of the Americas was the first WHO region to approve a strategy and plan of action on aging and health, in 2009(). In June 2016, the Organization of American States, with the technical support of PAHO and the Economic Commission for Latin America and the Caribbean (ECLAC), approved the Inter-American Convention on Protecting the Human Rights of Older People (). These instruments, which have been developed in the international context of health and aging, highlight the need for an innovative approach in the care of older persons. However, most of the countries in the Region still lack a holistic view of the demographic transition and do not provide an integrated approach to the care of older persons. The challenge posed by this change is viewed in a fragmented way, addressing the increased prevalence of chronic diseases, disability, and care dependency, or the consequent impact of these problems on health services, medication use, and long-term care. Therefore, it will be necessary to continue developing an integrated approach and working on comprehensive public health actions “to ensure healthy lives and promote well-being for all ages through universal health coverage including financial risk protection” ().

In the next decade, both population aging and individual aging will be major factors in modulating health needs, social security, and social protection, as well as the way in which these demands will be met. Despite the tangible implications of this aging trend for social security and public health, the Region still lacks a comprehensive vision of health for older persons. Knowledge about their health needs and care is not uniform, and most health systems lack indicators to monitor and analyze the impact of health measures. Coverage, continuity of care, and geographical, physical, economic, and cultural access to health services are inadequate, and the few persons who who do have access still do not receive services to meet their needs (). In this context, most experts agree that it is necessary to foster integrated health interventions () and to develop strategies that enable health systems to adapt to the new demographic and epidemiological realities ().

The Americas are aging: a window of opportunity

WHO’s Global Strategy and Plan of Action on Ageing and Health highlights the importance of demographic changes and how the changes will drive new challenges for public health and offer opportunities and a window for action created by the “demographic dividend” to be experienced during this decade (). The term demographic dividend refers to the dependency ratio in the population (i.e., the proportion of children aged less than 15 and adults over 59 years, compared with persons aged 15–59 years). The demographic dividend occurs when the dependency ratio drops substantially (Figure 1) due to the large pool of adult workers with low fertility combined with a relatively small group of dependent older people. Such a situation offers a “window of opportunity” to make investments in strengthening the country’s education, pension, and health systems (). The demographic dividend will span a much shorter period of time in countries with large pools of older persons than for those countries in the Region whose populations are still younger (). In the next decade, the extended work life of older people and their active participation in productive activities will require a review of the point at which they might be considered a “dependent” segment of the population.

Figure 1. Total child and old-age dependency ratios under different projection variants in LAC, 2010–2050

Source: United Nations Populations Division, Department of Economics and Social Affairs (DESA), population estimates and projections 2008 revision. Available from: http://www.un.org/en/development/desa/population/.

By international standards, Canada and the United States, in which some 20.7% of their population is at least 60 years of age, are already “old.” The aging of this population has taken place gradually over a period of 50 years. In contrast, in LAC, the number of persons 60 and older is expected to climb from 59 million to 196 million between 2010 and 2050. As shown in Figure 2, in LAC, the growth of the aging population will occur in a severely contracted interval of 20 to 30 years ().

Figure 2. Percentage change in the proportion of adults aged 60 or older in the Americas, for North American and for Latin America and the Caribbean (LAC), 2000–2015 and 2015–2030

Data Source: United Nations. World population prospects: the 2015 revision. New York: UN, Department of Economic and Social Affairs, Population Division; 2015.

Currently, people over 60 comprise about 13% of the population in the Caribbean, 12% of the population in South America, and 9% of the population in Central America. In contrast, by 2050, approximately 25% of the population of LAC will be 60 years and older (). These demographic trends will continue in the Region in the next 25 years and will be associated with a decrease in the proportion of children (aged 0–14) in the population, leading to drastic changes in the aging index (i.e., the ratio of older people to people under the age of 15) ().

In 2010, there were approximately 36 older persons for every 100 children in LAC. The projections indicate that this trend will reverse as of 2036, and by 2040, there will be 116 older persons for every 100 children younger than 15. With regards to the Caribbean, by 2040, the aging index could reach 142 older persons for every 100 children ().

Figure 3. Young children and older persons as a percentage of the population of the Americas: 1950–2050

Source: He W, Goodkind D, Kowal P. U.S Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015. Washington, D.C.: U.S. Government Publishing Office; 2016.

Life expectancy in the Region has increased by 21.6 years, on average, over the last 60 years and will continue to increase during the rest of the century. The octogenarians of the second half of this century have already been born, highlighting the importance of substantial investment in population health throughout the life course (this topic is discussed further the section “Building health throughout the life course“) (Figure 4).

Figure 4. Probabilities of survival to ages 60 and 80 among the 1950–1955 and 2000–2005 birth cohorts, by sex, for Latin America and the Caribbean (LAC) and for North America

Data Source: United Nations. World population prospects: the 2015 revision. New York: UN, Department of Economic and Social Affairs, Population Division; 2015.

While investment throughout the life course is imperative, the reality is that LAC will have to adapt much more quickly to the growth of the aging population at much lower levels of national income compared to the experience of higher-income countries in North America (). Unless there is unprecedented economic expansion, countries in LAC will generally experience rapid aging combined with increasing pressure for pension coverage that is already deficient for older people (). It is therefore essential that the Region develops a new paradigm of aging that views longevity as a period that continues to be productive and is characterized by self-care and involvement with family and community (). It is increasingly recognized that many countries in the Region will need to increase social security funds for older people, such as contributive and noncontributive public pensions. Additionally, removing the stigma of old age is essential for developing different approaches and ensuring not only the financial security but also the health and social protection of older people in a broad and equitable fashion ().

Not only can individuals expect to live much longer than previously, but families and communities are changing, too. Traditionally, the well-being of older people relied on support provided by younger relatives. Culturally, it was considered the responsibility of adult children to protect and care for parents. However, a significant shift has occurred in this norm due to changes caused by urbanization, migration, changes in living arrangements, increased life expectancy, and a rapid decline in fertility. These changes mean there will be fewer older people living with, or in proximity to, adult children who are able to provide support and care for them (). In countries with a younger population, the majority of older persons still live in multigenerational households; however, as populations age, the percentage of older persons living alone increases. In Central American countries, for example, only 10% to 23% of older adults live alone, while in Uruguay and Argentina over 50% live alone. By definition, as populations become older, fertility declines and life expectancy increases (). Only about one-third of adults in LAC receive income from pensions; as a result, material support for old age is still dependent on the extended family. Furthermore, rapid aging is occurring in a fragile institutional environment, i.e., in which the bulk of sources that guarantee minimum levels of social and economic support (such as old-age pensions) are being reformed or, in some cases, eliminated (). As families become smaller, it is conceivable that adult children will have to ration available resources in support of three and even four generations (). Thus, in LAC, a highly compressed aging process will take place in the midst of rapidly changing intergenerational relations and fragile public social protection structures, affecting pensions and access to health ().

Healthy aging in the Region will be determined by the availability of age-friendly policies and programs that create sustainable environments to allow older persons and their families to live with dignity and a high quality of life. The time to act is now, while most countries still have a window of opportunity (). The stage is set: the current older population in the Region grew up with a wide range of privileges and disadvantages that have resulted in sharp differences in life expectancy, longevity, and health. Therefore, the current policy challenge is to invest in necessary interventions to reduce health inequities in adults who are older, and to improve conditions that promote healthy aging and equity by building the infrastructure that is needed to address the continued expansion of the older adult population that will occur during the next decade ().

Aging beyond demographics: the search for equity

“When we are old, it is hard to do things; age takes over and we are no longer able to work like before… [I] don’t have the strength to do the things I used to do, my children are all gone; what can I do? Perhaps it is time for me to die.” (An indigenous older person in the qualitative study on aging in Ecuador)

The impact of aging extends to practically all spheres of life. It is especially evident in its economic, social, and public health spheres, and in family and personal life. The Political Declaration and Madrid International Plan of Action on Ageing () approved in Madrid in 2002, defined three priority areas: integrating older people into development strategies; providing enabling environments for aging and older people; and promoting the health of older people. These three priorities are now very much in force in the Region. The pursuit of equity through the life course is imperative for healthy aging (see “Building health throughout the life course“). Almost 50% of the older people interviewed for the Salud, Bienestar y Envejecimiento (SABE) study said that they did not have the financial means to meet their daily needs, and one-third did not have a pension or a paying job (). In developed countries, approximately 75% of the older population receives some pension; in LAC, only 40% of older people do. There is a significant difference between the genders, too; 11% of older men and 25% of older women have no income of their own (). The level of schooling among older people is lower than that of the general population, and they have very high illiteracy rates. Ill health in old age is not inevitable, and there is a demonstrable association between ill health and social and health conditions. In the United States, 77% of people over the age of 65 report they are in good health. In LAC, however, less than 50% of people over 60 describe their health as good. Furthermore, women in LAC say that they are in poorer health than men.

Inequality and indigenous populations

Studies in Ecuador and Peru offer a window into the experience of aging among indigenous populations in rural areas, which have high rates of extreme poverty. In Peru, in a sample of low-income “younger olds,” defined as the beginning of old age (), 61% reported that they had good or very good health, with no significant difference between rural and urban areas. However, among people 75 or older who lived in rural areas that percentage dropped to 48%. In contrast, in urban areas, 61% of those 75 and older reported they were in good health (). This difference is consistent with the number of self-reported chronic conditions untreated or unmanaged in rural versus urban areas and in the percentage of individuals who report difficulties with instrumental activities of daily living (). In a qualitative study of an indigenous population in Ecuador, aging is most frequently associated with the loss of capacity to do physical work and with dependence on others to meet basic needs ().

Figure 5. Percentage of older persons reporting good or very good health by age, and rural/urban residence

Source: ESBAM 2012. Ministry of Development Social Inclusion –General Department of Monitoring and Evaluation.

Aging, health, and functional capacity

With time, and especially after having reached a peak of development, humans experience important biological changes at the cellular and molecular level that lead to a decrease in the capacity of organs and systems. This is reflected primarily in a loss of reserve capacity, but eventually the changes also lead to a loss of functional capacity, exponentially increasing the risk of becoming ill or disabled, or dying. However, it is clear that all people do not age in the same way; although genetics is involved, aging is also determined by many positive and negative influences during the life course (). The development of geriatrics and gerontology in the last decades has allowed for a better understanding of the processes of health and aging and their relation to disease ().

The World Report on Ageing and Health defines healthy aging as “the process of developing and maintaining functional abilities that enable well-being in older age. Functional abilities are the health-related attributes that enable people to be and to do what they have reason to value; it is made up of the intrinsic capacity of the individual, relevant environmental characteristics and the interactions between the individual and these characteristics” ().

Ensuring healthy population aging begins before birth and continues throughout the life course. The challenge for policymakers today is to address increases in chronic conditions and frailty among older persons, as well as continuing to improve health along the life course. But addressing longevity requires systemic changes in health care systems; what works when the health care system focuses on primary prevention of noncommunicable diseases and on curing acute conditions does not necessarily work when the aim is to maintain health and functional capacity in adults and older adults with chronic conditions. These changes need to be informed by the diversity of health, disease, and functional trajectories that occur during the last four decades of life ().

In LAC, birth cohorts that reached 70 after the year 2000 are unique in that they are largely the product of public health interventions that increased childhood survival. This cohort was exposed to infectious diseases and early malnutrition that may contribute to the late onset of chronic conditions and frailty. Evidence that early childhood conditions affect adult health is mounting fast (). Empirical data as well as theoretical arguments () highlight four factors in early childhood that may influence later health: () conditions that developed in utero or shortly after birth may remain latent for long periods and may be expressed in late adulthood as chronic conditions (); () illnesses during early childhood may directly cause the late onset of some chronic diseases such as heart disease and rheumatic fever; () recurrent bouts of infectious diseases during early childhood and the processes of sustained inflammation in later life may cause the early onset of coronary heart disease; and () socioeconomic conditions in early childhood could have harmful health effects in a person’s later years (see Building health throughout the life course ).

Achieving the goals of healthy aging is “not simply a case of doing more of what is already being done or doing it better. Systemic change is needed” (). Aging is and will continue to be a driver in public health for decades to come. Population aging in the Region is not only a matter of increased number of people 60 and older, but the increased combination of multiple chronic conditions, recurrent infectious diseases, and geriatric conditions that include diminishing muscle mass, changes in sensory and cognitive functions, and a decline in immune functions. However, the current public health and health care systems were developed around a different set of demographic and epidemiological imperatives and are seriously unprepared to address the needs and priorities of a fast-growing older population (). Regardless of socioeconomic conditions in the Region, life expectancy at the age of 60 may now mean another 18 to 23 years of life can be expected. People aged 80 and older are the fastest growing population group in the Region (). This is an unprecedented reality, and their presence will affect existing paradigms of public health and health services.

About two in three older persons have a chronic condition, including arthritis, asthma, chronic respiratory conditions, diabetes, heart disease, and hypertension (). The prevalence of two or more concurrent chronic conditions increases with age (). As the number of chronic conditions in an individual increases, so do the risks of poor functional status and otherwise unnecessary hospitalizations.

The resource implications of addressing multiple chronic conditions are immense. In the United States, 66% of total health care spending is directed toward care for the approximately 27% of Americans with multiple chronic conditions (). The 2015 World report on ageing and health describes a systematic review of studies in seven high-income countries, which concluded that more than half of all older people are affected by multimorbidity for which the prevalence increases sharply in very old age (). Even though we lack information in LAC about the prevalence and impact of multiple chronic conditions, the increasing life expectancy and the aging LAC population will dramatically increase the need for health systems to change from a “young” system of care to a mature system that deals in large part with the effect of multiple chronic conditions in an older population.

The aging population will experience greater functional loss, dependence, and demand for care, and despite the visible implications that this phenomenon will have for social security and public health in the next 10 years, the Region still lacks a plan for long-term care. This scenario also requires that health care confront new prevention and treatment challenges. Health systems and services should prepare in a timely way to respond to the growing health care needs caused by those conditions and should not be focused only on cures or avoiding death. By 2020, the prevalence of severe disabilities affecting this population group in LAC will increase by 47%. In the year 2010, dementias were responsible for an estimated global cost of US$ 604 billion; in the Americas alone, the total estimated cost was US$ 235.8 billion ().

Preventing blindness in older persons

The aging process is frequently associated with declines in sensory functions that can have important implications for the well-being of older people and their families. Much of this dependence can be completely prevented with health interventions. Untreated sensory changes affect not only quality of life but also the level of dependency and disability, with the associated costs of caring for someone who becomes disabled in old age. In order to achieve universal access to health, health systems must develop simple interventions aligned to the health needs of older persons, including improved access to intraocular lenses used in cataract surgery. These lenses can make the difference between healthy aging and premature dependency on others. Cataracts that are not corrected by surgery continue to be the most common cause of blindness for three million people in the Americas. In Latin America, cataract surgery performed by the public sector or by NGOs costs about US$ 300; cataracts that go uncorrected cause 58.0% of blindness in Peru and 66.4% in Panama. In the United States, the 13-year societal cost perspective for the financial return on investment (ROI) for first-eye cataract surgery was US$ 121,198, a 4,567% gain over 13 years. The direct ophthalmic medical cost for unilateral cataract surgery in 2012 was US$ 2,653 ().

The public health response to aging

Poor health is not inevitable in old age, but a long life of good health is not a given. Older people have accumulated a lifetime of risk factors associated with multiple chronic conditions in addition to the physiological changes of old age. Faced with a long-lived population, it is necessary for public health systems to develop an approach focused on functional capacity and health, in addition to disease management.

Whether or not we are able to promote healthy aging and support the intrinsic capacity of older adults to maintain functional capacity will depend on how well we achieve systemic changes in the health care system. In turn, how well we promote healthy aging, in spite of multiple chronic conditions, will determine the cost of population aging and the capacity of the health system to respond to the health needs of the entire population.

The World report on ageing and health provides three key reasons to act. The first reason is the rights of older persons: an approach to health based on human rights means that health “embraces a wide range of socioeconomic factors that promote conditions in which people can lead a healthy life and extends to the underlying determinants of health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment” (). In addition, this approach recognizes that older persons’ autonomy, participation, and integration into the community are central to their well-being (). The second reason is to foster sustainable development: promoting older persons’ contribution to development promises to lead to a more equitable society. Healthy older adults contribute to the community in numerous ways. Conversely, lack of access to health care may lead to avoidable hospitalizations and loss of functional capacity, which in turn requires the care and resources of family members. The third reason is the economic imperative: based on the continuous contribution older people make to individuals, family, and the community, WHO presents a new paradigm.

The World report on ageing and health takes a novel approach to the economic implications of older populations. It states that “rather than portraying expenditures on older persons as a cost, these are considered as investments” (). These investments include expenditures in an integrated health system aligned to the needs of older persons, long-term care, and age-friendly environments. As with any other investment, doing what is known to work to improve and maintain functional capacity will yield a sustainable return on the investment. The public health response will suggest how some of these investments may be prioritized.

The Multisectoral Action for a Life Course Approach to Healthy Ageing: Draft Global Strategy and Plan of Action on Ageing and Health () defines five priority areas to concentrate the public health response to aging. One of the first steps in implementing the plan includes developing indicators with core baseline data to be used in monitoring progress in each of the priority areas and to document progress towards planning for a decade of healthy aging during 2020–2030 (). The identified priorities represent an important road map for the public heath institutions in America.

Commitment to action on healthy aging in every country

The WHO strategy recognizes that fostering healthy aging requires leadership and commitment. To enable all people to live a long and healthy life calls for a multisectoral approach with strong engagement from diverse sectors and different levels of government. Collaboration is also needed between government and nongovernmental actors, including service providers, product developers, academics, and older people themselves. A key step to fostering action must therefore be to build local, regional, and international coalitions to develop a shared understanding of the issues involved.

Much of the investment to foster healthy aging will also have direct benefits to other population groups and will tend to strengthen a country’s commitment to the Sustainable Development Goals. For example, multisectoral leadership will ensure that all actions to improve healthy aging foster the ability of the elderly to make multiple contributions in an environment that respects their dignity and human rights, free from gender- and age-based discrimination, and it promotes the social, political, and economic inclusion of all, irrespective of age. Within this framework, the rights of older persons become an important driver for meeting regional goals for sustainable development, human rights, and universal access to health. The Inter-American Convention on Protecting the Human Rights of Older Persons, adopted at the 45th regular session of the Organization of American States General Assembly (), recognizes the need to address matters of old age and aging from a human rights perspective, provides a framework to address and ensure those rights, and highlights the need to eliminate all forms of age discrimination in the Americas.

Several countries in the Region have developed at least one public policy tool (law, national plan, specific policy, or program) to address aging and/or specifically aging and health. The task ahead is to ensure that all public policy instruments develop indicators and core data for monitoring implementation and evaluating effectiveness. Therefore, a priority must be to strengthen Member States’ capacity to develop, monitor, and evaluate public policies for healthy aging.

Developing elder-friendly environments

Environments that are elder-friendly help to foster healthy aging in two ways: by supporting the building and maintenance of intrinsic capacity across the life course and by enabling greater functional ability so that people with varying levels of capacity can do the things they value ().

Whether or not individuals are able to function depends not only on the person’s intrinsic capacity, such as strength, musculoskeletal function, and other conditions that induce physiological limitations, but also on the individual’s environment and access to supportive services and devices. For example, a person who has difficulty walking one block due to osteoarthritis may be able to function independently with a combination of (a) appropriate assistive devices, such as a cane or walker, that compensate for decreased intrinsic capacity, and (b) a proven regimen of physical activities that supports and improves intrinsic capacity. Thus, healthy aging is framed in a way that focuses both on strengthening or maintaining intrinsic capacity and creating supportive environments and technologies.

In this context, multisectoral leadership, commitment, and resources at the local level are essential. A WHO global network of age-friendly cities and communities in the Region of the Americas would provide numerous examples of how coordinated action among municipalities and various public and private sectors can improve life for older people. The goal of age-friendly communities is to foster the autonomy and engagement of older people as well as to ensure access to transportation, housing, outdoor spaces, communication and information sources, employment, community support and health services, and encourage social and civic participation, respect, and social inclusion (). No sector can be solely responsible for promoting and supporting the ability of older persons to function and continue to contribute to society. Member States should collect and use age and socioeconomic disaggregated information on older people’s functional abilities and should assess the effectiveness of and identify gaps in existing policies, systems, and services in meeting the needs and rights of the older persons ().

Prevention of falls

Extensive evidence indicates that falls and the risk of falls can be reduced through systematically identifying risks and taking actions that include a combination of clinical and community-based interventions. Engaging older adults in strategies that help prevent falls is cost-effective (). Interventions that strengthen intrinsic capacity and technologies and environmental changes that compensate for decreasing intrinsic capacity can prevent many risks that result in falls (). Public health interventions to prevent falls should be evidence-based. Interventions are grouped into three categories: exercise-based, home modification, and multifaceted interventions that address a combination of risk factors ().

Table 1. Seven risk factors of effective fall interventions

Risk factor Modifiable by:
Lower body weakness Targeted strengthening exercises
Vitamin D deficiency Vitamin D supplementation
Difficulties with walking and balance Physical therapy intervention and mobility-assisted devices
Polypharmacy Medication review
Vision problems such as cataracts Timely cataract surgery and vision aids, as needed
Foot pain or poor footwear Foot care
Home and environmental hazards Home and environment are made age-friendly

Adapted from: Centers for Diseases Control and Prevention. Preventing falls: a guide to implementing effective community-based fall prevention program. Atlanta: CDC; 2015 ().

Aligning health systems to the needs of older populations

In order to ensure that older people have universal access to health, systemic changes are needed because old age does not mean simply living more years. It is a new phase in human development (). A health care system that is aligned to the health needs of older adults has policies, plans, and programs to improve or maintain functional capacity, manage multiple chronic conditions, and provide services and support for long-term care ().

With the longevity of the population, new challenges will appear as health systems address the health needs of adults in their 60s, and older adults present different problems related to health and frailty that have significant impact on the capacity of health systems across the Region. A system aligned to the needs of older people has the capacity to address the problems that matter to them: chronic pain; difficulties with hearing, seeing, walking, or performing daily or social activities; and depressive symptoms. Primary care services are still focused on diagnosis and treatment of diseases, but most problems that older people bring to the clinics are not necessarily identified as “diseases” in the traditional sense. Primary care personnel are not trained in nor do they receive much guidance in recognizing and managing health problems identified by older people. Nor are they able to identify community resources and the extended-care team needed to respond to the health issues of older persons. A focus on prevention requires that the health team better understand the intimate relationship that exists between intrinsic capacity, environment, and the technologies used to compensate for the normal losses that occur as part of the aging process.

Primary prevention focuses on four risk factors: harmful use of alcohol, unhealthy diet, physical inactivity, and tobacco use. These factors are important throughout the life course not only to prevent but also to manage noncommunicable diseases. Epidemiological data in the Region show that a significant number of adults and older adults will live with a chronic disease such as diabetes, lung and heart diseases, arthritis, and cancers for an average of 30 to 40 years (). Teaching older people how to be healthy, and how to live healthy lives even with these chronic diseases, is essential.

A WHO framework of integrated, people-centered health services sets forth a vision in which “all people have equal access to quality health services that are co-produced in a way that meets their life course needs…” (). The framework defines the concept of “co-production of health” as “care that…implies a long-term relationship between people, providers, and health systems where information, decision-making, and service delivery become shared” (). A health service aligned to the needs of older persons has the necessary human resources, technologies, and community partners to be able to assess risks and symptoms. Unlike acute care, where treatment is usually short and definitive, ongoing treatment and monitoring chronic conditions require productive interactions between health professionals and the individual with the chronic conditions. Person-centered care requires active participation in self-care management and promotes a partnership in improving and maintaining health. In the life of a typical person living with a chronic condition, health care system interventions take no more than a few hours a year. The rest of the time the patient is responsible for self-care management. Outcomes are determined not by the short time in the doctor’s office but by the daily behaviors of the individual. To achieve the goals of person-centered care, the health system needs to support the self-care management (for more information see the box Self-care programs) of individuals living with chronic conditions. Evidence-based programs are those that have been rigorously tested in controlled settings, proven effective, and translated into practical models that can be implemented at community sites. Primary health care services should seek to adopt evidence-based programs that provide skills and practice to older adults in the co-production of health ().

Self-care programs

Self-care or self-management requires processes that are designed to assist with behavioral changes and empowerment. Research has shown that patients can learn and change behaviors at any age. Programs specifically designed to improve patients’ self-efficacy, such as the Stanford University Chronic Disease Self-Management Program, have been used with adults of all ages and have proven effective in changing patients into proactive self-care managers. In a meta-analysis of 25 years of research findings, the Centers for Disease Control and Prevention concludes that, “At the population level, these interventions could have a considerable public health effect due to the potential scalability of the interventions, the relative cost to implement them, wide application across various settings and audiences, and the capacity to reach large numbers of people” ().

It must be a priority to retool the health care work force to deliver care centered on older persons and to create and use evidence-based programs to best promote healthy aging. In a 2007 Regional meeting, an informal survey was conducted in which 85% of the focal points who participated acknowledged not having any formal training in either gerontology or geriatrics. A “geriatricized” work force is one that has been provided with training in healthy aging and has basic skills and tools to develop elder-centered plans and programs aligned to meet the health needs of older persons and their families. It is a work force that understands elder-care priorities, that focuses on functional capacity, and that can avoid preventable complications. To fill this training gap, PAHO’s Regional Program on Health and Aging, in collaboration with other academic partners in the Region, has developed a 420-hour certificate in “Management of Aging and Health Programs.” It combines 40 weeks of total immersion and online training in a flexible format that is rich in tools and promotes online group learning. Since 2007, more than 250 individuals from 25 countries in LAC have completed the program.

In 2000, with the support of PAHO, the Latin American Academy of Medicine of Older Persons (Academia Latinoamericana de Medicina del Adulto Mayor, ALMA) was established to create a network of faculty members in medical schools across the Region for teaching geriatrics and for training medical students and primary health care doctors in the specialty of geriatrics. ALMA provides ongoing education and now has 220 faculty members from 16 Latin American countries. In 2005, ALMA published a guide to teaching geriatrics in general medical education ().

Despite these advances in training, rethinking the primary care work force for the 21st century for extremely fast aging scenarios requires a different approach to the education and training of the existing work force and to the expanded role the care team will need to assume to ensure universal access to person-centered care. There will be a growing need for nurses, physical therapists, dietitians, community health workers, and health educators who are trained in population health with a focus on diverse populations from birth to age 100 ().

Developing sustainable and equitable systems for long-term care

Families are the main providers of unpaid care in LAC: in particular, women account for 90% of all unpaid care providers. Family caregivers cut back up to 20% on paid work to provide care to older persons (). About 43% of caregivers, mainly informal/family caregivers, show symptoms of depression and anxiety; it is estimated that compared to non-caregivers, caregivers have twice the risk of heart disease and injuries. In addition, when care is provided in conditions of poverty and when caregivers have no training, resources, or social or institutional support, elders are at increased risk of morbidity; furthermore, the elderly who are being cared for are at increased risk of neglect and abuse by their overwhelmed caregivers ().

In the next decade, health systems must integrate medical, social, and supportive care in a more efficient way. A health system aligned to the needs of older adults develops elder-driven care plans and is aligned with the goals of both the older person and his or her family. This means that they have alternatives to hospitalization and institutionalization, and access to long-term care support and services designed to maintain health and functional capacity for as long as possible during a life phase that is marked by frailty and dependence.

Long-term care

“System of activities undertaken by informal caregivers (family, friends, and/or neighbors) and/or professionals (health, social, and others) to ensure that a person who is not fully capable of self-care can maintain the highest possible quality of life, according to his or her individual preferences, with the greatest possible degree of independence, autonomy, participation, personal fulfillment, and human dignity” ().

For people who live into old age, maintaining health and avoiding crises requires a very different health care system than the existing model. Just one generation ago, people rarely survived into frail old age. For those who survived, someone in the family was always able to provide care. But for millions of families caring for a loved one, this is no longer a simple affair. Urban settings are not elder-friendly, fewer children are available and able to provide care, and long-distance caregiving have all changed the dynamics of living into old age with supportive environments. When there are no options for caregivers, caregiving crises result in otherwise preventable, long-term, costly hospitalizations.

In a young society, one becomes accustomed to people dying of a terminal illness with a relatively short period between the onset of the fatal disease and death. However, in an aging society, there is a new phase in the life course for those who live into old age: frailty. In this phase, no terminal illness is identified, and the decline of functional capacity, speech, and ambulation may be prolonged for as many as 6 to 8 years ().

Access to family care is no longer the norm. Almost half of older adults live alone or with a spouse, not in a multigenerational family (). Intergenerational living takes place not only within households but also among generations regardless of living arrangements. The many SABE surveys consistently report a lifetime bidirectional distribution of resources going one way or the other in critical periods of life, with family relations often strained by illness and disability ().

Long-term supportive services at home are essential during this phase of life. The transition from being a healthy, functioning older adult to a frail, dependent adult is not as clearly defined as transitions in other stages of life, such as the transition from childhood to adolescence. However, these transitions are real, and society has to recognize that at the onset of frailty, the individual will need services from health care providers, family, and friends that are distinctly different from services provided to non-frail persons. Although the majority of older people will enjoy active and healthy aging until near the end of life, a significant number will suffer from dementia and other conditions that lead to disability, frailty, and the need of long-term care (see Box “The case of dementia” for more information regarding dementias). About 20% of people 65 and older will require long-term care services and support in order to perform activities of daily living ().

The case of dementia

Dementias are the most important contributor to disability and dependence among older persons. It is estimated that in the Americas the prevalence of Alzheimer’s disease and other dementias will double every 20 years, increasing from 7.8 million in 2010 to 14.8 million in 2030. The countries of LAC will be the most affected, where the number of people with dementias will increase from 3.4 million in 2010 to 7.6 million in 2030, surpassing the projected 7.1 million people with dementias in the United States and Canada. In 2010, the estimated cost of dementias in the Americas was US$ 235.8 billion ().

Dementias cause the second largest burden of years lived with disability (11.9%) (). The proportion of people needing care for dementias rises with age, from 30% of people between the ages of 65–69 to 66% of people 90 years and older. And unlike with other chronic conditions, people with dementias may need care beginning in the early stages of the disease and be increasingly dependent on caregivers as their condition worsens (). At the 54th Directing Council, PAHO approved Resolution CD54.R11, the Strategy and Plan of Action on Dementias in Older Persons; it urges Member States to strengthen the capacity of their health systems and health services networks in order to increase access to resources, programs, and services for people with dementias and their families ().

Improving measurement, monitoring, and research for healthy aging

The primary driver of change in public health is data. Public health addresses perceived threats to health when those threats are quantified and localized, and the action taken to address them needs to be driven by evidence: evidence of the threat to healthy aging; evidence that there are policies, interventions, and programs proven to improve healthy aging; and evidence that there is local capacity to adopt the policies, interventions, and programs with fidelity.

The Regional capacity to study aging and health issues has improved during the past 15 years. What is missing is a substantial effort to collaborate regionally in order to provide infrastructure and build capacity for analyzing and utilizing findings that support policies, plans, and programs that address the needs of the Region’s diverse, aging population. Strengthening the scientific foundation for policy-making that meets the challenges of healthy aging must be a priority for the Region ().

The goal for the next 5 years is for health systems throughout the Region to develop core indicators of health and functional capacity across the life course, segregated by sex and age groups, and representative of the population from birth to old age. The aim is to prepare and then adopt systemic changes that are needed for an aging population. With the support of PAHO, Member States will need to create a database that can provide indicators on healthy aging and that is focused on access to health and functional capacity, segregated by age groups and geographic areas. Local knowledge can then drive local decision-making in support of national plans. PAHO’s appointed multidisciplinary work group on aging research has a 5-year goal of ensuring that at least 40% of the Region’s countries will develop the capacity to manage a database on aging and health indicators and will be able to translate that research and data into evidence that can inform decision-making and public health interventions. The long-term vision is to use evidence, information, and research to help reduce inequalities in health and improve healthy aging, with a special focus on those who are at greatest risk of disability or premature death.

Conclusion

The next 5 years will require a major commitment by various sectors of government and society, including older people, to respond to the five key priorities for healthy aging. Member States will have many opportunities to exchange information, coordinate actions, and share lessons learned to support the development of healthy aging. The Region will need to strengthen national capacity to formulate evidence-based policies and programs. If the policies and programs are well crafted and implemented with an evidence-based approach, their cost will be a solid investment, and the return on that investment will be healthier older adults as a key step toward universal health.

Orienting health systems around intrinsic capacity and functional ability will require sustainably financed services, collaboration between sectors, and health and social systems that are aligned to foster healthy aging. Providing access to care and supportive services for people who live into old age will require substantial efforts to finance, create, and implement mechanisms to provide quality care. In general, the next 5 years will require collaboration among Member States, international development organizations, the scientific community, and all sectors of society, which will need to test a variety of approaches to further health and functional capacity in a rapidly aging, diverse population.

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Reference/Note:

Chronic conditions and diseases due to external causes

  • Summary
  • Introduction
  • Discussion
  • Tackling the Major NCD Risk Factors
  • Management of Noncommunicable Diseases
  • Mental Health
  • Road Traffic Injuries
  • Interpersonal Violence Prevention
  • Disabilities
  • Chronic Conditions, Life Course, and Social Stratification
  • Conclusions
  • References
  • Full Article
Page 1 of 12

Summary

Noncommunicable diseases (NCDs), which comprise cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases, are the leading causes of ill health, death, and disability in the Americas. Because of their high cost of care and economic impact, NCDs have a significant impact on development. Thus, tackling the common risk factors of NCDs (tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet) is an urgent priority. In addition, mental and substance use disorders are highly prevalent, and together with road traffic injuries and interpersonal violence, are also major causes of disability.

These conditions are driven by demographic changes, economic growth, negative effects of globalization, rapid and unplanned urbanization, and the epidemiological transition from infectious diseases to chronic conditions. Populations living in vulnerable conditions are more affected by these changes, and together with structural factors such as education, occupation, income, gender, and ethnicity, lead to a disproportionate impact of underlying social determinants on this population.

Prevention is the cornerstone of a response to these chronic conditions. Policy, regulatory, and health promotion interventions are recommended to reduce NCD risk factors, and all policies should be centered on public health interests. For mental health, the first steps are early prevention, correct identification, and treatment of emotional or behavioral problems. Prevention practices for road traffic injuries and disabilities include laws that prohibit speeding and drunk driving and that require the use of motorcycle helmets and seat belts.

Universal health coverage for equitable access to quality care for persons living with chronic conditions, and in many cases multiple chronic conditions, is necessary to improve health outcomes. For those at risk for or living with one or more NCDs, a chronic care approach is recommended. This includes organizing services for continuous and quality care, evidence-based guidelines, support for self-management, clinical information systems, coordinating care among providers, and community resources to support patients. People living with disabilities require special attention as they often seek more health care but have greater unmet needs. Barriers to care include physical barriers, financial barriers, and lack of appropriate services. The treatment gap for mental health and other conditions is significant and is expected to worsen with an aging population. Service delivery tends to be fragmented, with poor coordination between the primary, secondary, and tertiary levels, and there is a heavy emphasis on mental institutions. The Mental Health Gap Action
Program (mhGAP) of the World Health Organization (WHO) offers a model of care, with psychosocial assistance and medication, to improve mental health.

As the Region continues to develop, the focus shifts to the Sustainable Development Goals (SDGs); they include specific targets for NCDs, mental health, and road safety, among other issues. Achieving these goals will require governments to intensify their response to chronic conditions, as well as increased technical assistance from the global health community.

Throughout the text, the terminology of chronic conditions is used to encompass conditions that are recurrent or that manifest throughout the life course, and not necessarily related to disease or illness. From the perspective of a socially organized response, chronic conditions are expressed in more expanded time trajectories and in cycles of critical periods that trap health systems in ongoing health interventions. This perspective is aligned with the life-course approach and with the social determinants approach, both of which are discussed in separate chapters.

Introduction

Noncommunicable diseases (NCDs)—including cardiovascular diseases, cancer, diabetes, chronic respiratory diseases—are the leading cause of morbidity, mortality, and premature death in the Americas, accounting for 79% of all deaths in 2012 (). A significant proportion of these deaths is preventable by tackling the four common risk factors: tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity (). In addition, mental, neurological, and substance use (MNS) disorders are among the leading causes of the global burden of disease, responsible for 19% of the overall loss in disability-adjusted life years (DALYs) in the Region (). Recurrent depression, anxiety disorders, schizophrenia, bipolar affective disorder, suicide, dementia, and alcohol-use disorders are among the most common MNS disorders, for which significant treatment gaps exist in the Region ().

The number of people with disabilities in the Americas, estimated at 140 million people, is increasing due to the population aging, increasing prevalence rates of NCDs, and changes in lifestyles (). People with disabilities generally have poorer health, fewer economic opportunities, and higher rates of poverty, owing to the barriers of everyday living ().

Road traffic injuries continue to be a significant public health problem in the Americas, with a death rate of 15.9 per 100,000 population (). The situation is worsening with greater population growth, urbanization, economic development, and weak public transportation systems (). The Americas is also one of the regions with the highest levels of violence of all types (). This situation is strongly associated with the poor rule of law; weakening governance; cultural, social, and gender norms; increasing unemployment and income inequality; and limited educational opportunities.

In this section, we describe the situation for this group of NCDs and health issues, while highlighting effective public health interventions to address these conditions.

Discussion

Overview of noncommunicable diseases

NCDs are the leading causes of death in the Americas, causing an estimated 4.8 million deaths in 2012 (). Premature mortality is a major concern, given that 35% of NCD deaths occur in persons under 70 years of age. Cardiovascular diseases (CVDs) account for 37% of all NCD deaths, while cancer accounts for 25%, diabetes for 8%, and chronic respiratory diseases for 6% (). CVD mortality rates have declined steadily in most countries in the Americas, with an overall reduction of 19% from 2000 to 2010 (20% in women and 18% in men) (), while cancer mortality rates have remained relatively stable for both men and women over the past 15 years ().

NCDs are impeding economic growth and development in the Region, as countries face important lost output due to early deaths, disability, and costs of ill health (). The economic burden of NCDs (including mental health) in low- and middle-income countries has been estimated at US$ 21.3 trillion for 2011-2030 (). This is in contrast to the estimated cost of US$ 2 billion annually, equivalent to less than US$ 0.20 per person, to implement a set of cost-effective interventions to address NCD risk factors in low- and middle-income countries ().

NCDs disproportionately affect people living in vulnerable situations because of the complex interplay between social, behavioral, biological, and environmental factors, along with the accumulation of positive and negative influences over the life course (). For example, NCD mortality tends to be higher in populations with less education, lower income, less social support, and racial discrimination ().

NCDs and their risk factors manifest differently among men and women. For example, insufficient physical activity is more common among women than men (37.8% vs. 26.7%), and more women are obese compared to men (27.4% vs. 21.7%) (). More men smoke than women (24.1% vs. 14.2%) and also drink alcohol heavily (21.0% vs. 7.2% among women) (). Hypertension affects men and women equally; however, women show greater awareness of their hypertensive status and have higher rates of treatment and control than men (). As a result, CVD mortality rates are higher in men in all countries of the Americas, and premature mortality from CVD during 2000–2010 dropped more in women (average annual rate of 2.7%, vs. 2.3% among men) ().

Underlying NCD risk factors

NCDs are driven largely by forces that include demographic changes, epidemiological transition, economic development, rapid and unplanned urbanization, and negative effects of globalization, among other factors. These dynamics have had an impact on the four key risk factors that account for the majority of preventable deaths and disability from NCDs: harmful use of alcohol, unhealthy diet, physical inactivity, and tobacco use ().

Most of these are associated with the consumption of commodities, such as tobacco, alcohol, and ultra-processed products (UPPs) including sugar-sweetened beverages (SSBs). UPPs are a result of modern industrial food science; their nutritional quality is very low although they may be palatable and quasi-addictive (). Alcohol and tobacco are psychoactive substances with reinforcing and known addictive properties. As a consequence of globalization and market changes, alcohol, tobacco, UPPs, and SSBs are widely available, inexpensive, and heavily promoted through advertising, promotions, and corporate sponsorships. In the case of alcohol, the negative impact goes beyond NCDs and includes mental and neurological disorders, injuries, and associated diseases.

The consumption of these commodities is influenced by industries that massively produce, distribute, sell, and promote their products without adequate regulatory frameworks. In addition, favorable trends in economic development that increase people’s income can also increase the affordability of these products, but only if not combined with sound regulatory measures, including trade, fiscal, and investment policies that limit their consumption. This is shown in the relationship between foreign investment and the increase in tobacco consumption (); market deregulation and fiscal incentives and the increase in sales and consumption of UPPs (); and trade liberalization and harmful use of alcohol (). In addition, physical inactivity is reinforced by rapid urbanization, automation of many activities, an increase in violence and insecurity, and inadequate or expensive public transportation.

Overweight/obesity, physical inactivity, and unhealthy diet are strongly associated with type 2 diabetes, and more than half of these cases can be prevented by reducing these risk factors (). Furthermore, an estimated 30% to 40% of cancers can be prevented by reducing the main NCD risk factors. Tobacco control can significantly reduce chronic respiratory diseases, notably chronic obstructive pulmonary disease. Tobacco control and minimizing salt consumption can reduce population-level CVD risk. Control of elevated blood pressure (hypertension) is also a cost-effective intervention () to reduce cardiovascular risk, and secondary prevention can prevent and delay up to 75% of new cardiovascular events ().

More information on individual NCD risk factors is provided below.

Unhealthy diet and obesity. Hunger and nutritional deficits coexist with an increase in overweight and obesity; they share common determinants of poverty, inequities, and lack of healthy, nutritious food (). Changes in dietary patterns have emerged from globalization, urbanization, the incorporation of more women into the work force, and increased consumption of food outside the home concomitantly with the increase in marketing and availability of SSBs and UPPs (). The fastest increase in UPP sales, and in overweight and obesity, are found in Latin America and the Caribbean (). This is the result of food industry mass-marketing campaigns, foreign investments, and the takeover of domestic food companies (). Global producers are driving the “nutrition transition” from traditional, simple diets to highly processed foods, and the pace is accelerating ().

To address obesity in the Region and as part of the Plan of Action for Prevention of Obesity in Children and Adolescents (), PAHO commissioned an expert consultation group to develop a nutrient profile model (). The model has been used as a basis for legislation of front-of-package labeling in countries such as Chile and Ecuador.

Tobacco. Tobacco continues to be one of the main causes of preventable death (). In the Region, tobacco-related deaths account for 14% of all deaths in adults 30 to 70 years old. The average prevalence of tobacco smoking in the Region is decreasing, but this is not the case in all countries (). Research has shown that achieving the target of 30% reduction in tobacco use is fundamental to reaching the overall goal of 25% reduction in premature mortality from NCDs (). Despite the progress made in several countries by implementing the WHO Framework Convention on Tobacco Control (FCTC) and the growing engagement of civil society and Member States, a large proportion of the Region’s population is still not covered by even a single FCTC measure at the highest level of achievement (). Finally, the influence and interference of the tobacco industry has been, and continues to be, a severe obstacle to progress in tobacco control in the Region, as it is in the rest of the world ().

Harmful use of alcohol. Alcohol consumption is responsible for a host of often devastating consequences for the drinker, the family, and the community, including but not limited to death and disability (). Alcohol is the most common underlying risk factor associated with death in people 15–49 years of age and can cause significant disability throughout the life course. Alcohol use can lead to alcohol dependence, liver cirrhosis, traffic injuries, and over 200 illnesses, including cancers, cardiovascular disease, infectious diseases, and fetal alcohol spectrum disorders ().

The average per capita consumption among those aged 15 years and older in the Region of the Americas is higher than the global average (). The prevalence of heavy episodic drinking in adults and adolescents is also high (see Chapter 3) and appears to be increasing, consistent with initiation of drinking before the age of 14 (). The prevalence of alcohol-use disorders in women in the Region is the highest in the world, at 3.9% ().

Globally, alcohol consumption is responsible for 10% of DALYs lost due to NCDs (). Alcohol-attributable health conditions strike more men than women in every country, although, for the same amount of alcohol consumed, the risk for negative consequences is higher among women (). For some of these conditions, there is no known safe level of drinking (). Acute heavy episodic drinking is related to violence, injuries, and poisoning, while chronic disease is primarily associated with patterns of chronic or repeated episodic heavy consumption ().

Physical inactivity. The recommended physical activity levels are at least 60 minutes of moderate or vigorous physical activity every day for children and adolescents, and at least 150 minutes of moderate or 75 minutes of vigorous aerobic activity every week for adults of all ages (). Yet in the Americas, 50% of people do not meet this recommendation, raising the mortality risk by 20% to 30% ().

Physical inactivity leads to excess weight and obesity. Physical activity improves muscular and cardiovascular functions, improves bone health, and reduces depression and the overall risk of developing an NCD. Greater physical fitness also improves academic performance in children ().

The design of communities and cities and the ability of people to move about safely on foot, by bicycle, or using public transportation (all called “active transportation”) appear to have a major influence on levels of physical activity and obesity ().

Tackling the Major NCD Risk Factors

The global health community has adopted a set of nine targets to tackle major NCD risk factors and reduce NCDs (). This effort is reinforced by the Sustainable Development Goals, which include NCDs as a target within the health goal (Goal 3), with the aim of reducing premature mortality from NCDs 30% by 2030 ().

There is global consensus on the achievable, cost-effective measures to reduce NCD risk factors as described in Table 1 (). For tobacco, the interventions are defined by the WHO FCTC, the first international treaty negotiated under the auspices of WHO. The demand-side measures are summarized in the WHO MPOWER tool and include tax policies, health warnings, smoke-free environments, and a ban on advertisement, promotions, and sponsorship. Even though the Region has advanced in the implementation of smoke-free environments and health warnings, tax measures and marketing bans are well behind ().

Table 1. WHO Cost-effective interventions for NCD risk factors*

NCD risk factor Intervention
Tobacco use
  • Strengthen the implementation of tax policy and administrative measures to reduce the demand for tobacco products.
  • Implement comprehensive ban of tobacco advertising, promotion, and sponsorship, including cross-border advertising and on modern means of communication.
  • Implement plain/standard packaging and/or large graphic and legislated health warnings on all tobacco packages.
  • Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport, and all places of outdoor mass gatherings.

Other interventions:

  • Provide cost-covered, effective, and population-wide support (including brief advice, national toll-free quit line services, and mCessation) to everyone who wants to quit smoking tobacco.
  • Implement measures to minimize illicit trade in tobacco products.
Harmful use of alcohol
  • Increase excise taxes on alcoholic beverages.
  • Enforce bans or comprehensive restrictions on alcohol advertising (across multiple types of media).
  • Enforce restrictions on the physical availability of retail alcohol (by reducing the density of retail outlets and limiting hours of sale).

Other interventions:

  • Enforce drunk-driving laws and blood-alcohol concentration limits via sobriety checkpoints.
  • Provide brief psychosocial intervention for persons with hazardous and harmful alcohol use.
Unhealthy diet
  • Reduce salt intake by engaging the industry in a voluntary reformulation process.
  • Reduce salt intake by establishing a supportive environment in public institutions, such as hospitals, schools, and nursing homes, that encourages low-sodium meals to be provided.
  • Reduce salt intake through a mass-media, behavioral-change communication campaign.
  • Reduce salt intake through implementing front-of-package labeling.

Other interventions:

  • Completely eliminate industrial trans fats by developing legislation that bans their use in foods.
  • Promote breast-feeding and support exclusive breast-feeding for the first six months of life.
  • Implement subsidies to encourage people to eat more fruits and vegetables.
  • Replace trans-fats and saturated fats with unsaturated fats through reformulation, labeling, and fiscal and agricultural policies.
  • Reduce sugar consumption by taxing sugar-sweetened beverages.
  • Encourage limits on portion size to reduce energy intake and the risk of childhood overweight/obesity.
  • Implement nutrition education and counseling in different settings (e.g., schools, workplaces, hospitals, etc.) to increase the intake of fruits and vegetables.
  • Implement nutrition labeling to show better macronutrient information and total energy of foods (kcal).
  • Institute nutrition labeling in educational settings to improve dietary intake.
  • Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, fiber, and salt, and to promote the consumption of more fruits and vegetables.
Physical activity
  • Make counseling about physical activity a routine part of primary health care services.

Other interventions:

  • Ensure macro-level urban design that incorporates the core elements of residential density, connected street networks, and easy access to public transportation and to a variety of destinations.
  • Implement public awareness and motivational programs for physical activity, including mass media campaigns to encourage a change in levels of physical activity.
  • Ensure that adequate facilities are available on school premises to encourage recreational physical activity for all children.
  • Provide safe and adequate infrastructure to enable walking and cycling.
  • Implement multicomponent physical activity programs at workplaces.

For alcohol, the most cost-effective interventions are an increase in alcohol taxes, legislative measures to control alcohol marketing, and restrictions on the physical availability of alcohol. However, only four countries (Colombia, Costa Rica, Panama, and Venezuela) have tax policies that can limit alcohol consumption, only two have comprehensive marketing bans, and no country has comprehensive controls on the physical availability of alcoholic beverages (). Despite adopting the WHO Global Strategy for Reducing Harmful Use of Alcohol in 2010, then adopting a Regional Plan of Action in 2011, the Region has not made progress on any of the alcohol indicators of the PAHO Strategic Plan 2014-2019 ().

A “Health in All Policies” approach, as illustrated in Box 1, is needed to reduce NCD risk factors. Such an approach calls for all relevant sectors to consider the impact of their policies on NCDs and to utilize policy, legislative, regulatory, and fiscal measures to better prevent and control NCDs. The sectors include economic, trade, education, and agriculture, among others. Promising interventions for NCD prevention that can also address broader social determinants of health are urban planning, taxation (incentives or disincentives), pricing and subsidies (incentives or disincentives), production and marketing of goods, health-promotion financing, and legislative mandates ().

Box 1. Examples of multisectoral policies for NCD prevention and control

  1. Agriculture: subsidize healthy food production, substitute other crops for tobacco, maintain adequate land for agriculture and local food system development, encourage farmers markets, promote local food availability and sales.
  2. Environment: improve mass public transportation systems; design and plan roads to facilitate walking and cycling; develop green spaces, facilities, and spaces for physical activity; enforce environmental pollution standards.
  3. Education: develop school-based nutritious meal programs, curriculum on healthy lifestyles, and policies on sales of healthy foods and beverages; restrict marketing of foods and beverages to children in schools; increase time for physical education.
  4. Trade: increase import taxes on unhealthy products such as tobacco, alcohol, sugar-sweetened beverages, and ultra-processed foods; reduce import taxes on health-promoting products.
  5. Social-protection policies: consider a single-payer system that equitably funds treatment and care for persons with NCDs, mental health conditions, and disabilities.
  6. Law enforcement: promote crime reduction and safe communities to encourage physical activity; establish and enforce penalties for violating smoke-free environment laws and for excessive drinking and occupational and environmental pollution.
  7. Labor: provide incentives for worksite health-promotion programs.
  8. Media: ban smoking and alcohol use in TV and films; enforce bans on advertising tobacco and alcohol in the media, and on marketing foods and beverages to children.
Source: Lin V, Jones C, Shiyong W, Baris N. Health in All Policies as a strategic policy response to NCDs. Health, Nutrition, and Population (HNP) discussion paper [Internet]. Washington, D.C.: World Bank; 2014. Available from: The World Bank.

Role of the private sector in tackling NCD risk factors

Given that many of the products associated with NCD risk factors are produced by the private sector, that sector has the potential to play a significant role in preventing NCDs. The private sector has acknowledged the need to create healthier products for consumers, as well as to create healthier workplaces. Moreover, the international community has called on the private sector to contribute to NCD prevention, as described in Box 2 ().

However, the interests of some private entities may be opposed to the interests of health protection/promotion, particularly when there may be a negative impact on profits. For example, in tobacco there is a long history of deceptive strategies to undermine regulatory action; much of it was confirmed by the industry’s own internal documents that were made public and clearly exposed as a consequence of tobacco litigation in the state of Minnesota (United States). Article 5.3 of the FCTC states that “in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law” (). The guidelines for implementing this article detail how countries should interact with the tobacco industry (). Similar strategies are observed with food and alcohol industries, as well ().

Box 2. How the private sector can contribute to NCD prevention

  1. Take measures to implement the WHO recommendations to reduce the impact of marketing unhealthy foods and nonalcoholic beverages to children, while taking into account existing national legislation and policies.
  2. Consider producing and promoting more food products consistent with a healthy diet, including reformulating products to provide healthier options that are affordable and accessible and that follow relevant nutritional facts and labeling standards (information on sugars, salt, fats and, where appropriate, trans fat content).
  3. Promote and create an environment for healthy behaviors among workers by establishing tobacco-free workplaces and safe and healthy working environments that adhere to occupational safety and health measures, including good corporate practices, workplace wellness programs, and health insurance plans.
  4. Work towards reducing the use of salt in the food industry, to lower sodium consumption.
  5. Contribute to efforts to improve access to and affordability of medicines and technologies that help prevent and control noncommunicable diseases.
Source: United Nations. Political declaration of the high-level meeting on the prevention and control of noncommunicable diseases. New York: UN; 2011.

Strengthening regulatory capacity and the use of health law

Regulatory processes refer broadly to both legislative and executive action. Many of these measures require the correction of market failures or the modification of widespread social practices—changes that can only be achieved through the effective use of legislation or regulation, often in areas outside the traditional scope of health systems. These measures require the health authority to effectively work with other sectors of government to ensure that all policies take into account the impact on health. PAHO launched the REGULA initiative in 2014 to strengthen the regulatory capacity of the Region’s health authorities to reduce NCD risk factors (). Laws related to each risk factor in every Latin American country have been collected, and in selected countries an in-depth analysis of the regulatory capacity has been conducted. In addition, Member States adopted a Strategy on Health-related Law in 2015 to strengthen legal and regulatory frameworks that promote health based on the perspective of the right to health. It aims to protect health by strengthening coordination between health authorities and legislative branches ().

Management of Noncommunicable Diseases

The challenge for managing NCDs is to implement universal, financially and physically accessible, high-quality primary care services while also enhancing early diagnosis, timely treatment, and improvements in the quality of care, particularly in disadvantaged communities (). Box 3 summarizes why a focus on NCD management is such an important aspect of the response to the NCD problem.

Box 3. Why focus on NCD management?

It has been estimated that:

  1. Out of 100% of people who have an NCD, only 50% are diagnosed;
  2. Of those diagnosed, only 50% are treated;
  3. Of those treated, only 50% have their NCD under control;
  4. Of those under control, only 50% are successfully controlled;
  5. Therefore, among those who live with an NCD, fewer than 10% have it successfully controlled.

    Poor NCD control leads to poor health outcomes.

Source: Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice 1998;1(1):2-4.

Cardiovascular disease (CVD), the leading cause of death, requires intensified and specific health system interventions to reduce risk, control hypertension, manage acute episodic events, and prevent premature death (Table 2). Type 2 diabetes, a common comorbidity of hypertension, is a chronic metabolic disease that also requires specific primary care interventions (Table 2). However, a chronic care approach for integrated management of diabetes, CVD, and other NCDs has been proposed by PAHO (). This approach includes organizing health services to reduce barriers and promote prevention; self-management support to empower people to effectively manage their conditions; evidence-based guidelines and support for decision-making; coordinated care among the health team; a clinical information system to monitor patients; and community resources to support patient care.

Table 2. NCD management interventions

NCD Disease management objectives
Primary health care interventions
Counseling, patient education, and prevention Screening and early detection Treatment
Cardiovascular diseases (CVDs)
  • Assess risk and reduce risks for developing CVD
  • Diagnose CVD early and accurately
  • Control high blood pressure
  • Prevent acute events and complications
  • Improve self-care for CVD
  • Assess risk for CVD
  • Educate about risk factor reduction
  • Educate about healthy lifestyle
  • Measure and monitor blood pressure, body mass index (BMI), and blood lipid profile
  • Drug therapy for those who have had or are at risk for heart attack and stroke
  • Hypertension medication
  • Treatment of new cases of acute myocardial infarction with either:
    acetylsalicylic acid, or acetylsalicylic acid and clopidogrel, or
    thrombolysis, or primary percutaneous coronary interventions
    • Treatment of congestive cardiac failure with ACE inhibitor, beta-blocker, and diuretic
    Diabetes type 2
    • Prevent diabetes, including gestational diabetes
    • Assess risk for developing diabetes
    • Improve quality of care and outcome in people with type 2 diabetes
    • Reduce and maintain a healthy body weight
    • Control blood sugar levels
    • Reduce complications from poor diabetes management
    • Improve self-care for diabetes
    • Lifestyle education to prevent type 2 diabetes
    • Prenatal care and intensive glucose management among pregnant women to prevent gestational diabetes
    • Advice to overweight people to reduce weight by reducing food intake and increasing physical activity
    • Education on diabetes self-management, including foot care and eye care
    • Measure blood sugar
    • Screen for diabetic retinopathy
    • Drug therapy to control blood sugar
    • Drug therapy to prevent progression of renal disease
    Cancer
    • Prevent cancer
    • Detect cancer at early stages
    • Screen men and women for cancers amenable to early detection (cervix, breast, colorectal cancers)
    • Ensure prompt diagnosis, treatment, and supportive and palliative care
    • Health education on cancer prevention and healthy lifestyles
    • Hepatitis B vaccination for the prevention of liver cancer
    • HPV vaccination for the prevention of cervical cancer
    • Examinations for early signs and symptoms of common cancers (lung, prostate, colorectal, breast, cervix, stomach, leukemia, etc.)
    • Breast cancer clinical breast exam and/or mammogram, according to national guidelines
    • Cervical cancer – pap test, HPV, DNA test, visual inspection with acetic acid (VIA), cryotherapy for treatment of precancerous lesions, according to national guidelines
    • Oral cancer – screen in high-risk groups such as tobacco smokers
    • Colorectal cancer – fecal occult blood test or colonoscopy, according to national guidelines
    • Refer to secondary level care for diagnosis and treatment, including surgery, chemotherapy, and radiotherapy.
    • Provide post treatment follow up care
    • Offer supportive care and palliative care
    Chronic respiratory diseases
    • Control asthma and COPD
    • Improve quality of care for persons living with asthma and COPD
    • Health education on self- management for persons with asthma and COPD
    • Assess asthma control using severity and frequency of symptoms
    • Drug therapy to manage stable asthma and COPD, as well as exacerbated asthma and COPD.

    PAHO has disseminated this approach through the Evidence-Based Chronic Illness Care (EBCIC) course attended by over 1,000 primary health care providers. As a result, a total of 81 chronic care projects in 27 countries have been implemented, some of which have shown impact. For example, in Argentina, the REDES program increased the proportion of people with hypertension who were taking medication and decreased mortality due to stroke (personal communication, Sebastian Laspiur, Argentina Ministry of Health). In Cuba, after applying a chronic care approach, 62% of people achieved good glycemic control, according to international norms (). In Porto Alegre, Brazil, a chronic care program decreased hospitalization due to CVD and diabetes and improved hypertension control from 60% to 77% ().

    Two other examples of a chronic care approach applied to improve hypertension control include the Canadian Hypertension Education Program () and the Kaiser Permanente model in northern California (). These models include a simple, standardized, and evidence-based treatment algorithm; the availability of and access to a set of core, high-quality medications; a clinical registry for monitoring patients and evaluating performance; and teamwork, with shared responsibilities, patient empowerment, and community participation. This approach was tested in Barbados with promising results, including improvement in hypertension control, development of a clinical registry, and improvement of prescription practices (). Similar hypertension control interventions are in place in Chile, Colombia, and Cuba.

    An initiative of broader scope for CVD, the Global Hearts Initiative, has been launched that aims to reduce heart attacks and strokes by improving management of CVD in primary health care. Global Hearts is led by WHO in collaboration with the Centers for Disease Control and Prevention of the United States, PAHO, the World Heart Federation, the World Stroke Organization, the International Society of Hypertension, the World Hypertension League, and other partners ().

    While these are illustrative examples of NCD management, most countries in the Region continue to have important gaps in the implementation of clinical NCD preventive services, secondary CVD prevention, and cardiac rehabilitation management (). For example, data from Argentina, Brazil, Colombia, and Chile show that only 18% of people with hypertension had blood pressure controlled (<140/90 mmHg) (), and only 12% of those with coronary heart disease or stroke were under treatment with three or more drugs of proven efficacy in preventing recurrence ().

    Additionally, most countries report a lack of progress in health system response to managing CVD acute events. Public awareness is low, capacity and resources for early reperfusion therapy are insufficient, and infrastructure (such as stroke units) is inadequate (). Five priority interventions are recommended to improve this situation: (1) public communication and education to recognize symptoms and warning signs and seek emergency care; (2) equitable availability of emergency medical services; (3) broadened access to early reperfusion therapy, including availability of basic technologies; (4) coronary and stroke units within the health system that give priority to patients at highest risk of complications and death; and (5) rehabilitation programs for social reintegration of patients ().

    Cancer includes a group of diseases with multiple causes that require specific health system interventions at all levels of care (Table 2). To effectively control cancer, PAHO/WHO promotes the development and implementation of national cancer control plans (Table 3), with public health and health service interventions that provide primary and secondary prevention, accurate and timely diagnosis and treatment, and palliative care (). More than half the countries in the Region (23 of 34 countries, 67%) report having a national cancer control plan, strategy, or policy in place (). Peru’s national cancer plan, Plan Esperanza, is an example of how a cancer plan can have an impact. Since it was launched in 2013, over 16 million Peruvians have received free cancer prevention services; 2.5 million have been screened for cervical, breast, stomach, colon, or prostate cancer; and the proportion of patients who paid out-of-pocket expenses for cancer treatment decreased from 58% to 7% ().

    Table 3.National cancer control plan

    Primary prevention Screening and early detection Diagnosis and treatment Palliative care
    • Policies for tobacco, alcohol, healthy diets, physical activity
    • Vaccination for hepatitis B and HPV
    • Policies to reduce exposure to carcinogens in the workplace and the environment
    Organized screening program, with quality assurance, for:

    • Cervical cancer (HPV test, Pap test, or VIA test)
    • Breast cancer (mammography)
    • Colorectal cancer (fecal occult blood test or colonoscopy)

    Knowledge of early signs and symptoms of cancer, with prompt referral for diagnosis

    • Pathology services
    • Chemotherapy, surgery, radiotherapy
    • Palliative care
    • Regulations and education for access to opioids

    Notable progress is being made in cervical cancer prevention, in which mortality has declined in 11 countries: Brazil, Canada, Chile, Colombia, Costa Rica, El Salvador, Mexico, Nicaragua, Panama, Venezuela, and the United States (). To date, 23 countries in the Region (58%) report introducing human papillomavirus (HPV) vaccines and 33 countries (87%) report available cervical cancer screening services, although only 5 of those countries report having adequate screening coverage of 70% or higher. Despite that breast cancer is the most common cancer in women, only 16 countries (42%) report that mammography is available, and only 3 countries report a screening coverage likely to have an impact (70% coverage or greater) ().

    Prostate cancer continues to be the leading cause of cancer in men and is increasing in some countries in the Region (). Black men of African descent, specifically Jamaican men, are at greater risk of prostate cancer; the explanations for this are inconclusive (). Prostate cancer screening has not decreased mortality, and harm (impotence and incontinence) associated with prostate-specific antigen (PSA)-based screenings is frequent (). The current approach is, therefore, to strengthen cancer diagnosis and treatment ().

    Cancer treatment in the form of radiotherapy and chemotherapy is generally available in the public sector in the majority of countries in the Americas (), but most cancer cases are diagnosed at an advanced stage, when treatment is less effective (). Palliative care is necessary to improve the quality of life of patients and their families by managing pain and providing physical, psychosocial, and spiritual support. Yet access to opioid medications, such as oral morphine for pain management, continues to be a challenge; availability is reported in only 50% of the countries ().

    A set of cancer-control priorities, suitable for all resource levels, have been recommended as follows:
    – primary prevention through tobacco control, alcohol reduction, healthy diet, and physical activity
    – prevention of liver cancer through hepatitis B vaccination
    – prevention of cervical cancer through HPV vaccination (two doses) for girls 9–13 years old; and through screening for women aged 30–49, either through visual inspection with acetic acid (VIA), Pap smear (cervical cytology) every three to five years, or HPV test every five years; linked with timely treatment of precancerous lesions
    – early detection of breast cancer through screening with mammography (once every 2 years for women aged 50–69 years), linked with timely diagnosis and treatment
    – population-based colorectal cancer screening through a fecal occult blood test starting at age 50 years, linked with timely treatment
    – home-based and hospital-based palliative care with a multidisciplinary team and access to opiates and essential supportive medicine;

    However, implementing these interventions will require strengthening health care systems, as follows:
    – increase financial resources for cancer control, including access to high-cost drugs and procedures
    – develop social protection policies against catastrophic health expenditure for poor individuals towards equitable services and coverage
    – reduce long waiting times for diagnosis and treatment, especially in rural and remote regions and
    – address the shortages of cancer specialists through use of telemedicine, and retraining of specialists ();

    While they share the main cancer risk factors associated with other NCDs, cancers attributable to occupational exposures and environmental pollution have additional important sources of risk. The most common types of occupational cancer are lung, bladder, mesothelioma, leukemia, and skin. In general, the most common agents in the Region include solar radiation, environmental tobacco smoke, crystalline silica, pesticides, and asbestos (). The WHO global plan of action on workers’ health calls on governments to strengthen legislation and regulations to eliminate carcinogenic exposures in the workplace, to protect and safeguard workers’ health ().

    A population-based cancer registry (PBCR) is recommended by WHO to inform cancer programs (). However, this requires significant resources, and in the Americas only 11 countries have high-quality PBCRs: Argentina, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Ecuador, Puerto Rico, Uruguay, and the United States (). Convened by the International Agency for Research on Cancer, the Global Initiative for Cancer Registry Development (GICR) is using regional expertise to establish hubs in Latin America and in the Caribbean in order to expand the coverage and quality of data from PBCRs.

    Chronic respiratory disease (CRD)—principally chronic obstructive pulmonary disease, asthma, and occupational lung diseases—is responsible for approximately 372,000 deaths annually in the Americas (). Tobacco use, air pollution, and occupational chemicals and dusts are the most important risk factors for these diseases, which cannot be cured but for which effective treatment is available. Treatment is reported as generally available in the primary care facilities of the public health sector in the Region: 28 countries (74%) report availability of steroid inhalers and 33 countries (87%) report availability of bronchodilators. Guidelines on the management of CRD, however, are only implemented in 9 countries (24%), and only 8 countries (21%) indicate that they have an operational policy, strategy, or action plan specific for CRD. Better surveillance to establish the magnitude of CRD, and primary prevention to reduce risk factors and improve health care for people with CRD, are urgently needed to improve quality of life for those affected by CRD.

    Mental Health

    No health without mental health

    It is widely acknowledged that mental health is a fundamental component of health (). Member States adopted the Plan of Action on Mental Health 2015–2020 (), committing to “a region in which mental health is valued, promoted, and protected, mental and substance-related disorders are prevented, and persons with these disorders are able to exercise their human rights and to access both health and social care.” The plan includes four strategic lines of action on mental health policies: community-based services, promotion and prevention, information systems, and evidence and research. Mental, neurological, and substance-use (MNS) disorders were recognized in the global scenario as health priorities and ratified in the international development agenda ().

    Burden of MNS disorders

    Mental disorders represent an alarming public health concern. Ten percent of the world’s population and 20% of children and adolescents suffer from some mental or neuropsychiatric disorder, and this doubles among populations facing humanitarian emergencies (). MNS disorders are responsible for 12.35% of disability-adjusted life years (DALYs) and 35.9% of years lived with disability (YLDs), making them the leading cause of global disability. In the Americas, MNS disorders are the leading cause of disease burden, accounting for 19% of DALYs, and they are the largest source of disability, responsible for 34% of YLDs. Depression is the leading factor, or 8% of YLDs, while anxiety and substance use disorders (including alcohol) are responsible for 5% and 3% of YLDs, respectively ().

    Socioeconomic impact

    The global cost of MNS disorders has increased to US$ 8.5 trillion and is projected to double by 2030 (). Although scaling-up services for depression and anxiety might cost only US$ 1.50 annually per person, the resources gap is significant due to the existing low coverage levels. The disparity between burden of disease and available resources results in treatment gaps of 73.5% among adults with severe/moderate disorders, 82.2% among children and adolescents (), and bigger gaps among indigenous and African-American descendants (). Nevertheless, such investment could represent a return value of US$ 709 billion and benefit-to-cost ratios of up to 3:1 (). For the Region, not taking action represents a gross domestic product (GDP) annual loss of 0.82% in Costa Rica, 0.58% in Jamaica, and 1.42% in Peru (). Costs are higher if also considering mid- to long-term effects of maternal depression and poor care practices on early child development, burden of substance use disorders (), and dementia as growing Regional concerns ().

    Emergencies

    Mental health preparedness and response are critical components of any emergency (); the relationship between mental and physical health becomes closer and bidirectional following emergencies (), and exposure to extreme stressors is a main risk factor for mental illness (). Community-based services constitute an important intervention level during emergencies, with communities engaging in nonspecialized activities across sectors aiming for a return to normal living conditions (). Indeed, emergency settings became opportunities to improve regular sustainable mental health systems ().

    Human rights

    Multiple treaties and conventions () require countries to adopt a paradigm shift to an approach firmly rooted in the promotion and protection of human rights (). People with mental disorders experience a wide range of violations of human rights (). Children with psychosocial disabilities are neglected in particular when living in institutional settings, a harmful but still a common practice; mental institutions are associated with human rights infringements (); and in low-income countries, people with severe mental illness die up to 30 years younger than their peers ().

    Main MNS conditions

    Most common mental disorders

    Depression results from a complex interaction of social, psychological, and biological factors; it can develop after exposure to adverse life events that become chronic stressors, and at moderate or severe intensity it can lead to suicide (). Anxiety disorders include acute problems and chronic conditions involving significant stress-related symptoms; recurrent, excessive, sudden, or progressive displays of anxiety or worry; and impaired daily functioning (). Depression and anxiety account for 13% of YLDs and 5.5% of DALYs in the Americas.

    Severe mental disorders

    Schizophrenia results from an interaction of genetic, environmental, and psychosocial factors. People with schizophrenia are 2.5 times more likely to die early; they also experience stigma and neglect when treated in traditional psychiatric hospitals (). Bipolar affective disorder is a severe type of depression consisting of manic and depressive episodes separated by periods of normal mood (). Schizophrenia and bipolar disorder account for 3.4% of YLDs and 1.5% of DALYs in the Americas ().

    Children and adolescents

    Developmental and behavioral disorders are specific conditions affecting children and adolescents; they usually have an early onset and a regular sustained development, and they can persist into adulthood. These disorders are characterized by impairment or delay in functions related to maturation of the central nervous system, diminished ability to adapt to the daily demands of life, and increased vulnerability to physical illness and to other mental and neurological conditions (). Developmental and behavioral disorders account for 2.2% of YLDs and 0.9% of DALYs in the Americas ().

    Suicide

    Suicide is determined by the interaction between psychosocial, biological, and psychiatric factors. A systematic review from 2003 showed that up to 90% of suicidal victims have a diagnosable mental disorder (). Attempted suicide is 10-20 times more common than completed suicide (), and while suicidal ideation is a predictor of suicidal acts (), the strongest risk factor is a previous suicide attempt. In the Americas, according to estimates from 2005–2009, suicide has a mortality rate of 7.3 per 100,000 and is responsible for 1.6% of total DALYs. Chile, Uruguay, and Trinidad and Tobago have rates of more than 10 per 100,000. Suriname and Guyana have the highest rates of the Region, with 23.3 and 26.2 per 100,000 population, respectively (). Significant efforts in suicide prevention are being conducted. Guyana, for instance, has launched a National Mental Action Plan for 2015–2020 and a National Suicide Prevention Plan.

    Dementia

    Dementia is a syndrome in which there is deterioration in memory, thinking, behavior, and the ability to perform everyday activities beyond what might be expected from normal aging. With more people reaching an advanced age, dementia constitutes a big concern for Latin America and the Caribbean (LAC), with a projected increase of 47% by 2030 in the prevalence of severe disabilities affecting people aged 60 and older (). Dementia accounts for 1.2% of YLDs and 2% of DALYs in the Americas ().

    Epilepsy

    Epilepsy can be caused by genetic and congenital abnormalities, brain damage, tumors, and infections such as meningitis, encephalitis, neurocysticercosis, and cerebral malaria (). In the Americas, epilepsy is one of the most frequent chronic neurological disorders; it affects 5 million people and accounts for an annual death rate of 1.04 per 100,000 population. Although epilepsy responds to treatment 70% of the time and the cost of medication is as low as US$ 5 per patient per year, more than 50% of persons in LAC with epilepsy do not receive treatment (). Epilepsy accounts for 0.8% of YLDs and 0.5% of DALYs in the Americas ().

    Substance use disorders

    Some 85 million people use illicit substances each year in the Americas; their use is associated with adverse health and social consequences, particularly for young people (). A public health approach to reduce substance use includes prevention, treatment services, monitoring, and surveillance. Substance-use disorders account for 1.8% of YLDs and 1.5% of DALYs in the Americas ().

    Conditions of disability

    In the Americas, 140 million people live with some form of disability, and rates are increasing due to the aging population and their chronic conditions. Those living in psychiatric institutions experience higher levels of disability. Among persons with disabilities, only 3% have access to rehabilitation. MNS disorders are the biggest contributors to the burden of disabilities. Their treatment cannot be limited to the physical domain, but should also include the psychosocial axis, addressing the needs of, and impact on, relatives and communities ().

    Strategies and interventions

    Insufficient treatment coverage and inadequate and outdated models of care need to be addressed. The service structure is fragmented and there is insufficient coordination between primary, secondary, and tertiary levels. There exists a heavy emphasis on mental institutions at the expense of delivering mental health care in primary- and secondary-care settings and at the expense of developing community-based models (). Allocated resources are scarce and are distributed inequitably and inefficiently. While LAC countries assign 1%-5% of the total public health budget to mental health, 88% of funds are allocated to psychiatric hospitals that serve 10% of those requiring mental health services. Psychiatric hospitals persist as a result of tradition and the absence of comprehensive models of care. People living in mental institutions do not receive individualized care based on their needs and rights (). Mental health should be integrated into existing care delivery channels as a key strategy to close the treatment gap in the Region. That effort targeted prevention and promotion programs; services through primary health care; rational cost-effective roles for secondary and tertiary levels of care; comprehensive community-based services; and synergetic interactions with key areas, stakeholders, and actors within and beyond the health sector ().

    Prevention and promotion

    The first step in reducing the burden of mental illness is tackling its onset with evidence-based interventions to help prevent MNS disorders and protect mental well-being, particularly in the early stages of life. Because up to 50% of adult mental disorders begin before the age of 14, fundamental action lines include early prevention, identification, and treatment of emotional or behavioral problems in childhood and adolescence. Powerful models of mental health promotion and prevention provide strong evidence about their effectiveness and represent promising starting points in reducing mental health illness and its consequences. Because suicide is a potential outcome of MNS disorders, suicide prevention is an essential component of any strategy ().

    Care levels and community-based services

    To integrate basic mental health services into primary health care (PHC), it is extremely important to adopt task-sharing approaches (also known as task shifting), especially in countries with limited specialized human resources (). With proper care from PHC professionals, psychosocial assistance, and medication, tens of millions could be treated for MNS disorders, prevented from suicide, and begin to live normal lives even where resources are scarce ().

    Developing a community-based model with new services and alternatives is a key element in offering comprehensive, specialized, and continuous mental health services (). The recommended strategy is to shift resources allocated to mental hospitals into development of service networks that cover persons with MNS disorders and other potential users. This model allows progressive replacement of mental institutions and offers a higher quality of secondary-level care to people who need acute, mid- and long-term specialized care. The objective is recovery rather than cure; the services include psychosocial rehabilitation and they combine psychosocial and pharmacological interventions. Recommended services to develop include: (a) community mental health centers with specialized professionals in charge of the mental health needs in specific catchment areas; (b) coordination with facilities that provide acute care and support from health workers at the PHC level; (c) community-based residential facilities that provide overnight residence for people with relatively stable and long-term mental disorders; (d) psychiatric services in general hospitals to take care of patients’ needs during acute phases and the needs of nonpsychiatric patients in the hospital (interconsultation); and (d) day hospitals that provide more intense treatment and structured support for users who have failed to respond to outpatient care or have been discharged from inpatient care ().

    Opportunities for integration and challenges

    Community-based interventions are an opportunity for integrating referrals and coordinating interventions between sectors, sharing material and human resources, and innovation and sustainability. Key areas for collaboration include maternal and child health and nutrition; children and adolescents; gender, aging, and disability; noncommunicable diseases such as cancer, diabetes, and cardiovascular disease; and communicable diseases such as HIV/AIDS and tuberculosis; and substance-use problems and disorders ().

    Barriers to introducing this model and implementing the required reforms include the complexity of decentralizing mental health services; resistance from authorities and health professionals; the low number of workers trained and supervised in mental health care; and a scarcity of public health perspectives in mental health leadership (). Although 81% of countries in the Region have a stand-alone mental health policy/plan, 50% do not have laws or regulation frameworks. Just 34% have mental health legislation that is partially or fully implemented and in satisfactory compliance with human rights standards ().

    In addition to national authorities, civil society also typically tries to create conditions that encourage successful community integration and participation (). Together, government institutions and civil society share responsibilities to build tools and promote and monitor effective implementation. The Region is making serious efforts to overcome the challenge of shifting from services at traditional psychiatric hospitals to a community-based model that results in better care and rehabilitation of people with MNS disorders and other types of disabilities ().

    Road Traffic Injuries

    Road transportation is considered the most complex and dangerous essential human activity (). In the Americas, road crashes kill 154,089 people each year, or 12% of road traffic deaths worldwide (). The regional death rate is 15.9 per 100,000 people, marginally lower than the global rate of 17.4 per 100,000 (). However, there are variations between countries, with national rates ranging from a low of 6.0 per 100,000 population in Canada to a high of 29.3 per 100,000 population in the Dominican Republic (). Nearly half the world’s road traffic deaths occur among pedestrians (22%), motorcyclists (20%), and cyclists (3%), all of whom are considered vulnerable road users ().

    A combination of economic changes, unmet need for public transportation, traffic congestion, and a number of other factors associated with motorcycle use (their comfort, low cost, readily available financing, ease of maintenance, and the appeal of urban mobility) have resulted in motorcycle sales outpacing economic development. The results is that the number of motorcycles on the roads has increased by more than six-fold ().

    In the Americas, 73% of road traffic deaths occur in middle-income countries, whereas 26% take place in high-income countries. The motorcycle fleet in the Region has increased by 45%, while the automobile fleet has grown by 11%. The rapid and massive introduction of motorcycles in countries of the Americas—used for activities varying from urban delivery services to cattle driving in rural regions—is a relatively recent phenomenon, and has not yet been absorbed into the culture of local road traffic.

    Although motorcycles have provided unprecedented mobility for many, the rapid rise in their use has led to large increases in motorcycle injuries and death. Mortality among motorcyclists increased from 15% to 20% in 2013, and in some countries of the Americas, the proportion of motorcycle users involved in road fatalities has exceeded pedestrian fatalities. Furthermore, poorer countries in the Region have higher motorcycle fatality rates than richer countries ().

    In the early 2000s, after the United Nations requested that WHO coordinate global efforts to tackle road traffic injuries (RTIs), PAHO/WHO emphasized their importance as a public health concern. This launched a multisector response involving the health sector, law enforcement, traffic/transport engineering, and road safety education. The effort has faced challenges, particularly in defining the role the health sector can play and what impact it can have in improving road safety.

    PAHO has provided direct technical support to ministries of health, with plans, programs, projects, legislative improvements, publications, and road safety policies. It has monitored road safety indicators through regular reports, encouraged the collection and analysis of national data, and built local capacity for integration and technical cooperation between countries. Also, it has advocated designating road safety as a public health issue in national policies, and for strengthening the health sector’s response on road safety initiatives.

    The Vida no Trânsito (“Life in Traffic”) project, implemented in Brazil in 2010, is illustrative of the health sector’s approach to road safety. The project, led by PAHO and Brazil’s Ministry of Health, was based on the need for good data and multisectoral coordination. It was initially implemented in five state capitals and was later extended to other cities. The strategy consists of national and local multisectoral road safety commissions that are firmly backed by program directors and authorities such as mayors.

    Local commissions gather data from multiple sources (health, police, and traffic/transport) and generate information on the crashes (type, nature, time, days, places, etc.), victims’ profiles, and the risk factors involved. This resulted in focused interventions with measurable goals to build capacity, raise awareness, and implement best practices for road safety. The initiative’s visible results include increased speed control and alcohol checkpoints and sobriety tests (with fewer drivers testing positive). As a result, the mortality rate declined in most of the cities that enacted the project.

    In 2011, PAHO adopted the Plan of Action for Road Safety (), which was approved during the 51st Directing Council. This plan is consistent with the UN Decade of Action for Road Safety 2011&ndash2020, which acts as a call to action for Member States to adopt road safety policies. More recently, the 2nd Global High-Level Conference on Road Safety, held in Brazil in 2015, provided further opportunities for countries to strengthen their road safety response. There, Member States adopted the Brazilian Declaration on Road Safety (), developed through a long intergovernmental process involving consultation with different stakeholders. The Brazilian Declaration highlights road safety measures coupled with equity/inclusion issues that are highly relevant in the Region. Furthermore, it extends the health sector’s role beyond RTI prevention and addresses issues such as mobility and active, sustainable modes of transportation—walking, cycling, and public transportation.

    The Brazilian Declaration, endorsed by the 58th United Nations General Assembly (), reinforces the Sustainable Development Goals (SDGs), to reduce road traffic deaths and injuries by 50% by 2020, and it consolidates the linkage of road traffic safety and sustainable mobility policies. This is reflected in the SDG 11.2 target, which aims to provide access to safe, affordable, accessible, and sustainable transport systems for all. Its objective is to improve road safety, notably by expanding public transportation, with special attention to the needs of those in vulnerable situations, e.g., women, children, persons with disabilities, and older persons.

    Interpersonal Violence Prevention

    Interpersonal violence takes many forms, including multiple manifestations of violence against children, youth, and women, as well as the elderly. All forms of interpersonal violence lead to negative health outcomes, threaten development, undermine quality of life, and erode communities’ social fabric. Recognizing the impact that violence has on development, the 2030 Agenda for Sustainable Development includes multiple targets relating directly to violence under Goal 5 for achieving gender equality and empowering women and girls (targets 5.2 and 5.3) and under Goal 16 for promoting just, peaceful, and inclusive societies (targets 16.1 and 16.2).

    The Americas is one of the regions with the highest levels of violence, a phenomenon that has had a significant negative impact, particularly in the countries where it is most common. The 2014 Global Status Report on Violence Prevention (GSRVP) () shows that there were an estimated 185,235 deaths from homicide in the Region in 2012 (the last year for which data are available). The average homicide rate was 19.4 per 100,000 (35.1 for males and 4.1 for females). Young male adults (aged 15–44 years) bear much of this burden, accounting for about 72% of the deaths. Over the period 2000–2012, homicide rates were estimated to have increased by about 20% in the Americas as a whole; nearly all of the increase was in low- and middle-income countries, while high-income countries reported negligible changes ().

    Women, children, and older persons bear the brunt of nonfatal physical, sexual, and psychological abuse. Such violence can contribute to lifelong ill health—particularly for women and children—and early death. For example, one in three women in the Americas has experienced violence from an intimate partner or sexual violence by a nonpartner during her lifetime () and over 99 million children report experiencing some form of child maltreatment in the last 12 months ().

    Interpersonal violence can be effectively prevented and its far-reaching consequences can be mitigated, although different types of violence may require different strategies. According to the GSRVP (), several countries in the Americas have begun to implement prevention programs and victim services and to develop national action plans, policies, and laws to prevent and respond to violence. However, planning efforts have been undermined by severe lack of data to guide actions, and by lack of funding for national plans and policies on violence prevention. As for the lack of data, most instances of nonfatal violence against women, children, and older persons do not even come to the attention of authorities or service providers. In addition, while countries are investing in violence prevention programs that include the seven WHO strategies for violence prevention (Box 4 (159)), their investment is not on a level commensurate with the scale and severity of the problem. Moreover, since evidence regarding “best buy” violence prevention strategies is limited and biased in favor of high-income countries, it may be challenging for governments in low- and middle-income countries to decide where to invest.

    Box 4. “Best buy” violence prevention strategies

    1. Develop safe, stable, and nurturing relationships between children and their parents and caregivers.
    2. Develop life skills in children and adolescents.
    3. Reduce the availability and harmful use of alcohol.
    4. Reduce access to guns and knives.
    5. Promote gender equality to reduce violence against women.
    6. Change cultural and social norms that encourage violence.
    7. Identify victims and provide them with care and support programs.
    Source: Pan American Health Organization. Status report on violence prevention in the Region of the Americas. Washington, D.C.: PAHO; 2014.

    The GSRVP also shows that countries of the Americas have addressed key risk factors for violence through policy and other measures, such as ones on the harmful use of alcohol or the accessibility to firearms. However, fewer than half of the 22 countries surveyed have implemented social and educational policies that would help mitigate these risk factors—such as incentives for youth who are at risk of violence to complete secondary schooling, or housing policies explicitly aimed at reducing violence by reducing the concentration of poverty in urban areas.

    Moreover, the GSRVP reported that although laws to prevent violence are largely in place, enforcement is often inadequate. The biggest gaps between the existence of laws and their enforcement were laws pertaining to rape, to sexual violence involving contact but without rape, and to noncontact sexual violence. Finally, the report indicated that the availability of high-quality care and support services to identify, refer, protect, and support victims of violence is highly variable. For example, the medical-legal services most widely reported to exist on a large scale are services pertaining to sexual violence and child protection; services least likely to exist are those pertaining to elder abuse. (The quality of these services and their accessibility were not ascertained.)

    To realize the full potential of violence prevention, policies, plans, and programs should be adequately funded; data collection and management should be strengthened; research regarding effective violence prevention strategies should be promoted; national violence prevention action plans should be developed and should be people-centered, context-specific, comprehensive, evidence-informed, and integrated into other health and nonhealth platforms; laws should be enforced; and care services for victims should be comprehensive and informed by evidence ().

    In 2016, PAHO joined efforts with numerous UN and national government agencies to launch the INSPIRE project (), an initiative to help countries and communities achieve the SDGs 5 and 16. INSPIRE includes seven strategies (Table 4) that together provide a framework for ending violence against children and that may also prevent violence against women. These agencies stand together and urge countries and communities to intensify their efforts to prevent and respond to violence against children by implementing the strategies in this package.

    Table 4. INSPIRE package for preventing and responding to violence against children aged 0–18 years ()

    Strategy Approach
    Implementation and enforcement of laws
    • Laws banning violent punishment of children by parents, teachers, or other caregivers
    • Laws criminalizing sexual abuse and exploitation of children
    • Laws that prevent alcohol misuse
    • Laws limiting youth access to firearms and other weapons
    Norms and values
    • Changing adherence to restrictive and harmful gender and social norms
    • Developing community mobilization programs
    • Promoting bystander interventions
    Safe environments
    • Reducing violence by addressing “hot spots”
    • Interrupting the spread of violence
    • Improving the built environment
    Parent and caregiver support
    • Via home visits
    • Via groups in community settings
    • Via comprehensive programs
    Income and economics
    • Cash transfers
    • Group saving and loans combined with gender-equity training
    • Microfinance combined with gender-norm training
    Response and support services
    • Counseling and therapeutic approaches
    • Screenings combined with interventions
    • Treatment programs for juvenile offenders in the criminal justice system
    • Foster care interventions involving social welfare services
    Education and life skills
    • Increasing enrollment in preschool, primary, and secondary schools
    • Establishing a safe and enabling school environment
    • Improving children’s knowledge about sexual abuse and how to protect themselves from it
    • Providing training in life skills/social skills
    • Offering programs for adolescents focused on preventing violence between intimate partners

     

    Disabilities

    The number of people with disabilities in the Region of the Americas is growing due to the aging population, an increase in NCDs, and changes in lifestyles (). It is estimated that these disabilities represent 66.5% of DALYs in low- and middle-income countries (). Occupational injuries and those caused by traffic accidents, violence, and humanitarian crises are most common, with 1.7% of DALYs attributed to injuries caused by traffic accidents and another 1.4% to violence and conflict ().

    The World Report on Disabilities shows that about 15% of the world population lives with some type of disability (). In the Region of the Americas, approximately 140 million people are living with disabilities; 2% to 3%, or 2.8 to 4.2 million people, have disabilities serious enough that they affect functioning. Only 3% of those with some type of disability have access to rehabilitation services, and 3% have a high level of dependency on another person to perform their vital activities ().

    Disabilities disproportionately affect vulnerable populations: the highest prevalence is among the poorest quintile, as well as women and the elderly. People with low incomes, without work, or with little academic training have an increased risk of disability, as do ethnic minorities and indigenous groups. Compared to those without disabilities, people with disabilities have worse health outcomes, less education, higher poverty rates, and participate less in economic activity. This is due in part to the obstacles they face in accessing health services, education, employment, transport, and information ().

    Estimating the prevalence of disabilities in the Region continues to present major challenges primarily because there is little consistency in the criteria for measuring them. However, the 2010 round of censuses provides an accurate estimate of the prevalence of disabilities and of country-to-country comparisons (Figure 1). Women have a higher rate of disability than men, especially women over 60, who are more likely to have health problems and often become disabled; this population also often lacks resources and access to affordable support services. They are among those who devote more time to caring for a family member with a disability, and are at greater risk for acquiring a disability themselves. Also, people living in rural areas are at greater risk of living with a disability compared to those in urban areas. Finally, the censuses show that compared to other groups, people of African heritage in Brazil, Colombia, Costa Rica, Ecuador, El Salvador, Panama, and Uruguay are more likely to be disabled, particularly men and children under the age of 18.

    Visual impairments, hearing problems, and limitations in mobility associated with increasing age, as well as mental and neurological disorders and intellectual disabilities, are all very common in Latin America and the Caribbean ().

    Although significant, the direct and indirect economic and social costs of disability are difficult to quantify. It is important to know the cost of disability in order to determine the investments that are needed and to design good public policies and implement services. However, even in the developed countries, information on the cost is scarce and fragmented, partly because neither definitions nor methods of measurement are standardized. Standardized definitions and methodologies are needed.

    For people with disabilities, the greatest challenge is improving aspects that affect the quality of life—accessibility, social acceptability, educational opportunities, job opportunities, and the right to exercise citizenship. The WHO World Report on Disability () and ECLAC report on the Social Panorama of Latin America () found that people with disabilities have the poorest health outcomes and highest rates of poverty. They also have poorer educational performance, lower rates of participation in economic activity, more restricted opportunities, and are more likely to be dependent.

    To meet the needs of people with disabilities, it is necessary to overcome social, environmental, and physical challenges—developing appropriate policies, addressing negative social views, improving accessibility and delivery of services, making reliable data more available, and involving people with disabilities in decision-making. To address these issues, PAHO/WHO is working with Member States to develop programs, strengthen rehabilitation services (including health and social services and access to devices for technical assistance), and improve data.

    Figure 1. Prevalence of disabilities in the Americas (based on 2010 census data)


    Source: PAHO/WHO elaboration according to publically available census data from 2010

    Chronic Conditions, Life Course, and Social Stratification

    Health disparities are closely linked to social, economic, and/or environmental disadvantage. Subgroups that have historically faced discrimination and exclusion encounter greater obstacles to health, and the disparities they face are caused by factors beyond any individual’s behavior or choices (). Individual behavior accounts for only approximately 30% to 50% of deaths and other health outcomes.

    Over the course of a life, social stratification and social and economic conditions have a strong modifying effect on health of the population (). Even small initial differences in the conditions at birth and in early childhood widen with passing years and can lead to large health differences among adults (). Improvements in living conditions and health during the last decades of life invalidate the assumption that the elderly are more vulnerable simply because of their age. Due to increased life expectancies, growing proportions of people with limited resources are now reaching the age of retirement and a very old age. However, because of the social determinants of health, there are larger gaps in health outcomes in the older population, which are reflected mainly in indicators of morbidity and mortality associated to chronic diseases and conditions (). Also, social stratification and a life course perspective are closely interconnected. Family and social support can be significant resources, but they can also be sources of stress when responses are nonadaptive.

    Conclusions

    Unprecedented socioeconomic, demographic, and epidemiological changes in recent decades in the Americas have led to significant changes in the population’s health status. NCDs, mental disorders, disabilities, road traffic injuries, and interpersonal violence are, cumulatively, the leading health problems and urgently require strengthening of multisectoral policies and health systems.

    NCDs are largely preventable by tackling their common risk factors; they can be better managed by improving health systems to provide chronic care for people at risk of or living with an NCD. There are global commitments and targets for reducing the burden of NCDs, as well as consensus on cost-effective and feasible health policies and health service interventions; it is now a matter of making greater investments, strengthening multisector collaboration, and building country capacity to implement the interventions. The treatment gap for mental disorders can be reduced by integrating mental health care in primary- and secondary-care settings and moving away from providing treatment in mental institutions. Road safety measures should be addressed through legislation and regulations, which are urgently needed to reduce speed, enforce the wearing of seat belts, and increase the use of motorcycle helmets. People with disabilities, both physical and mental, need better access to community-based rehabilitation services, health services, and more support services. Violence of all types, a significant problem in the Americas, is strongly associated with weakened governance; poor rule of law; cultural, social, and gender norms; increasing unemployment; income inequality; and limited educational opportunities. Stronger violence prevention measures are needed, with legislation and regulations that limit access to firearms and other weapons, reduce excessive alcohol use, and offer enhanced services for victims of violence.

    Advances in science, technology, and knowledge, together with the Sustainable Development Goals and numerous public health commitments to tackle health issues, offer a promising future for improved health and well-being for the people of the Americas.

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    Reference/Note:

    1. Information and reference on the Vida no Trânsito project is located on the PAHO website: https://www.paho.org/bra/index.php?option=com_content&view=category&id=1249&layout=blog&Itemid=787.

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

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    Reference/Note:

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

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

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

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

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

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

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

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

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

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

    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.

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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