Inequities and barriers in health systems
Equity in the context of Regional transformation processes in health
The quest for equity is a persistent challenge for health systems in the Region of the Americas. Significant advances have been achieved in health in part as a result of the economic and social development of countries, the consolidation and strengthening of health systems, and the ability to incorporate and apply emerging technologies to improve health and well-being. The political commitment of countries to respond to the health needs of their populations has been an essential contributing factor to these achievements ().
Despite the advances, poverty and inequities remain a challenge in the Region. Recent data suggest that Latin America and the Caribbean (LAC) remains the most inequitable region in the world, with 29% of the population below the poverty line and the poorest 40% of the population receiving less than 15% of total income. Such inequities are reflected in health outcomes: for example, the Region of the Americas did not achieve the Millennium Development Goal (MDG) target for the reduction of maternal mortality by 2015, and despite significant reductions in infant mortality, very sharp differences exist between countries. Without specific interventions to transform health systems, economic growth is not sufficient to reduce inequities ().
In October 2014, PAHO Member States approved the Strategy for Universal Access to Health and Universal Health Coverage (from here on, referred to as “universal health”) (). The strategy emphasizes the need to strengthen health systems to achieve universal access and coverage, namely by reducing health inequities; expanding access to comprehensive, quality care; and improving the health and well-being of the population. The strategy underscores the need for more and better investments in health, in particular to strengthen the first level of care, and for moving decisively toward integrated health services. In addition, it calls for strengthening intersectoral approaches to the social determinants of health in order to reduce social inequalities and inequities in access and health outcomes.
Achieving equitable, comprehensive, and integrated health services will require important transformations in the model of care and in the organization of health care delivery. The countries of the Region agree that models of care based on the values and principles of the primary health care strategy should govern health care organizations or networks to provide integrated, quality, people- and community-centered services (). Certain changes will be essential, including more equitable health financing, new or adjusted regulatory frameworks, innovative approaches to human resources education and allocation, and strong leadership by the national health authorities.
Most health systems in the Region of the Americas struggle with the dichotomy of a declared policy intention to move toward universal health and people- and community-centered models of care based on the values and principles of primary health care and the reality of maintaining structures and practices of the old biomedical model. In curative services–oriented systems, a preponderance of funds is allocated to inpatient care. Evidence of this can be found in the way in which most ministries of health in the Region allocate the larger portions of their budgets to hospital services that are inequitably distributed nationwide.
In light of the above, countries urgently need to accelerate the transformation of their health systems—with universal health as a deliberate goal. Comprehensive strategic actions implemented in a progressive and sustained manner are required to build health services that are responsive to the needs of all populations. As democratic processes in the Region are consolidated and greater decision-making power is transferred to people and their communities, the social demand for universal health can be expected to grow, supported by increasingly well organized advocacy efforts.
Inequities and barriers in health systems: defining the problem
It is important to differentiate inequality from inequity. Inequalities, as defined by WHO (), are differences in health status or in the distribution of health determinants between different population groups. Inequities are those inequalities that are considered avoidable, unnecessary, and unfair ().
This means that not all inequalities are avoidable or unfair. Differences in life expectancy between men and women are a good example. When variances are due to intrinsic biologic differences, they are not considered unfair; however, when they are caused by social policies or barriers to the exercise of essential rights, they become inequalities that are unfair, unnecessary, and avoidable—thus, inequitable ().
The current debate on inequities in health introduces new terms and definitions that are useful in characterizing important aspects of the problem. One such term, structural inequities, refers to “how policies and practices embedded in systems such as social welfare, economic, justice and health care operate to produce inequitable distribution of the determinants of health” (). As such, “inequities are structural because they are entrenched in the political and economic organizations and they are violent because they cause injury to people” ().
Health systems–generated inequities and barriers
The health system is an important cause of inequity in health. As stated by Barbara Starfield, “Inequity is built into health systems—especially western health systems that are based on a view of health needs disease-by-disease” ().
Due to certain conditions of their historical development, the traditional organizational structure of health systems in the Americas was in most countries characterized by uncoordinated subsystems providing care to different strata of the population. This led to a high level of segmentation and fragmentation, profoundly affecting the systems’ performance, efficiency, solidarity, and equity. Indeed, health systems with these characteristics do not adapt to the needs of populations with present-day epidemiological profiles, in which aging and noncommunicable chronic conditions are increasingly important challenges.
The segmentation and fragmentation observed in the majority of health systems in the Region result in inequity and inefficiency that compromise universal access, quality, and financing. Segmentation and fragmentation are perpetuated by poor governance and weak regulatory capacity of health systems (). Fragmentation, on its own or with other factors, generates difficulties in access to services, delivery of services of poor technical quality, irrational and inefficient use of available resources, unnecessary increases in production costs, and great user dissatisfaction. Moreover, the evidence indicates that in insufficient coverage schemes, the focus on disease rather than meeting the health needs of people and communities results in not only greater costs but also loss of income, creating a vicious cycle of disease and poverty in families.
Although health services in the majority of the Region’s countries are fragmented, the degree of fragmentation and the underlying causes vary from country to country. The literature reviewed and consultations in countries suggest multiple causal factors, including institutional segmentation, decentralization, suboptimal funding, predominance of vertical programs, separation of public health services from curative services, disease-centered models, weak steering capacity, and human resources in health that are numerically insufficient, inadequately trained, and poorly distributed ().
Fragmented health services, which are predominantly based on the model of inpatient hospital care, undermine the capacity to respond to the overall health needs of the population. In most health systems, the current delivery model centers on episodic care of acute conditions in hospital centers, with intensive use of technology and specialist physicians. Health system investments and reforms have not always been targeted to meet new challenges, and new technology and innovation have not been sufficiently incorporated into the management and delivery of services. In many of the Region’s countries, this creates an unbalanced investment in urban hospital-based services and new technologies, to the detriment of health promotion and preventive interventions at the first level of care. Meanwhile, services in rural communities or for populations in conditions of vulnerability are neglected or under-resourced.
Fragmentation is not simply a problem of referral mechanisms. More importantly, it affects comprehensiveness, coordination, and continuity of care between different health facilities, levels of care, and clinical specialist/teams throughout the life course. It therefore demands more complex approaches and solutions. Lack of coordinated care is further compounded by limited resolution capacity. This is particularly true at the first level of care, which affects the capacity to respond to emerging health needs, especially the growing needs of aging populations and the growing burden of chronic conditions throughout the Region.
On the other hand, in many countries of the Region, health care services do not respond appropriately to the differential health needs of people and communities. Populations in conditions of vulnerability (extremes of life, women and children, ethnic minorities, patients with chronic and/or incapacitating diseases, etc.) are the most affected by this problem. For example, women’s health issues are a combination of health risks and disorders that they have in common with men, and issues that exclusively affect women because they relate to biology. Both are strongly affected by gender, ideology, and politics.
The changing scope of the worldwide burden of disease shows important advances in some of women’s foremost health priorities (), but considerable challenges and inequalities exist. While the achievement of sexual and reproductive health rights is still an unmet goal, noncommunicable diseases such as cardiovascular disorders, stroke, cancer, diabetes, chronic obstructive pulmonary disease, and mental health disorders are now the leading causes of death and disability for women of almost all countries (). On the other hand, in the Americas, men die from external causes four times more often than women. The lack of appropriate coverage of these groups affects their right to health and well-being and has negative effects on the social and economic development of countries. The same is true for populations subject to structural racism (especially indigenous and Afro-descendant populations). Structural racism describes the confluence of institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups. In the United States, “structural racism, the systems-level factors related to, yet distinct from, interpersonal racism, leads to increased rates of premature death and reduced levels of overall health and well-being” ().
Problems of exclusion and lack of access to quality services persist for large sectors of the population. The lack of appropriate coverage and access has a considerable social cost, with catastrophic effects on population groups in conditions of greatest vulnerability. In the Region, 30% of the population does not have access to health care for financial reasons and 21% does not seek care due to geographical barriers. Populations in conditions of vulnerability are among the groups most affected by this problem ().
Barriers in access to services and inequities in coverage
Classically, access to health has been defined in three dimensions. The first is physical access, understood as the availability of good health services in different parts of a country, of reasonable scope, with opening hours as well as other amenities that make it possible for users to obtain services when needed. The second dimension is financial access, which consists of monetary arrangements that affect the capacity to make use of services and that include not only fees but also indirect costs (e.g., transportation). The third is sociocultural acceptability, which represents the will to request services and is understood as the capacity of the services to adapt and respond to the realities and social and cultural requirements of the population. Acceptability is lowest when people perceive that services are ineffective or when, for reasons of language, age, sex, sexual orientation, ethnic origin, or religion, the service provider dissuades them from seeking care. Inequalities exist in girls’ and women’s access to health care for their comprehensive needs across the life course. The reproductive health services that are most unequally distributed among women by socioeconomic status, ethnicity, and age are prenatal care, skilled birth attendance for delivery, and family planning. These disparities have many complex sources, including poverty, poor education, disempowerment, weak health systems, and gender discrimination. The poor technical and interpersonal quality of care for all women has also been highlighted as a frequent problem. Improving health services coverage demands analyzing and selecting actions to modify and eliminate the barriers to access in each of these dimensions. For communities seeking to achieve universal health, services should be physically accessible, financially attainable, and socioculturally acceptable for individuals.
PAHO defines access as the availability of comprehensive, appropriate, timely, quality health services when they are needed. But more specifically, access takes into account cultural and ethnic preferences, is linguistically appropriate and gender-sensitive, and bases actions and interventions on the identified needs of the populations. Further, such services promote health, prevent diseases, and throughout the life course, provide quality care that includes diagnosis, treatment, rehabilitation, and palliative end-of-life care. Quality health service encompasses intersectoral approaches to the social determinants of health and encourages active participation of individuals and social and community organizations.
Analysis of health infrastructure distribution in the Region reveals significant inequities in the concentration of service facilities, particularly hospitals, in large urban centers. Likewise, the farther removed health facilities are from cities or urban areas, the greater the shortage of competent personnel and inputs. This affects access and aggravates inequities. At the first level of care, the lack of adequate infrastructure (in number, geographical distribution, and response capacity) generates, among other adverse phenomena, excessive use of emergency services. This drives up costs, hampers efficiency, negatively affects both the continuity and quality of care, and increases the level of dissatisfaction among users and health care workers.
Poor quality care, provided by models that are inappropriate for the needs and health priorities of the population, also negatively impact health equity. Poor quality and warmth in the delivery of services—such as, courteous indifference, crowded waiting rooms, poor or lack of information, long wait times for surgery or other procedures or treatments, opening days and hours that do not accommodate people’s preferences and needs, refusal to provide care or treat patients who cannot pay, and poor maintenance of ancillary facilities (e.g., restrooms that lack soap and water or that are unclean or out of order, and a general absence of commodities such as seating in the waiting area) are unfortunate characteristics of many health services in countries of the Region. These situations are further compounded by frequent cancellation of long-awaited appointments due to the absence or shortage of personnel, malfunctioning diagnostic and treatment equipment, or unavailability of essential supplies, particularly medications.
The critical role of human resources for health
Serious imbalances and gaps persist in the availability, distribution, composition, competency, and productivity of human resources for health, particularly at the first level of care. Worldwide, evidence indicates that a threshold of 25 health workers/10,000 population (physicians, nurses, and certified midwives) is a useful benchmark for achieving adequate coverage (i.e., 80% of the target population) for programs or basic health interventions such as immunization and deliveries attended by skilled personnel (). However, this threshold does not account for the broader offering of health services made necessary by changes in the burden of disease, particularly by the growing prevalence of chronic conditions. The regional variation ranges from 3.6 health workers per 10,000 people in Haiti to 135 per 10,000 people in Cuba. In total, 16 countries of the Region demonstrate a critical shortage of health workers. The situation is even more serious if one considers the availability of health workers at the first level of care ().
The shortage of human resources for health care constitutes one of the main challenges or stumbling blocks in achieving universal health. The first challenge is relevant to all countries of the Region regardless of income level: providing care to dispersed populations in rural or remote areas and to communities in conditions of vulnerability. The second challenge is the profound historical imbalances in many countries; there are significant differences in the availability, distribution, composition, competencies, and productivity of the health care work force, which to a great extent is determined by segmented and asymmetrical work markets. In turn, training institutions play a critical role in the quality of training for health workers but respond to an educational market that is mostly unregulated. Finally, depending on the leadership and managerial capacity of the health system and the strategies implemented, health care workers and their organizations may either contribute to creating more equitable health systems or may become an impediment.
The available data suggest that by 2030, the majority of the countries in the Region will have surpassed the minimum level of 25 health care workers per 10,000 population, although a small number will still have critical deficits. However, in light of present commitments in countries of the Region, changing epidemiological and demographic profiles, and the ongoing transformation of the model of care, the relevance of this indicator needs to be reassessed in relation to the challenge posed by universal health.
The availability of health workers nationally does not reflect the profound imbalances in how they are distributed relative to health needs. One indication is the high concentration of health care workers in large cities to the detriment of the most remote, rural areas. For example, a study conducted in Brazil documents a doctor shortage in 1,280 non-metropolitan municipalities, (primarily in the northern and northeastern regions of the country) that affects more than 28 million people ().
The composition of the health care work force is another critical element that affects access to skilled health workers, consistent with the health needs of the population and the transformation of the model of care. In many countries, medical professionals, particularly specialized physicians, often serve as patients’ first point of contact in the health care system. There are only five countries in which primary care physicians constitute more than 40% of the total medical work force. Regarding the ratio of nurses to physicians, with the exception of the English-speaking Caribbean (where a majority of countries have a ratio of 3–5 nurses per doctor), there are significant nurse-to-doctor imbalances; only five countries in Latin America register a ratio close to one nurse per physician ().
Another relevant challenge is the availability of personnel with the right competencies; this is related to cooperation among educational institutions and with health authorities. Important gaps persist in the ability of countries to institute undergraduate curricula oriented toward primary health care, and to ensure that students from underserved populations have access to educational opportunities in the health professions. Only two countries in the Region reported that at least 80% of the health science schools have reoriented their curricula toward primary health care and have incorporated strategies for interprofessional training. Thus, building a health care work force trained and aligned to the current objectives and goals of primary health care and universal health has emerged as the great pending challenge in the area of human resources for health education and training.
Access to medication and appropriate health technologies
Access to and rational use of safe, effective, quality medicines and other health technologies, as well as respect for traditional medicine, continue to present challenges for most countries of the Region and affect quality of care. Supply problems, the underuse of generic drugs, higher-than-expected drug prices, and inappropriate and ineffective use of medicine all constitute additional barriers to universal health coverage affecting equity in health (). The regulatory capacity for medicines and health technologies is improving Region-wide, but it remains a challenge, particularly for the newer and more complex health technologies required by health systems.
For significant sectors of society, expenditures on drugs remain the most important component of out-of-pocket expenditure due to absent or inadequate health care coverage. Per capita, the average out-of-pocket expenditure for drugs in LAC reached US$ 97; it ranged from US$ 7 in Bolivia to US$ 160 or more in Argentina and Brazil. Additionally, compared to men, women pay 16–40% more for health care, they live longer, provide more unpaid health care more, and have more unmet health needs.
In the majority of countries of LAC, expenditures on medications are among the most significant items in health budgets (along with human resources); the costs constitute 25% to 65% of a country’s health-related expenditures. In comparison, in developed countries, expenditures for pharmaceuticals range from 7% to 30% of their total health-related expenditures.
Accordingly, increases in the cost of medications (and the lack of financial protection to cover those costs) limit individuals’ access and impact the sustainability of health systems and the attainment of universal health.
A similar challenge is posed by the dizzying development of health technologies in diagnostic imaging and radiation therapy; often there is a gap in access to these services. Additionally, the often rapid incorporation and use of these technologies create important inefficiencies.
Social determinants: barriers to equitable health and well-being
In the Americas, efforts to achieve universal access to health and universal health coverage began as early as the 1970s. Over the past three decades, several countries in the Region have implemented health system reforms that fostered inclusion, citizen participation, and equitable access to health care. Despite this progress, however, most countries in the Region still experience great inequities in health status and coverage of health interventions, with the result that there are major differences in health outcomes based on people’s wealth, education, geographic location, gender, ethnicity, and/or age ().
In LAC, for example, affordability is one of the most important determinants of access to and coverage of health care, and populations from poor communities are less likely to seek or attain care due to the direct and/or indirect cost of treatment (). Although many countries throughout LAC have made substantial efforts to expand health services to poor populations, health inequities caused by economic factors remain widespread in the region, especially for women, infants, and children (). In the United States, health inequity is a persistent problem, despite attempts to address it. United States government reports show that since 2007, “inpatient care for people with heart failure has actually grown worse for Hispanics or Latinos, Native Americans, and Alaska Natives. These minorities…are younger than their white counterparts. They also encounter socioeconomic, language, and cultural barriers to care that lead to higher rates of re-admission to hospitals and to poorer outcomes” ().
On the other hand, in Haiti and Nicaragua, the gap between the poorest and wealthiest women who have had at least four prenatal visits is more than 30%. Also, women from the poorest quintile in El Salvador, Guatemala, Bolivia, and Panama have unmet needs for contraception that is four times higher than the women from the wealthiest quintile ().
For populations living in poor settings, a range of different interventions has proven effective in overcoming financial barriers to health care. For example, by redistributing tasks to trained community health workers at the health facility level, a “task shifting” intervention, which was originally piloted in Haiti and later validated by WHO, has improved access to health services at the facility level by decreasing indirect costs (such as for transportation and lodging) for populations living in these settings ().
Education is another factor that significantly impacts access to health care. According to a systematic review of health literacy and health outcomes, individuals with lower levels of health literacy consistently had poorer health-related knowledge and comprehension, were less able to demonstrate taking medications properly, and were less likely to understand medication labels and health messages. They also had more hospitalizations and emergency care, received less preventive care and, among the elderly, had poorer overall health status and higher mortality ().
Furthermore, a recent study showed that low education levels affect women’s abilities to access basic health commodities (). This is evident in Costa Rica, El Salvador, Guatemala, Panama, Peru, and Suriname, where women with no education have an unmet need for contraception that is at least twice as high as that of women with secondary education or higher ().
In order to respond to the low levels of literacy, countries must improve access to effective school education, including providing adult education for those who missed out. The WHO Commission Report concludes that “removing the numerous barriers to achievement of primary education will be a crucial part of action on the social determinants of health” (). Thus, achieving high literacy levels in the population is not only a vital development goal, but will also produce substantial public health benefits (). The education of girls, expansion of social protection, and protection of the environment can have substantial health benefits. Less well established but equally important is how these investments affect women’s roles as health care providers and producers. Gender-responsive policies that recognize health as more than a sectoral outcome, and multisectoral programs that involve women in an enabling environment can empower them to achieve their full potential at home, in their communities, and in the health care work force.
Geographic residency is a third factor that significantly impacts access to health care. In LAC, people who live in rural and/or geographically marginalized areas often encounter barriers that limit their ability to get the health services they need. For instance, in many countries there is often a shortage of health care professionals in certain areas; this limits the supply of available services and in turn reduces access to care. Further, people in rural and/or geographically marginalized areas are more likely to have to travel long distances for health services, which can impose significant burdens on health, money, and time. In addition, there is often a lack of reliable public transportation, making it even more difficult to access needed care (). Other barriers to health services in these remote areas include social stigma and privacy concerns, poor health literacy, facility overcrowding, inability to take time off work, and lack of alternate childcare (). Such barriers to services result in unmet health care needs, which ultimately threaten the well-being and optimal health of populations.
There are many different strategies that can improve access to health care among populations living in rural and/or geographically marginalized areas. Establishing equity-based interventions have proven effective in reaching remote populations. For example, casas maternas (maternity waiting houses) are community-run health facilities that host pregnant women for days or weeks before their scheduled delivery. The objective is to increase access to maternal health services, including births attended by skilled health staff, for populations living in rural and/or geographically marginalized areas (). Several studies indicate that this community-based strategy has been effective in increasing the number of assisted births in geographically remote areas, which consequently decreased the probability of complications during delivery ().
In spite of the vast progress made in the Americas, inequities in vaccine coverage within countries have often been masked by high estimates of vaccine coverage nationally. However, population groups that are unvaccinated or that are vaccinated at lower than the national level are among the most underserved and poorest municipalities or areas. In 2015, in 56% of 15,000 municipalities in Latin America and the Caribbean (8,456 in all), fewer than 95% of children received three doses of diphtheria, pertussis, and tetanus vaccine (DPT3), missing the target level (). The proportion of children under 1 year living in municipalities with suboptimal coverage for DPT3 is almost 20% higher in countries in the lowest income quartile compared with countries in the highest income quartile. The high risk of exposure for diseases that can be prevented with a vaccine is attributable to the prevailing economic inequality between countries in the Region ().
In order to ensure equitable access to vaccines, it is essential to maintain efforts and to further analyze, at both the Regional and national levels, the causes of inequity, including those related to the social determinants of health. Immunization coverage should be a key indicator for achieving universal health given that immunization has the potential to be directly integrated with other services, including prenatal care, adolescent sexual and reproductive health, elderly care, and prevention and control of chronic conditions.
Measuring equity in health systems performance: the paucity of information
Measuring inequalities and equity in health systems is a challenging task for many countries in the Region. As is often said, if it is not measured there is no way to know where we are, where are we going, and whether we are making progress. On the other hand, there is still much debate on some of the basic definitions—for example, what we mean by “unfair” inequalities.
Many measurement frameworks for inequity in health have been proposed and discussed, and there is no shortage of approaches in the specialized literature (). This continues to be a complex issue that “requires consideration of ethics (e.g., defining unfair inequalities), methods (e.g., quantifying health inequities), and policy (e.g., offering policy relevant information)” ().
Aside from methodological difficulties, countries often lack capacity for generating and sharing quality data to inform assessments of inequalities and inequities. PAHO Member States will require purposeful interventions and investments in health information and statistical systems to build competencies that will provide effective capacity to measure and report on health inequities on a regular basis.
In the interim, PAHO has proposed including proxy indicators for measuring equity in health care services in the assessment framework of PAHO’s Strategic Plan 2014–2019 (). Technical cooperation with Member States will be key to building capacity to achieve this goal and to further develop a Regional framework for measuring and monitoring inequalities and inequities in health.
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1. Resolution capacity in this context is defined as the ability of health services to provide health care responses adapted to people’s needs and demands, in line with current scientific and technical knowledge, resulting in an improvement in health status.
2. The PAHO Gender equality policy recognizes that there are differences between men and women with regard to health needs, and to the access and control of resources, and that these differences should be addressed in order to correct the imbalance between men and women ().
3. As of 2010, 36 million people in the Region did not have access to drinking water fit for human consumption. Some 120 million lacked improved services for the disposal of waste water and sewerage, and almost 25 million people in Latin America and the Caribbean defecate in the open ().
4. Behavior displayed by service personnel (not only in health services) who speak to clients or users using courteous language but whose demeanor, body language, and attitude displays lack of warmth, poor interest, or indifference and even aggressiveness.