The quest for universal health: summary of indicators on health systems performance
Health systems aim to improve the health and well-being of the entire population through the progressive attainment of universal access to health and universal health coverage (hereinafter called universal health) (). Appropriate governance, human resources, and financing ensure the capacity and preparedness of the health system to deliver treatment, prevention, rehabilitation, and palliative health services to the entire population. This capacity and preparedness are measured in the availability of infrastructure, equipment, essential technologies and medicines, human resources, and information systems that are appropriate and necessary for offering health services to the population (). While securing coverage of health services is necessary for the health and well-being of the population, health systems also require the definition and implementation of policies and actions with a multisectoral approach to address the social determinants of health and equity. Income, education, gender, ethnicity, and age are some of the social determinants that affect people’s access to health and well-being. Access to health is then measured in the capacity of the population to use comprehensive, appropriate, timely, and quality health services when needed, without encountering barriers when trying to use those services. Both universal access to health and universal health coverage are necessary in order to improve equity in health outcomes and other basic objectives of health systems ().
This section examines the progress made in the last 5 to 10 years on health systems’ performance and impact on universal health metrics across the Region of the Americas. Broad measures of population health status attributable to health service delivery, such as the mortality rate due to chronic conditions, are addressed in previous sections of this chapter. PAHO’s resolution for universal access to health and universal health coverage provides the mandate to the Pan American Sanitary Bureau (PASB) to measure progress towards universal health using the indicators identified in the Strategic Plan of the Pan American Health Organization 2014-2019 () and to report on the advances through the biennial assessments on the implementation of the Strategic Plan. To fulfill this mandate, the Department of Health Systems and Services of the PASB has developed a monitoring and measuring framework and tool in collaboration with Member States (). Based on that framework, the PASB has been supporting Member States to monitor and measure their progress towards universal health. Part of the metrics and information presented herein were selected based on this monitoring and measuring framework. Access to health is measured based on proxy indicators such as utilization of health services, likelihood to report unmet medical needs, and perceived access barriers. Health coverage is thus measured using metrics such as population coverage, availability and distribution of human and physical resources, essential technologies and medicines, and information systems. These measures are analyzed with an equity lens, to present results beyond averages and establish the linkages with the social determinants of health.
Acknowledging that Member States have used different approaches to organize their health systems, the analysis presented here does not intend to compare health systems among countries in the Region. Instead the aim is to identify gaps and priority areas that need special attention and document successful experiences and lessons learned to help guide the policy-making process taking place in the Region. Furthermore, the findings presented here need to be interpreted with caution and within the economic, political, legal, historical, and cultural context of each particular country, with their own health challenges and priorities. This analysis illustrates how health systems have changed over the last years along three dimensions: (1) universal access and coverage of quality health services, (2) health financing and elimination of direct payments, and (3) capacity of health care services and activities.
Universal access and coverage of quality health services
Universal access to health
Most of the global discussion on monitoring and evaluation strategies for universal health has focused on two elements for assessing universal health coverage, namely, service coverage and financial protection (). While these metrics offer a comprehensive understanding of the quality, pertinence, and affordability of the services provided to the population, measures are needed that can describe more accurately the different dimensions of access to health (). Measuring patterns of service use does not provide the full picture about the different barriers that individuals might encounter when trying to access health services nor does it inform policymakers on what types of interventions and programs are necessary to improve access to health care (). Monitoring universal health requires metrics that can properly capture the dimensions of both access and coverage that are behind this initiative.
Coverage, utilization, and access barriers to health
Despite Member States’ efforts to collect information to systematically monitor and evaluate health access and coverage of health services, greater efforts are needed to track progress beyond averages with quality data disaggregated by key dimensions such as income, education, migrant status, indigenous status, ethnicity and disability, and urban-rural areas. Figure 1 presents data available for population coverage, access barriers, and utilization of preventive services for Chile, Colombia, Mexico, Peru,the United States, and Uruguay between 2010 and 2015. The data show that these countries have made improvements in both coverage and access metrics and that this has been, in general, accompanied by reductions in income-related inequities over time. The results also show how the coverage and access metrics compare and complement each other and illustrate how both dimensions, access and coverage, are necessary to improve health equity.
Figure 1. Evolution of income-quintile distribution of population coverage, preventive visits, and access barriers, 2010–2015
Notes: * Utilization of preventive services for both private and public institutions. The rate of utilization of preventive services tends to be higher in public facilities, particularly in Chile.
**Access barrier measures the percentage of the population who had a health problem and did not receive medical services due to lack of money, time, difficulties obtaining medical appointment, and/or preference.
Between 2014 and 2015, levels of population coverage were high across the countries studied: from around 98% in Chile and Uruguay, 95% in Colombia, 90% in the United States, 80% in Mexico, and 73% in Peru. Levels of coverage were, however, lowest in the poorest households, particularly for the United States and Colombia, while this relation was the opposite in Peru. It is worth noting that high levels of population coverage did not always coincide with high rates of utilization of preventive health care visits or low rates of people reporting access barriers.
Ensuring access to preventive health care visits is a fundamental element of universal health. Preventive visits are critical to promote and maintain the health of the population through the prevention and early diagnosis of diseases as well as the screening of risk factors and the promotion of healthy lifestyles (). Furthermore, it is expected that all adults have at least one preventive health care visit every year (). Data available for 2011 to 2015 show that countries in the Region have high inequalities and diverse levels of utilization of preventive health care services, from 21.04% in Peru, followed by the United States (24%), Chile (24.3%), Colombia (68.25%), and Mexico (76.3%) of the adult population having at least one preventive visit yearly in 2015 or most recent year (Figure 1). Overall data trends show that the utilization of preventive health care services increased, particularly in Colombia and Mexico, and became less unequal in most countries studied, though with persistent gaps between the poorest and richest families. In the United States, Colombia, Mexico, and Peru, utilization of preventive services was highest in the richest households, while this relation was the opposite in Chile in the 2013–2015 period. The interpretation of the data presented is limited as no further information exists on the quality of the care provided, and the reasons why the use of preventive visits varies across countries. With respect to barriers to access health services, the percentage of the population reporting access barriers between 2014 and 2015 varied from around 66% in Peru to 36.9% in the United States, 28.8% in Colombia, 20% in Mexico, and 6.8% in Chile. Similarly, the percentage of households reporting access barriers was highest in the poorest households, particularly in Colombia and Mexico. It is noteworthy that disparities have declined in most countries for all metrics studied, indicating improvements in equity.
Coverage of reproductive, maternal, and child health services
The Region of the Americas has achieved significant progress in the last two decades in the areas of maternal and child health, especially for maternal and under-5 mortality rates, which declined by 40% and 69%, respectively, in Latin America and the Caribbean (LAC) between 1990 and 2013 (). Despite this progress, the Region fell short of the MDG target of a 75% reduction in the maternal mortality rate by 2015, with persisting inequalities between the poorest and wealthiest countries and population groups. In light of the continued commitment to women and children’s health in the post-2015 development agenda, further efforts are necessary to reduce socioeconomic inequalities that hinder universal access to the health services that women seek for themselves and their children before, during, and after pregnancy. Strong health systems prepared and equipped for the provision of preventive and treatment interventions across the continuum of care for reproductive, maternal, newborn, and child health are proven to be key to reduce maternal and child mortality and morbidity ().
In 2015, most countries in the Region reached universal (100%) or near universal (93%) aggregate coverage of key reproductive and maternal health interventions, though with important gaps between the wealthiest and poorest countries in the Region (Figures 2a to 2c). Coverage of skilled attendance at birth ranged from 100% (or nearly 100%) in most countries to a low of about 50% in Haiti, followed by Guatemala and Bolivia with 67% and 74%, respectively. The poorest countries also had the lowest coverage rates for antenatal care visits, with Guatemala having by far the lowest coverage rate (43%), followed by Dominica with 56% and Suriname and Haiti with 67% each. The proportion of women with unmet family planning ranged from about 10% in Costa Rica, Cuba, Canada, and Uruguay to a high of 39% in Bolivia, followed by Haiti, Peru, and Guyana. Regarding the indicators included for child health services, most countries in the Region reached high coverage (93 to 100%) of DPT3 immunization, with the exception of Ecuador, Guatemala, Haiti, and Panama, which had less than 80% aggregated coverage (Figure 2d).
Figures 2. Infant and maternal health services coverage, Region of the Americas, 2015 or 2016
Data available to measure the reduction of inequities in the utilization of maternal and child services within countries show that overall, the utilization of these services has become more equitable in the Americas over the last decade, though in some countries the gap is still large between the lowest income quintiles (quintiles I and II). For instance, in Peru the gap between the richest and the poorest women using maternal and reproductive health services has significantly narrowed between 2000 and 2015, yet women in the lowest income quintile still lag far behind their wealthier peers (Figures 3). It is noteworthy that the increase observed in the utilization of these services is mainly due to the expansion of coverage among women in the lowest income quintiles (quintile I and II) as coverage was already high among high-income women (quintiles 4 and 5) in Peru at the beginning of the evaluated period (Figure 3). Data for Bolivia, Colombia, Dominican Republic, and Haiti on utilization of maternal and child health services show similar trends, with Colombia and the Dominican Republic achieving greater improvements in reducing disparities in the use of these services, while Bolivia and Haiti are lagging behind (Figures 4 and 5). Despite the improvements, significant income-related inequalities persist in all countries evaluated.
Figure 3. Income-quintile distribution of access and reproductive health services in Peru from 2000 to 2015
Universal access to quality maternal and child health interventions is key to reduce inequities and improve maternal and child health; however, the data available do not allow for this type of analysis. Coverage for health services measures the number of individuals receiving a set of health services expressed as a percentage of the corresponding midyear population for a specific year, in a given country, territory, or geographic area. This measure captures intervention use, but does not focus on the quality of the intervention measures as the actual health benefit experienced from the service. Most importantly, these sources of information do not capture the gap between crude (i.e., vaccination) and effective coverage (i.e., seroconversion), which, for example, can be higher than 20% for immunization (). Within this context, effective coverage has been proposed as an ideal metric because it unifies in a single metric service use (utilization of service), need (individual/population in need of a particular service), and quality (actual health benefit experienced from the service), but there are insufficient data in the Region to conduct that type of study (). Furthermore, the increased use of health services is associated with decreased likelihood to report unmet medical needs; however, perceived access barriers are more desirable measures of access because realized utilization does not necessarily mean that people do not face significant obstacles when seeking health services. Conversely, lack or poor use of services does not always imply that people have poor access ().
Figure 4. Evolution of income-quintile distribution of maternal health interventions, selected countries and years
Source: Prepared by the authors based on data from WHO Health Equity Monitor; data are based on Demographic and Health Surveys (DHS).
Comprehensive, quality, people- and community-centered health services
Mortality amenable to health care. Mortality amenable to health care refers to a subset of premature deaths that should have not occurred with timely health care interventions (). While this measure provides an indication of the quality and accessibility of health services, it is not a definite measurement of the quality of health care in countries. Other factors beyond health systems performance and health policies influence amenable mortality rates. Furthermore, although statistics on death are widely available across Member States, persistent problems with death under-registration and data quality limit the interpretation of the data presented. Monitoring amenable deaths can nonetheless highlight areas that can be further studied.
Data for the Region of the Americas indicate that between 2013 and 2014, more than 1.2 million deaths could have potentially been avoided in the Region with health care systems offering accessible, quality, and timely health care. There were, however, large variations in amenable mortality rates across countries (Figure 5a). Amenable mortality rates ranged from about 47 to 350 deaths per 100,000 population. Death rates were lowest for Anguilla, Honduras, Cayman Islands, and Canada, with age-standardized mortality rates from around 47 to 62 deaths per 100,000 population. On the other hand, amenable mortality rates were highest in Guyana, St. Vincent and the Grenadines, Suriname, Grenada, and Belize, with figures ranging from 194 to 350 deaths per 100,000 population.
Figure 5. Amenable mortality rates (a) 2000, 2010, and 2014 (or nearest year); (b) rate change from 2010 to 2014 )
Between 2010 and 2014, the rate of amenable deaths decreased in most countries of the Region, though with important exceptions. Amenable deaths declined at the highest pace in Belize, Anguilla, Montserrat, and Suriname, while they increased in St. Vincent and the Grenadines, St. Kitts and Nevis, and the Dominican Republic (Figure 5b).
Source: (a) Prepared by the authors based on data from PAHO Health Information Platform for the Americas (PLISA). Data retrieved in November 2016. Data for Bahamas, Barbados, Cayman Islands, Colombia, El Salvador, French Guiana, Guadaloupe, Honduras, Martinique, Nicaragua, and Venezuela correspond to 2013. Data for Dominican Republic, Guyana, St. Kitts & Nevis, and Virgin Islands (US) refer to 2012, and data for Canada and Jamaica refer to 2011.
Figure 6 presents the average amenable mortality rate for countries in the Region distributed by income for 2000, 2010, and 2014. Overall, income-related inequalities in amenable mortality have decreased over time and between countries, but there remain persistent gaps. It is noteworthy that the rate of amenable mortality was mostly invariant for countries in the richest income quintile between 2010 and 2014, while poorer countries experienced important reductions. Interestingly, countries in the second income quintile bear the biggest burden of amenable mortality rate. Disparities related to sex are also visible in all countries studied, with men being more affected than women (Figure 7).
Figure 6. Income-tertile distribution between countries for mortality amenable to health care, 2000, 2010, and 2014
Figure 7. Mortality amenable to health care, by sex, 2014 (or 2013)
Hospitalizations for ambulatory care-sensitive conditions. In light of the growing prevalence of chronic conditions in the Americas, and the associated need to improve health promotion and disease prevention activities, it is a key priority that countries recalibrate their health systems to invest in quality, comprehensive, accessible, and effective primary- and community-care-led services. In most countries of the Region, health services development and investments have largely focused on hospitals and highly specialized, costly technology. This has compromised in many cases the development of the first level of care (). Strengthening the first level of care is essential to achieve universal health as in the Region of the Americas and in the wider global context the availability of quality and effective services in these care settings has long been associated with health systems that are able to respond adequately to the health problems of the people and communities with equity and efficiency (). A first level of care with resolution capacity to provide comprehensive and coordinated care to all, including patients with complex health care needs through multidisciplinary health teams and intersectoral partnerships, is a requirement of a people- and community-centered model of care ().
The assessment of ambulatory care-sensitive conditions (ACSC) evaluates the response capacity of the first level of care in terms of avoidable hospitalizations, under the logic that hospital admissions for conditions such as asthma, diabetes, or hypertension, for example, can be avoided or reduced with better health promotion programs, specific interventions for prevention, and timely access to the first level of care (). Hospitalization for ACSC is an indicator of hospital activity that has proven useful as an indirect measure of the functioning of the first level of care. It can inform the process of decision-making regarding the configuration of integrated health service networks and contributes to the effectiveness of care. Moreover, the assessment of ACSC may provide evidence on the technical quality, effectiveness, and continuity of care. Figures 8a and 8b show the average hospital admission rates for ACSC between 2001 and 2009 for Argentina, Colombia, Costa Rica, Ecuador, Mexico, and Paraguay. Hospitalization rates ranged from 10.8% for Costa Rica to 21.6% for Colombia. Infectious gastroenteritis had the largest share of avoidable hospitalizations in Argentina, Ecuador, and Paraguay, accounting for 33%, 27%, and 22% of all ACSC reported cases, respectively. Lower airway diseases, which comprise diagnoses such as bronchitis and emphysema, occupied the highest percentage of ACS for Colombia and Costa Rica, with an average of 15%. Mexico had by far the highest rate of hospitalizations for diabetes (16%) compared to other countries (average of 5%). The result of this indicator should be interpreted in relation to the situation in each country because the demand for hospitalization in some locations may be related to the availability of resources, epidemiological transition leading to growing prevalence of noncommunicable diseases (NCD), and the deficiencies of the health system. Therefore, it is important to consider other issues affecting the response capacity of the health service network to evaluate this indicator. One goal of PAHO’s Strategic Plan 2014-2019, as agreed by Member States, is to reduce by at least 10% hospitalizations for ACSC in 2019; hence, it is paramount that countries continue measuring and reporting progress in this indicator.
Figure 8. Hospitalizations for ambulatory care-sensitive conditions, selected countries and average 2001–2009
(a) percentage of total
Source: Figure prepared using data in Guanais F, Gómez-Suárez R, Pinzón L. Series of avoidable hospitalizations and strengthening primary health care: primary care effectiveness and the extent of avoidable hospitalizations in Latin America and the Caribbean. Washington, D.C.: Inter-American Development Bank; 2012. Data presented by the respective national health authorities for studies commissioned by the Inter-American Development Bank in 2012.
(b) grouped by condition
Access to essential medicines and other health technologies
Access to medicines and other health technologies remains a priority for Member States. Inequities in access to health services and medicines are still pronounced in LAC countries, and occur both between countries and between different social groups and areas within the same country (). This section provides an overview of some critical indicators and data sources to better understand the current situation on access to safe, quality-assured, and effective pharmaceuticals, biologics including blood and blood products, as well as critical radiological services. For the purpose of this document, medicines and other health technologies include medical products such as pharmaceuticals, biologicals (including blood and blood products), medical devices, and diagnostics.
Countries in the Region have adopted policies and strategies aimed at addressing these inequities and improving access to cost-effective, quality-assured, safe, and efficacious medical products. Comprehensive national policies for medicines and other health technologies are a necessary condition to achieve universal access to health and universal health coverage and thus improve the health and quality of life of the population. Yet, not all countries in the Region have adopted these policies. In 2014, only 13 of 28 surveyed countries had a national pharmaceutical policy (46%), while 18 of 35 countries had a national blood policy (51%).
Having a functional National Regulatory System for medicines and other health technologies is critical for ensuring that the medical products that are introduced to the health systems are quality assured, safe, and effective. Moreover, national regulatory authorities (NRA) act as gatekeepers for the introduction of medical products and are critical in determining the rate of introduction of new products. While the Region has experienced a well-documented improvement in regulatory capacities in many Member States, a significant number of countries have yet to improve their regulatory capacities to the point of being considered functional (Figure 9). Countries with weak regulatory capacities may struggle to ensure the availability of quality-assured products and, consequently, generate a public health risk. In addition, the inappropriate use of medicines and other health technologies jeopardizes the quality of care and/or the efficiency of the health system. The extent of the development of the pharmaceutical sector, the availability of trained human resources and financial resources, and the existence of adequate infrastructure influence the performance of these functions.
Figure 9. Basic medicines regulatory capacity achievement by geographical subregion in the Americas
Source: Bulletin of the Observatory – PRAIS. Year 1, No. 1, March 2014. Basic medicines regulatory capacity in the Americas, Pan American Health Organization.
Pharmaceutical expenditure. The escalating cost of medical products poses a particular challenge for improving equitable access to medicines and other health technologies and to the sustainability of health systems. Costly products have become a very significant portion of medical expenditure. The total pharmaceutical expenditure per capita, as a percentage of the GDP and as a percentage of the total health expenditure (2010–2012), is highly variable among countries (Figures 10a, 10b, and 10c) and, in many cases, a high budgetary burden on health budgets. Importantly, in many countries pharmaceutical expenditure is financed through private out-of-pocket spending, increasing the risk of people incurring financial difficulties, impoverishment, and exposure to catastrophic expenditure (Figure 10d.).
Figure 10. Total pharmaceutical expenditure, selected countries, 2010–2012
(a) as percentage of GDP
(b) per capita (US$)
(c) as percentage of the total expenditure in health
(d) public and private pharmaceutical expenditure per capita (US$)
Diagnostic imaging and radiotherapy. Radiological services are essential for providing comprehensive and quality health care. These services rely heavily on the availability of appropriate and quality medical devices in addition to trained human resources. The Region is benefiting to some extent from advances in diagnostic imaging technologies. Depending on their income level, countries are incorporating state-of-the-art technology to one degree or another, primarily in the private sector. Table 1 presents the total density of complex diagnostic imaging technologies per million inhabitants. It must be noted that the number shown is just a general indicator of the technology reported, but the population’s access to it still depends on many economic and geographic factors, among others. Furthermore, the indicator does not necessarily mean that the technology is used in an efficient manner or that the quality of the services provided is similar in all facilities. To incorporate complex health technologies within health services, it is necessary to consider during the planning process many aspects, including human resources, functioning costs, sustainability, epidemiological data, and geographical circumstances. Proper assessments at the local levels are therefore mandatory before the decision is made.
Table 1. Total density of complex diagnostic imaging technologies per million inhabitants
|Total density per million population: magnetic resonance imaging||Total density per million population: computed tomography units||Total density per million population: positron emission tomography*||Total density per million population: gamma camera or nuclear medicine*|
Source: World Health Organization. Baseline country survey on medical devices, 2014 update. Available from: http://www.who.int/diagnostic_imaging/collaboration/global_collab_maps/en/. Accessed 29 November 2016.
*N/A = not available.
Similarly, radiation therapy has improved significantly in recent years, although some of the Region’s countries still lack the necessary technology and human resources to provide cancer treatment service properly and in a timely manner. Table 2 and Figure 11 show the number of high-energy teletherapy units (cobalt-60 and linear accelerators) per million inhabitants. The use of cobalt-60 units continues to decline, while the use of linear accelerators keeps growing.
Table 2. Number of high-energy teletherapy units (cobalt-60 and linear accelerators) per million inhabitants
|Country||Clinical accelerators||Co-60||Total high-energy teletherapy units||Population (millions) ||High-energy teletherapy units per million inhabitants |
|Antigua and Barbuda||1||0||1||0.1||10.9|
|Saint Kitts and Nevis||0||0||0||0.1||0.0|
|Saint Vincent and the Grenadines||0||0||0||0.1||0.0|
|Trinidad and Tobago||3||2||5||1.3||3.7|
|United States of America||3818||143||3961||325.1||12.2|
|Latin America & the Caribbean||1023||624.665||1023||624.7||1.6|
Source: IAEA/PAHO, 2016. PAHO elaborated from the International Atomic Energy Agency/World Health Organization, Directory of Radiotherapy Centres 2016. Available from: http://www-naweb.iaea.org/nahu/dirac/default.asp. Accessed 29 November 2016.
Figure 11. Number of high-energy teletherapy units (cobalt-60 and linear accelerators) per million inhabitants
Source: IAEA/PAHO, 2016. PAHO elaborated from the International Atomic Energy Agency/World Health Organization, Directory of Radiotherapy Centres 2016. Available from: http://www-naweb.iaea.org/nahu/dirac/default.asp. Accessed 29 November 2016.
Blood and blood services. Universal access to blood transfusions and safe blood products is essential to save lives and improve the health of people who need them. Blood transfusions have been identified as one of the eight key life-saving interventions in health centers that offer emergency obstetric services. Therefore, the Plan of Action for Universal Access to Safe Blood seeks to promote universal, timely access to safe blood in order to save lives and improve the health conditions of all patients who need it (). Transfusions are also necessary for the care of the following: (a) children with severe anemia; (b) patients with hemoglobin disorders such as thalassemia and sickle cell anemia; (c) people injured in accidents; (d) cancer patients; (e) people who undergo major surgery and other surgical interventions such as transplants; and (f) patients with chronic age-related diseases such as bleeding resulting from vascular problems or orthopedic surgery, among other causes. To achieve universal access to safe blood for transfusions, the following key strategies and priorities have been identified:
a) Effective and sustainable integration of national blood programs and services into the national health system to achieve blood self-sufficiency, safety, efficiency, availability, and universal access to blood and blood products;
b) Self-sufficiency in safe blood and blood products through 100% voluntary non-remunerated donations;
c) Quality management in the national blood system and screening for transfusion-transmitted infections; and
d) Health surveillance, hemovigilance, risk management, monitoring, and evaluation.
There is a marked difference in the level of access to blood between low- and high-income countries. The blood donation rate is an indicator for the general availability of blood in a country. The median blood donation rate in high-income countries is 33.1 donations per 1,000 people, compared to 11.7 donations per 1,000 people in middle-income countries and 4.6 donations per 1,000 people in low-income countries. The blood donation rates for 2015 are presented in Figure 12.
Figure 12. Blood donation rate per 1,000 people, selected countries 2015
Source: PAHO, Supply of blood for transfusion in Latin America and Caribbean countries. Washington, D.C.: PAHO; 2015.
An adequate and reliable supply of safe blood can be ensured by a stable base of regular, voluntary, and unpaid blood donors. They comprise the safest group of donors as the prevalence of blood-borne infections is lowest among this set. World Health Assembly resolution WHA63.12 urges all Member States to develop national blood systems based on voluntary unpaid donations and to work towards the goal of self-sufficiency. The percentage of blood collection in LAC by voluntary, replacement, and remunerated blood donations is illustrated in Figures 13a and 13b, respectively.
Figure 13. Percentage of blood collection in selected (a) Latin American countries and (b) Caribbean countries by voluntary, replacement, and remunerated blood donations, 2014.
PAHO/WHO recommends that all blood donations prior to use be screened for HIV, hepatitis B and C, and syphilis (Treponema pallidum). Figure 13c shows the percentage of blood units screened for HIV, hepatitis B, hepatitis C, Chagas (T. cruzi), and syphilis in Latin America in 2014. Figure 1.5.11 depicts the percentage of blood units screened for HIV, hepatitis B, hepatitis C, HTLV I-II, and syphilis in the Caribbean in 2014.
Figure 13. Percentage of blood units screened for HIV, hepatitis B, hepatitis C, Chagas, and syphilis, selected (c) Latin American countries and (d) Caribbean countries, 2014
Health financing and elimination of direct payments
Public expenditure in health
Countries in the Region agreed to increase public expenditure in health up to at least 6% of their GDP as a necessary condition to reduce inequalities and increase financial protection within the framework of universal health (). One of the most common and informative indicators to determine the sustainability of changes to health care spending is the ratio of health care spending relative to the size of the economy (GDP). Moreover, increased public investment in health is associated with reductions in mortality rates and prolonged life expectancy (). The data presented in Chapter I demonstrate that public expenditure in health is also a fundamental factor for improving health outcomes and financial protection in the Region of the Americas.
In 2014, total health spending accounted for 14.2% of GDP on average for the Region of the Americas, though Uruguay, Costa Rica, Canada, United States, and Cuba were the only countries in the Region that allocated 6% or more of their GDP to public expenditure in health (Figure 14a). Twenty-two countries in the Region witnessed growth in their public expenditure in health to GDP ratio between 2010 and 2014 (Figure 14b). Ecuador, Paraguay, Dominican Republic, Bolivia, Nicaragua, and Peru experienced the highest percentage increases during the period. Despite these improvements, percentage increases in the 22 countries were smaller compared to the 2005-2010 period, with the exception of Bolivia, Peru, and Uruguay. Many countries in the Region experienced cuts ranging from 2% to 36% in public spending in health to GDP in the 2010-2014 period. The amount that countries spent on health varied across the Region of the Americas between 2010 and 2014. Several factors explain the differences observed: income (GDP per capita), population age structure and epidemiological patterns, progress in health technologies, health systems characteristics, and the economic crisis in 2008.
Figure 14. Public expenditure in health:
(a) as a percentage of GDP, 2014
(b) percentage change from 2005–2010 to 2010–2014
Source: Figures prepared by authors based on data from WHO Global Health Expenditure Database (GHED), accessed October 2016.
Out-of-pocket health expenditure
Out-of-pocket health expenditure constitutes payments made by an individual or households at the point of service, including gratuities and in-kind payments in formal settings (clinic, hospital, pharmacy) or informal settings (complementary medicine), while deducting any refund. It is a part of private health expenditure. The burden of out-of-pocket spending in health creates barriers to access health care services in the Americas. The share of households directly financing health spending varied considerably across the Region in 2014, ranging from as little as 4% of total health spending in Cuba to as high as 64% in Venezuela (Figure 15). Between 2010 and 2014, out-of-pocket health expenditure grew by up to 172% in St. Vincent and the Grenadines, Argentina, Guyana, Venezuela, and Nicaragua, and declined by up to 36% in the Dominican Republic, Peru, Bolivia, and Paraguay. The data need to be interpreted with caution, however, as country data may differ in terms of definitions, data collection methods, population coverage, and estimation methods used.
Figure 15. Out-of-pocket health expenditure by country: (a) 2014; (b) percentage change from 2005–2010 to 2010–2014
Health care capacity and activities
Human resources for health
Achieving universal health not only requires policy efforts to ensure an appropriate density of human resources for health (HRH), but also to focus on ensuring an even geographic and social distribution. Offering better economic incentives and work conditions in remote and underserved areas, limiting transnational migration, reshaping education programs to fit the new models of care, and improving quality and performance of the health personnel are necessary conditions to meet the health needs of the population along their life course with an intersectoral, intramural, and extramural approach ().
Minimum availability of health personnel. The World Health Organization established a parameter of 25 health personnel per 10,000 population as the minimum availability of human resources required to achieve high coverage of essential public health interventions (). In 2015, the Region of the Americas met the minimum recommended availability of health personnel with an average of 70 physicians and nurses per 10,000 population and 35 countries and territories reached the target of 25 doctors and nurses per 10,000 population (Figure 16). Nevertheless, values varied widely across countries. Cuba had by far the highest number of physicians and nurses (around 158 per 10,000 population), followed by the United States, Canada, Cayman Islands, and Martinique. Meanwhile, 10 countries did not reach the target of 25 doctors and nurses per 10,000 population: Belize, Brazil, Bolivia, Guatemala, Haiti, Honduras, Jamaica, Nicaragua, Guyana, and Venezuela. Among these countries, Bolivia, Guatemala, Haiti, and Honduras had deficits of health personnel with less than 15 physicians and nurses per 10,000 population, which represents less than 60% of the minimum availability recommended.
Figure 16. Availability of physicians and nurses per 10,000 population, circa 2015
Source: PAHO, Basic indicators: health situation in the Americas, 2016. Data may be underestimated. Data refer to physicians and professional nurses. The occupational category “midwives” was not considered to ensure comparability between countries. Certified nurses do not include auxiliary and unlicensed personnel.
Distribution of health workers. Universal health also requires an adequate distribution of the health work force, especially in the first level of care and remote areas, to ensure proper access according to need (). Difficulties in recruiting and retaining health personnel are often geographical (rural areas, dispersed populations, distance from metropolitan centers) and cultural (i.e., native populations) (). Many countries in the Region are implementing programs to encourage health personnel to work in remote areas, many of which have been successful in increasing the availability of health personnel in rural and underserved locations. Examples include programs in Colombia (Mandatory Social Service [SSO for its Spanish acronym]), Brazil (Mais Médicos [More Doctors] Program), Peru (Rural and urban-marginal health service [SERUMS]), Costa Rica (Articles 10 and 19 of Costa Rica’s Law on Incentives), and Mexico (Programa de Calidad, Equidad y Desarrollo en Salud (PROCEDES) [Programme for Quality, Equity and Development in Health]) (). Despite the efforts and progress achieved, problems with the uneven distribution of health personnel persist across the Region (Figure 17). For instance, the level of physicians and nurses between subnational jurisdictions in the United States varied from 81.8 to 170.4 per 10,000 population in areas with the lowest density vs. highest density. In Canada, while the disparities in the distribution of physicians and nurses decreased from 2011 to 2015, the density of health personnel was still unequal between subnational jurisdictions with the lowest and highest density (81.5 to 142.2 per 10,000 population, respectively). In addition, countries such as Bolivia, El Salvador, Panama, Paraguay, and Peru were still facing challenges in both the availability and distribution of health personnel in 2012/2013.
Figure 17. Regional distribution of health personnel, range between geographical jurisdictions
United States: U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. The U.S. Health Workforce – State Profiles, Rockville, Maryland; 2014; Canada: Canadian Institute for Health Information (CIHI), Physicians in Canada, 2015: Chartbook, Ottawa, ON: CIHI; 2016 & Health Workforce Database, Regulated nursing workforce by health region, 2006, 2011 and 2015, Canadian Institute for Health Information; Statistics Canada; Panama: Ministerio de Salud 2013, cited in Carpio, Carmen; Santiago Bench, Natalia. 2015. The health workforce in Latin America and the Caribbean: an analysis of Colombia, Costa Rica, Jamaica, Panama, Peru, and Uruguay. Directions in Development–Human Development. Washington, D.C.: World Bank. © World Bank. https://openknowledge.worldbank.org/handle/10986/22027.
Note: MRA: Minimum recommended availability of 25 health personnel per 10,000 population./span>
When comparing the distribution of health personnel in rural versus urban areas in some countries of the Region, the percentage of physicians is up to 80 percentage points higher in urban areas, compared to rural (or nonmetropolitan) areas (Figure 18). For instance, in the United States, while primary care physicians are more likely to practice in rural areas than nonprimary care specialists, primary care doctors still are more concentrated in urban areas (22.5% vs. 77.5%, respectively). Within the primary care work force, nurse practitioners are more likely than physicians to work in rural areas (16% vs. 11%). PAHO’s Department of Health Systems and Services has assisted in conducting two assessments of goals for human resources for health development in 24 countries in the Region (). One of the Regional targets calls for a reduction of at least 50% in disparities in the geographic distribution of health workers (physicians, nurses, and midwives). Results from the last measurement show that in 2013, only Costa Rica and Nicaragua achieved the target, while seven countries made progress in relation to the first measurement: including Bolivia, Dominican Republic, El Salvador, Guatemala, Honduras, Paraguay, and Peru (Figure 19).
Figure 18. Disparities in the distribution of physicians per 10,000 population, rural vs. urban areas and selected countries
Source: Prepared using data from Bolivia: Segunda Medicion 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: data for the United States correspond to physicians working in primary care.
Figure 19. Percentage of progress in the reduction of regional disparities in the distribution of health personnel, selected countries, 2009-2013
Source: Prepared using data from the Regional Goals for Human Resources for Health 2007-2015: Final Report, 54th Directing Council, Washington, D.C., Sept. 2-15 (CD54/INF/1). Data refer to progress (measured in percentage) in the reduction of at least 50% in the number of health workers (physicians, nurses, and midwives) between subnational jurisdictions having a lower density of health workers than the national density. The main limitation of this indicator is the availability of reliable and valid data for the number of medical doctors, nurses, and midwives nationally and in each subnational jurisdiction.
Ratio of nurses to physicians. On average across countries in the Americas, there were 48.7 nurses per 10,000 population in 2015 (Figure 20a). North America had by far the highest density of nurses, which was more than 7 times higher than in LAC (110.9 vs. 13.6 per 10,000 population). The United States, Canada, Martinique, and Cuba had the highest density of nurses (81.3 to 111.4 per 10,000 population), while Argentina, Dominican Republic, Haiti, and Honduras had the lowest density (3.5 to 3.8 per 10,000 population). A minimum ratio of one qualified nurse for one qualified doctor is recommended to ensure proper competency of health care teams, with a higher ratio recommended in the first level of care ().
Figure 20. Status circa 2015: (a) nurses per 10,000 population; (b) ratio of nurses to physicians
In 2015, nurses outnumbered physicians in most countries in the Region with an average of 2.4 nurses per each physician, though the nurse-to-physician ratio ranged from 0.1 nurses per physician in Haiti to 6.9 nurses per physician in Montserrat (Figure 20b). While most countries reached the set minimum nurse-to-physician ratio of 1:1, Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, Uruguay, and Venezuela had more doctors than professional nurses.
The results presented here need to be interpreted within the context of each country. The dependency of the health system on health personnel not only varies according to the composition and distribution of HRH, but also the epidemiological patterns and cultural characteristics that shape and create the demand for different and new capabilities. Further, the data presented here combine the availability of physicians and professional nurses. The occupational category “midwives” was not considered to ensure comparability between countries; consequently, the total number of health personnel in each country (nurses, physicians, and midwives) can be underrepresented. Data collection varies from country to country, depending on the national planning cycle, and further limits the interpretation of the data.
Health care services capacity and utilization
Hospital beds ratio. The hospital beds ratio measures the number of hospital beds available per every 1,000 population, for a stated year, for a given country, territory, or geographic area. The indicator provides a metric of the resources available for delivering services to inpatients in hospitals. In 2014, the number of hospital beds per 1,000 population was particularly highest among English Caribbean countries in the Region, and Argentina (Figure 21a). Barbados, Montserrat, Bermuda, Cuba, and Guadalupe had the highest number of beds with more than 5 beds per 1,000 population. On the other hand, Nicaragua, Haiti, Honduras, and Turks and Caicos Islands had the lowest hospital beds ratio, with less than 1 bed per 1,000 population. The number of hospital beds slightly increased in many countries in the Region from 0.3 to 1.6 more beds per 1,000 population in 2014 compared to 2010 (Figure 21b). Antigua and Barbuda, Cayman Islands, Trinidad and Tobago, and Argentina had the largest increases (0.9 to 1.6 extra beds per 1,000 population). In contrast, Barbados and Cuba experienced the highest decreases in the number of beds per 1,000 population (0.8 and 0.7 less beds per 1,000 population, respectively). There is no standard for the necessary number of beds for hospital settings; thus, the interpretation of the data presented here needs to be further evaluated in terms of the particular context and characteristics of each health system and country. The necessary number of hospital beds depends on a variety of factors, such as changes in epidemiological patterns and the age structure of the population, which may increase the need for hospitalizations. Improvements in efficiency of diagnosis and treatment also play a role in reducing the need for hospital beds, while in some countries, cuts in health budgets lead to reductions in hospital capacity as a strategy to reduce costs. Furthermore, redefining the model of care to one that prioritizes the role of the first level of care can lead to reductions in the need of hospital capacity (). Finally, determining the number of hospital beds does not provide an indication of the necessary hospital infrastructure by itself as other factors, including the health personnel, equipment, and medicines, are also important to ensure the capacity of hospitals to deliver proper care.
Figure 21. Hospital beds ratio per 1,000 population, 2014 (or 2013)
(a) 2014 (or 2013)
(b) ratio change from 2010 to 2014 (or nearest year)
Source: Prepared using data from PAHO, Core Health Indicator Database [retrieved in October 2016]. Data for Bahamas, Chile, Ecuador, French Guiana, Guadaloupe, Haiti, Panama, Puerto Rico and United States correspond to 2013. Data in Figure 21a for Bolivia, Colombia, Grenada, and Uruguay refer to 2011 and 2014.
Hospital discharge rate. The hospital discharge rate is an estimate of the degree of utilization of in-patient health care services It measures the formal release of hospitalized individuals (per year per 1,000 population) due to death, return home, or transfer to another institution. Several factors affect the hospital discharge rate in a country, including the capacity of hospitals to treat individuals, the ability of the first level of care to prevent avoidable hospitalizations, and aging and epidemiological patterns of the population that may increase the demand for hospitalizations (). In 2014, hospital discharge rates were highest among the English Caribbean countries in the Region, and for Uruguay (Figure 22a). French Guyana, Guadeloupe, and Cayman Islands had the highest hospital discharge rates (249, 196, and 127 per 1,000 population, respectively), while Colombia, Paraguay, and Honduras had the lowest rates (33.5, 37.2, and 42 per 1,000 population, respectively). Data available from selected countries in 2010 and 2014 (or closest year) show that Uruguay had the highest increase in hospital discharge rates by about 43 hospitalizations per 1,000 population, followed by Guadeloupe and Cuba with increases of about 23 and 14 hospitalizations per 1,000 population, respectively (Figure 22b). On the other hand, Montserrat, Turks and Caicos Islands, and the British Virgin Islands experienced the highest decrease in hospitalization rates (41.3, 36.7, and 20.6 per 1,000 population, respectively). The implications of the data presented here need to be further studied in terms of the efficiency, quality, opportunity, and equity of health services delivery in each country. Indeed, the data need to be interpreted with caution. The number of hospitalizations is based on public institutions only and may exclude hospitals within the public network, which results in underestimations in the data. There also exist variations across countries in the coverage and definition of the hospitalizations affecting comparability of the data. Furthermore, other important indicators of hospital activity and efficiency, such as occupancy rate and average length of stay, are not included here (as there is no common source of information for all countries in the Region), further limiting the interpretation of findings.
Figure 22.Hospital discharge ratio per 1,000 population: (a) 2014 (or 2013); ratio change from 2010 to 2014 (or nearest year)
Source: Prepared using data from PAHO, Core Health Indicator Database. Data retrieved in October 2016. Data for Bahamas, Barbados, Bermuda, Canada, Chile, Colombia, Ecuador, French Guiana, Guadaloupe, Jamaica, Mexico, Panama, Paraguay, Puerto Rico, Saint Lucia, and Saint Vincent & the Grenadines correspond to the year 2013. Data in Figure 3.2.4 for Bahamas, Canada, Chile, Colombia, Ecuador, Guadaloupe, Mexico, and Puerto Rico compares 2011 vs. 2013.
Outpatient health care visits ratio. The outpatient health care visits ratio is defined as the number of outpatient health care visits per every 1,000 inhabitants, in a given year, for a given country, territory, or geographic area (). Outpatient visits include curative, preventive, and specialized services at emergency departments in hospitals and physicians’ offices, which may in turn include tests, procedures, and even minor surgery as long as it does not require hospitalization. Furthermore, many factors drive outpatient health care utilization, including changes in the age distribution of the population, policy initiatives and the availability of human resources, supplies, and payment methods. Consequently, the rate of outpatient visits does not fully describe what type of services are being provided and thus cannot be used as a proxy of either access to specific services or quality of care (). Nevertheless, monitoring outpatient visit trends can bring attention to areas that need to be further evaluated in terms of the quality, opportunity, and equity of specific health services.
Figure 23. Outpatient health care visits ratio per 1,000 population, 2014, 2012, and 2010 (or closest years)
Source: Prepared using data from PAHO, Core Health Indicator Database. Data retrieved in October 2016.
WHO/PAHO country offices and technical Regional programs provide the data reported by the national health authority. Data come mainly from administrative sources.
In 2013 and 2014, the number of outpatient consultations in 29 countries of the Region ranged from about 195 per 1,000 population in St. Vincent and the Grenadines to 9,657 in Cuba (Figure 23). Outpatient visits were highest in Cuba, Brazil, Chile, and Uruguay and lowest in St. Vincent and the Grenadines, St. Martin, Haiti, and Dominican Republic. Overall, the rate of outpatient visits increased for most countries studied between 2010 and 2014 (or closest year). Data available for Argentina, Brazil, Chile, Guatemala, Jamaica, and Mexico plotted by income quintile distribution for outpatient services show higher use by the rich population, although inequalities decreased over time in the countries studied (Figure 24). Compared with outpatient services, the proportion of the population receiving inpatient services in all countries was much smaller, and most hospital services were equally distributed among the rich and poor, or show a slight pro-rich inequality, with a greater pro-rich inequality in Guatemala and Jamaica. The data need to be interpreted with caution, however. There are variations across countries in the coverage and definition of these consultations, notably in outpatient departments of hospitals, which hinders comparability of the data. Figures are estimated based on public institutions only, and in some cases exclude institutions within the public network.
Figure 24. Income quintile distribution of inpatient and outpatient visits, selected countries.*
Source: Prepared using data from Dmytraczenko T, Almeida G, eds. 2015. 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. *Inpatient visits refer to hospital services that require at least one night of hospitalization.
Access to preventive health services improved in the Region, but further efforts are necessary to increase access to comprehensive care and address persisting inequities:
- Nearly all countries in the Region have reached universal (or near universal) aggregate coverage for maternal and child health interventions, except for the poorest countries. While these indicators show overall improvements, inequities in wealth and other social determinants of health persist and have a significant impact on health and access to health services.
- Data available show many countries in the Region have reached high levels of population coverage of health insurance, but that did not always translate into high levels of utilization of preventive health care services or low levels of access barriers. Levels of utilization of adult preventive health care services varied across countries studied from 21.04% to 76.3%. In most countries studied, the utilization of preventive health care services increased over time and was accompanied by improvements in wealth inequities, though with persistent gaps between the poorest and richest families. Meanwhile, the percentage of the population reporting access barriers varied greatly among countries (from 6.8% to 66%) and was highest in the poorest households.
The quality of health care has improved, but progress has been uneven in the Region:
- Mortality amenable to health care has reduced in most countries from 2010 to 2014, reflecting improvements in the quality of health care in the Americas, but it has also risen in non-Latin Caribbean countries indicating the need for greater efforts to improve quality of health service delivery.
- Infectious gastroenteritis, lower airway diseases, and diabetes were the main drivers of avoidable hospitalizations between 2001 and 2009.
About one-third of countries in the Americas have yet to meet the minimum recommended availability of 25 health workers of per 10,000 population:
- The following 10 countries did not reach the target of 25 doctors and nurses per 10,000 population: Belize, Bolivia, Brazil, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, and Venezuela.
- Despite the efforts and progress achieved by other countries, problems with the uneven distribution of health personnel persist across the Region, while other countries face challenges regarding both the availability and distribution of health personnel.
Health expenditure shows significant variations across countries in the Region with minimal progress in terms of public spending:
- Canada, Costa Rica, Cuba, United States, and Uruguay and are the only countries in the Region that allocate more than 6% of their GDP to public expenditure in health. Twenty-two countries in the Region witnessed growth in their public expenditure in health to GDP ratio between 2010 and 2014, but at a smaller percentage increase compared to the 2005-2010 period, except for Bolivia, Peru, and Uruguay.
- Health spending directly paid by people remains high across most countries in the Americas. More than half of the countries reduced out-of-pocket health expenditure by up to 36% between the 2010-2014 period, while others experienced an increase.
- The total pharmaceutical expenditure is highly variable among countries studied and, in many countries it is financed through private out-of-pocket spending, increasing the risk of people incurring financial difficulties, impoverishment, and exposure to catastrophic expenditure.
1. Pan American Health Organization. Strategy for universal access to health and universal health coverage. 53rd Directing Council of PAHO. Washington, D.C., 2014 Sep 29–Oct 3 (CD53.R14). Available from: https://www.paho.org/uhexchange/index.php/en/uhexchange-documents/technical-information/26-strategy-for-universal-access-to-health-and-universal-health-coverage/file.
2. World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: WHO; 2010. Available from: http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf.
3. Pan American Health Organization. Monitoring framework and tool for universal health. Washington, D.C.: PAHO; In press.
4. The PLOS Medicine Editors. Monitoring universal health coverage collection: managing expectations. PLOS Medicine 2014;11(9):e1001732.
5. World Health Organization, World Bank. Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets. Geneva: WHO; 2014. Available from: http://apps.who.int/iris/bitstream/10665/112824/1/WHO_HIS_HIA_14.1_eng.pdf?ua=1.
6. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Medical Care 1981;19(2):127–140.
7. Thorpe JM, Thorpe CT, Kennelty KA, Pandhi N. Patterns of perceived barriers to medical care in older adults: a latent class analysis. BMC Health Services Research 2011;11:181.
8. Noordman J, Koopmans B, Korevaar JC, Van der Weijden T, Van Dulmen S. Exploring lifestyle counselling in routine primary care consultations: the professionals’ role. Family Practice 2013;30(3):332–340.
9. Gravelle H, Morris S, Sutton M. Are family physicians good for you? Endogenous doctor supply and individual health. Health Services Research 2008;43(4):1128–1144.
10. Dmytraczenko T, Almeida G. 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 Pan American Health Organization; 2015. Available from: https://openknowledge.worldbank.org/bitstream/handle/10986/22026/9781464804540.pdf?sequence=2&isAllowed=y.
11. United Nations. The Millennium Development Goals report 2015. New York: UN; 2015. Available from: http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20%28July%201%29.pdf.
12. Requejo JH, Bhutta ZA. The post-2015 agenda: staying the course in maternal and child survival. Archives of Disease in Childhood 2015;100(S1):S76–S81.
13. Colson KE, Zúñiga-Brenes P, Ríos-Zertuche D, Conde-Glez CJ, Gagnier MC, Palmisano E, et al. comparative estimates of crude and effective coverage of measles immunization in low-resource settings: findings from Salud Mesoamérica 2015. PLoS ONE 2015;10(7):e0130697.
14. Ng M, FullmanN, DielemanJL, Flaxman AD, Murray CJL, Lim SS. Effective coverage: a metric for monitoring universal health coverage. PLOS Medicine 2014;11(9):e1001730.
15. Pan American Health Organization. Strategic plan of the Pan American Health Organization 2014–2019, compendium of indicators. 52nd Directing Council of PAHO, 65th Session of the WHO Regional Committee for the Americas, Washington, D.C., 2013 Sept. 30–Oct. 4 (OD345). Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=27015&Itemid=270&lang=en.
16. Pan American Health Organization. Integrated health service delivery networks concepts, policy options and a road map for implementation in the Americas. Washington, D.C.: PAHO; 2011. Available from: https://www.paho.org/hq/dmdocuments/2011/PHC_IHSD-2011Serie4.pdf.
17. World Health Organization. The world health report 2008: primary health care (now more than ever). Geneva: WHO; 2008. Available from: http://www.who.int/whr/2008/en/.
18. Pan American Health Organization. Renewing primary care in the Americas: a position paper of the Pan American Health Organization. Washington, D.C.: PAHO; 2007. Available from: https://www.paho.org/hq/dmdocuments/2010/Renewing_Primary_Health_Care_Americas-PAHO.pdf.
19. Saltman R, Rico A, Boerma WGW. Primary health care in the driver’s seat: organizational reform in European primary care. New York: European Observatory of Health Systems and Policies; 2006. Available from: http://www.euro.who.int/__data/assets/pdf_file/0006/98421/E87932.pdf.
20. Starfield B. Primary care: balancing health needs, services and technology. New York: Oxford University Press; 1998.
21. Beaglehole R, Epping-Jordan J, Patel V, Chopra V, Ebrahim S, Kidd M, et al. Improving the prevention and management of chronic disease in low- and middle-income countries: a priority for primary care. The Lancet 2008;372(9642):940–949.
22. Pan American Health Organization. Plan of action for universal access to safe blood. 53rd Directing Council of PAHO, 66th Session of the WHO Regional Committee for the Americas, Washington, D.C., 2014 Sept. 29–Oct. 3 (CD53/6). Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=34262&lang=en.
23. Novignon J, Olakojo SA, Nonvignon J. The effects of public and private health care expenditure on health status in sub-Saharan Africa: new evidence from panel data analysis. Health Economics Review 2012;2:22.
24. World Health Organization. World health report 2006: working together for health. Geneva: WHO; 2006. Available from: http://www.who.int/whr/2006/whr06_en.pdf.
25. Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bulletin of the World Health Organization 2013;91(11):853–863.
26. Gravelle H, Sutton M. Inequality in the geographical distribution of general practitioners in England and Wales 1974–1995. Journal of Health Services Research Policy 2001;6(1):6–13.
27. Stapleton G, Schröder-Bäck P, Brand H, Townsend D. Health inequalities and regional specific scarcity in primary care physicians: ethical issues and criteria. International Journal of Public Health 2014;59:449–455.
28. Carpio C, Bench-Bench N. The health workforce in Latin America and the Caribbean: an analysis of Colombia, Costa Rica, Jamaica, Panama, Peru, and Uruguay. Directions in Development–Human Development. Washington, D.C.: World Bank; 2015. Available from: https://openknowledge.worldbank.org/handle/10986/22027.
29. Molina J, Tasca R, Suárez J. Monitoring and evaluation of the PAHO/WHO cooperation project, the Mais Médicos (More Doctors) Program: a mid-term assessment. Ciência & Saúde Coletiva 2016;21(9):2925–2933.
30. Pan American Health Organization. Regional goals for human resources for health 2007–2015: final report. 54th Directing Council, 67th Session of the Regional Committee of WHO for the Americas Washington, D.C., 2015 Sept. 2–15 (CD54/INF/1). Available from: http://iris.paho.org/xmlui/handle/123456789/28426.
31. McKee M. Reducing hospital beds: what are the lessons to be learned? Copenhagen: World Health Organization/European Health Observatory on Health Systems and Policies; 2004. Available from: http://www.euro.who.int/__data/assets/pdf_file/0011/108848/E85032.pdf.
32. McKee M. What are the lessons learnt by countries that have had dramatic reductions of their hospital bed capacity? Copenhagen: World Health Organization; 2003. Available from: http://www.euro.who.int/document/hen/hospitalbeds.pdf.
33. Organization for Economic Co-operation and Development. Health at a glance 2015: OECD indicators. Paris: OECD; 2015. Available from: http://apps.who.int/medicinedocs/documents/s22177en/s22177en.pdf.
34. Pan American Health Organization. Basic indicators glossary. In: Data and statistics [Internet]; 2016. Available from: https://www.paho.org/hq/index.php?option=com_content&view=article&id=2470&Itemid=2003.
35. Bernstein AB, Hing E, Moss AJ, Allen KF, Siller AB, Tiggle RB. Health care in America: trends in utilization. Hyattsville: National Center for Health Statistics; 2003. Available from: https://www.cdc.gov/nchs/data/misc/healthcare.pdf.
1. This value is based on data available from 38 countries that reported in 2014 and 2013 to the PAHO Health Information Platform for the Americas.
2. Refers to subnational jurisdictions (state, province, or Region) having the lowest and highest density of health workers than the national density.
3. A hospital is defined as any medical facility with an organized medical and professional staff and beds available for continuous hospitalization of patients formally admitted to it for medical observation, care, diagnosis, or surgical and nonsurgical treatment.