The quest for universal health: summary of indicators on health systems performance

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 (4, 5). 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 (6). 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 (7). 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

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 (8, 9). Furthermore, it is expected that all adults have at least one preventive health care visit every year (10). 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 (11). 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 (12).

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 (13). 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 (14). 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 (7).

Figure 4. Evolution of income-quintile distribution of maternal health interventions, selected countries and years

4a

4b

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 (15). 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.¹ 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 )

5a

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).

5b

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 (16). 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 (17-20). 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 (21).

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 (15). 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

(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 (10). 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

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

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

Figure 11. Number of high-energy teletherapy units (cobalt-60 and linear accelerators) per million inhabitants

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 (22). 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

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.

(a)

(b)

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

(c)

(d)

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