Values and principles of universal health
The Strategy for Universal Access to Health and Universal Health Coverage is based on the core values of the right to health, equity, and solidarity (). Throughout the world, embracing these values has been a lengthy process—one that has had a very positive reception in the Region of the Americas in the context of the human rights and social justice movement. The right to health is recognized in the constitution of 19 countries in the Region, guiding the development of strategies, plans, and policies in health and social protection. Nevertheless, differences in the limited information on health access and outcomes (disaggregated by the characteristics of population groups) reveal marked disparities in people’s ability to exercise this right. This is why equity is a value that forms part of the right to health. Solidarity can be considered a guiding value of social protection—society’s effort to ensure that the situation of people in conditions of greater vulnerability can be improved by redistributing the wealth of the more privileged. This implies that the healthy make common cause with the sick, the young, and the elderly, as well as the rich with the poor. Solidarity becomes a reality through financing mechanisms that distribute risk and prevent impoverishment from unanticipated health expenditures.
This section presents an overview of these values and examines the progress made in the Region during the period. It also identifies and analyzes the challenges to steady progress in a complex situation of political, social, and economic change; technology development; and growing social engagement.
Brief historical outline
The public’s participation in different types of organizations, coupled with social policy trends, particularly in labor and health, explain how these values have been embraced in terms of social development in Latin America and the Caribbean. Health coverage was originally conceived in association with terms of employment, giving rise to a segmentation that still affects the health system’s performance. In retrospect, the segmentation of the health system was a negative design externality of the modalities for expanding health coverage. At the same time, the criteria for social security eligibility led to the exclusion of people who were not in the workforce, as well as informal workers and their families, creating inequity in access and outcomes.
Health systems have since evolved, sometimes increasing segmentation and creating fragmentation with the well-intentioned goal of improving the access and coverage of specific population groups. Nevertheless, in the process, the notion and value of health as a social right began to gain ground. Some authors have identified four stages in this process:
- The period prior to the creation of national health institutions (from independence to the creation of a ministry of health or similar agency).
- The creation of modern national health institutions (ministries of public health and social security institutions).
- The growing delivery of health benefits to the nonsalaried poor, in tandem with further segmentation of the health system.
- The search for equity, characterized by reforms aimed at equalizing the health benefits received by different population groups and offering financial protection against catastrophic and impoverishing expenditure. Two experiences that marked the beginning of this stage were the creation of Chile’s National Health Services in the early 1950s and the full integration of Cuba’s health system in the 1960s ().
Guaranteeing the right to health: an unfinished agenda in the Region of the Americas
The right to health is a value enshrined in the Universal Declaration of Human Rights () and explicitly stated in the Constitution of the World Health Organization (WHO) of 1946: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political ideology, or economic or social condition” (). Subsequently, the International Covenant on Economic, Social, and Cultural Rights, adopted in 1966, represented progress, with Article 12 on the right to health specifying the steps to be taken by the States Parties to achieve full realization of this right—steps that included the creation of conditions that would ensure medical services and medical attention to all in the event of sickness, thus making the social protection of health one of the hallmarks of a system that honors the right to health (). In 2000, Article 12 (“The right to the highest attainable standard of health”) of General Comment No. 14 of the Committee on Economic, Social, and Cultural Rights highlighted other characteristics in addressing the substantive issues related to application of the International Covenant on Economic, Social, and Cultural Rights ().
The right to health should be understood as the right to the enjoyment of a wide range of facilities, goods, services, and conditions necessary for achieving the highest attainable standard of health. It should not be understood as the right to be healthy, since that depends on a series of personal factors, both genetic and behavioral.
General Comment No. 14 indicates two areas that contribute to the enjoyment of the right to health. First, it states that the health system is expected to provide services that are accessible (understood as nondiscriminatory, physically accessible, affordable, and with access to information), acceptable, and of good quality. Second, it recognizes the need for intersectoral efforts to guarantee other rights that complement health system efforts to meet the health needs of the population. The Comment notes that population health outcomes depend on the existence of a series of underlying determinants and the manner in which they are approached, including water and sanitation conditions, diet, nutrition, housing, occupational and environmental health, education, and infrastructure. Thus, guaranteeing the right to health requires States to address these rights, which not only have intrinsic value but directly affect the health of the population.
In terms of social development, recognizing the complementarity of the Millennium Development Goals (MDGs), the Economic Commission for Latin America and the Caribbean (ECLAC) has indicated that poverty, malnutrition, and hunger are determinants of the health of the population that hinder the enjoyment of health as a civil right ().
The committees charged with monitoring human rights conventions periodically visit their member countries. During these visits, they consult with public and private entities working in this area to learn about the situation, progress, and constraints to strict fulfillment of government commitments. The guarantee of the right to health is affected by other related rights. Thus, a review of the reports from these visits yields an overview of the progress made and areas that need strengthening in health and other sectors. It is critical that the national health authority be familiar with the reports of the committees that review and inform on progress in fulfilling the commitments made by its government in human rights instruments and treaties. These committees provide important information for improving the health system response and strengthening intersectoral action for progress toward universal health. Table 1 lists entities that monitor and observe fulfillment of the guarantee of health-related rights in the Region.
Table 1. Relevant reports on the guarantee of the right to health
|International Covenant on Civil and Political Rights||Committee on Human Rights|
|International Convention on the Elimination of All Forms of Racial Discrimination||Committee for the Elimination of Racial Discrimination|
|Convention on the Elimination of All Forms of Discrimination against Women||Committee for the Elimination of Discrimination against Women|
|Economic and Social Council||Committee on Economic, Social, and Cultural Rights|
|Convention on the Rights of the Child||Committee on the Rights of the Child|
|Convention on the Rights of Persons with Disabilities||Committee on the Rights of Persons with Disabilities|
The advocacy of the past five years has been accompanied by significant progress in public policy-making and legislation to guarantee the right to health in the Region. The Information System on Early Childhood (SIPI) in Latin America, sponsored by the United Nations Children’s Fund (UNICEF), monitors enforcement of the rights of young children in Latin America. With regard to health, SIPI monitors compliance with the articles of the Convention on the Rights of the Child () concerning the health conditions of young children; maternal and newborn health care; nutrition and breastfeeding; access to timely, quality health services; the right to family planning services; and children with HIV/AIDS. The following events in the period 2010–2015 should be noted:
- Chile. Law No. 20595 (2012), creating the Ethical Household Income program, establishes conditional subsidies and transfers to extremely poor households and creates a subsidy for women’s employment. Within this framework, the Healthy Child Checkup Subsidy was created as a conditional monetary transfer initiative under the Ethical Household Income program. Its purpose is to guarantee access to health services for children under 6 from extremely poor households through an economic incentive. The subsidy is conditional to the verification of scheduled health checkups ().
- Dominican Republic. Decree No. 102 (2013), which declares the protection and comprehensive care of all people aged 0-5 years residing in the nation’s territory to be a matter of high national interest ().
- Paraguay. Law No. 4698, the Early Childhood Nutrition Guarantee Act (2012). The purpose of this legislation is to guarantee prevention, care, and control of malnutrition in all children under 5 and pregnant women (from the third month of pregnancy to six months postdelivery) who are poor, underweight, and suffering from malnutrition or any nutritional vulnerability ().
- Peru. Law No. 30021, Law Promoting a Healthy Diet for Children and Adolescents (2013). The purpose of this legislation is to promote and protect the population’s right to public health and adequate growth and development through education, the promotion of greater physical activity, the creation of healthy food stands and lunch rooms in regular basic education institutions, and the supervision of advertising, information, and other practices connected with the sale of food and nonalcoholic beverages for children and adolescents to reduce and eliminate overweight- and obesity-related conditions and chronic noncommunicable diseases ().
Other countries that have legislated to protect the right to health in the past 5 years include the following:
- Colombia. This country enacted Statutory Law No. 1751/2015, which guarantees the basic right to health and establishes regulations and measures to protect it (). It also enacted Law 1804/2016, establishing the Government policy of “integrated early childhood development from age 0 onward,” aimed at strengthening the institutional framework for recognizing, protecting, and guaranteeing the rights of both pregnant women and children aged 0-6 years, as well as establishing the Social Welfare State ().
- Mexico. In December 2014, Mexico published the General Law on the Rights of Children and Adolescents, which recognizes that children and adolescents have rights. It includes a section on the right to health protection and social security, indicating that children and adolescents have the right to the enjoyment of the highest attainable standard of health and to receive free, quality health services to prevent disease and protect and restore their health, together with the right to social security. This piece of legislation will make this priority right a reality for children and adolescents, work in their best interests, and guarantee substantial equality and nondiscrimination ().
- Puerto Rico. The Right to Health in Puerto Rico Act was amended in May 2016 to create the Fund for Services for Remediable Catastrophic illnesses ().
PAHO’s collaboration with the Member States to guarantee the right to health for different population groups is reflected in both the development of strategies based on the right to health and the recommendation to draft national legislation consistent with the international legal framework in health. Prior to adopting Resolution CD50.R8 (“Health and Human Rights”) in 2010, in which the Member States of PAHO committed to intensifying efforts to make the right to health a reality, the Member States had already referred specifically in their mandates to the connection between the exercise of human rights and the enjoyment of health by the following groups in vulnerable situations: (a) persons with mental illness; (b) older persons; (c) persons with disabilities; (d) women and adolescent girls, in the context of maternal mortality and morbidity, gender equality, and the prevention of violence against women; (e) persons living with HIV; (f) indigenous populations; and (g) adolescents and young adults of either sex (). In 2013, lesbians, homosexuals, bisexuals, and trans people were also included ().
Within the framework of the United Nations’ Global Strategy for Women’s and Children’s Health () and implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health (CoIA) () in the Region of the Americas (), the lawmakers of the human rights, family, health, and education commissions, together with ministry authorities in the social sector, agencies charged with safeguarding the exercise of human rights, civil society, academics, and international agencies, engaged in a dialogue to develop collaboration strategies, considering the technical guidelines for the development and implementation of policies and programs for reducing maternal mortality and morbidity consistent with human rights standards. In 2013, a document was published describing progress in the conditions for guaranteeing the right to reproductive health and healthy motherhood ().
In September 2015, the Member States approved the Strategy on Health-Related Law, whose purpose is to “provide guidance that the Member States can consider and use, as appropriate, based on the respective national context, in order to strengthen: (a) greater coordination between the health authority, the legislative branch of government, and other State authorities, and other stakeholders, as appropriate, in the formulation, implementation, or review of health-related law; (b) legislative and regulatory measures to protect health and address the determinants of health; (c) the harmonization or implementation of the recommendations of the Governing Bodies of PAHO/WHO related to the formulation, implementation, or review of health-related law, taking into account national contexts and priorities” ().
Finally, the Strategy for Universal Access to Health and Universal Health Coverage incorporates the recommendations of General Comment No. 14 on the availability, access, acceptability, and quality of health systems, offering explicit guidance to enable the Member States to make the necessary decisions to guarantee the right to health for their peoples.
Despite the progress toward recognition of the right to health and other related human rights and the efforts to guarantee them, the reports of the various United Nations commissions reveal gaps and deficiencies that should be the object of intersectoral dialogue. Table 2 summarizes the main comments from a series of reports on 11 countries in the Region on aspects that pose challenges that should be addressed in the intersectoral dialogue on health determinants.
Table 2. Summary of comments from 11 Latin American and Caribbean countries
On young children
On socioeconomic status
On access to work and employment conditions
On housing and living conditions
On disease prevention systems
Source: PAHO. The social determinants of health in selected countries in Latin America and the Caribbean [unpublished report].
Note: The review included Argentina, Belize, Brazil, Chile, Costa Rica, Cuba, El Salvador, Jamaica, Mexico, Peru, and Suriname.
Experience with explicit use of the human rights approach in the Region has made a difference, revealing the existence of systematic discrimination against populations in vulnerable situations. It has also provided the rationale for reallocating resources from the health budget to increase equity, improve the quality of care, improve surveillance, and, in the long term, increase the recognition that access to quality services is a political and legal right ().
Progress and challenges to achieving health equity in the Region of the Americas
The term “health equity” refers to the absence of unfair avoidable differences in health status, access to health care and healthy environments, and the treatment received in the health system and other social services (). The inequities in the Region have been abundantly documented, revealing it to be one of the most inequitable regions in the world. Inequity is seen in both income distribution and access to the benefits of economic growth, expressed in the indicators of social progress (i.e., education, health, access to drinking water and sanitation systems, and housing conditions). Clearly, over the past 25 years, concern has become more explicit regarding equity in public policies, with the concept of justice adding value to the analysis of inequalities and the response to them. To put this into context, it should be recalled that in 1991, following the “lost decade” and consequent structural adjustment programs, the Economic Commission for Latin America and the Caribbean (ECLAC) reported that the region’s economies were characterized by an overall loss of buoyancy and a marked deterioration in equity. In historical terms, the 1980s were a turning point in development patterns in Latin America and the Caribbean. ECLAC subsequently issued a proposal for the development of Latin America and the Caribbean, promoting “the transformation of the region’s productive structures within the framework of progressive social equity” (). Given these circumstances, ECLAC and other partners in development have promoted public policies that result in better distribution of the benefits of economic growth and are reflected in better social indicators among the groups most impacted by inequity.
The call for such policies has persisted and grown louder, particularly within the framework of the Millennium Development Goals. In 2008, ECLAC stated that progress toward equity in health promotes economic development, since investments in this area help stimulate productivity and prosperity insofar as the benefits of economic development are distributed with a reasonable degree of justice ().
A review of some indicators shows the progress made in the direction of more equitable societies. Differences in ethnicity, income level, and education have been identified as representative variables in the analysis of health equity for women and children. The Region of the Americas has made great strides in maternal and child health over the past two decades. For example, the maternal mortality ratio (MMR) in Latin America and the Caribbean fell from 117 to 68 maternal deaths per 100,000 live births between 1995 and 2015. Despite this progress, however, the Region did not reach the MDG target of a 75% reduction, and serious inequalities are seen among and within the countries of the Region. For example, the five countries in the Region with the lowest MMR in 2015 were Canada (7), United States (14), Puerto Rico (14), Uruguay (15), and Chile (22), while the five with the highest MMR were Haiti (359), Guyana (229), Bolivia (206), Suriname (155), and Nicaragua (150) (Figure 1).
Figure 1. Maternal mortality ratio in the Region of the Americas, 1995 and 2015
Source: PAHO Health Information Platform for the Americas (Plataforma de Información en Salud de las Américas, PLISA), from data gathered in August 2017, https://www.paho.org/data/index.php/en/.
Furthermore, although mortality in children under 5 in the Region fell substantially between 1990 and 2015, from 54 to 17 deaths per 1,000 live births, for a 69% reduction (), the available data from household surveys show that the rate of progress between 2000 and 2012 was not the same for every household in the Region. The mortality rate in children under 5 of the poorest households is generally more than double that of the wealthiest households (Figure 2). In addition, the mother’s education is still one of the greatest determinants of inequality in infant mortality (Figure 3). Moreover, the probability of dying before the age of 5 is higher in rural areas than urban areas, and among boys than girls (). It should be noted, however, that mortality rates have fallen faster among the poorest families, indicating growing equity.
Figure 2. Mortality in children under 5 by income level
Source: Prepared by author from the database of the WHO Health Equity Monitor, based on data from the Demographic and Health Surveys (DHS/EDS).
Figure 3. Mortality in children under 5 by maternal educational level
Source: Prepared by author from the database of the WHO Health Equity Monitor, based on data from the Demographic and Health Surveys (DHS/EDS).
The probability of dying from cardiovascular disease, cancer, diabetes, or chronic respiratory disease between the ages of 30 and 70 is 15% in the Region of the Americas (). In fact, chronic diseases represent more than 79% of all causes of death in the Americas. There is strong evidence in the literature to suggest that the poor and people with an informal education or living in marginalized groups are more likely to die from chronic diseases than are members of other groups (). Furthermore, low socioeconomic status or living in middle- or low-income countries increases the risk of developing cardiovascular disease, stomach and lung cancer, type 2 diabetes, and chronic obstructive pulmonary disease (). Surprisingly, survey data from Argentina, Brazil, Chile, Costa Rica, Jamaica, and Mexico on the diagnosis of asthma, depression, diabetes, and heart disease do not show a clear socioeconomic gradient for these chronic diseases (Figure 4). For example, visible inequalities are not found for asthma, and a definite socioeconomic gradient is not observed for diabetes and heart disease. The data from Brazil show no differences in depression. In Mexico, more depression is reported by wealthy people than poor people, while in other countries, the opposite is true.
Figure 4. Averages and distribution of chronic diseases by income level, 2000–2012 (or nearest year)
Source: Dmytraczenko T, Almeida G, eds. Toward universal health coverage and equity in Latin America and the Caribbean: evidence from selected countries. Directions in Development. Washington, D.C.: World Bank and PAHO; 2015.
Tackling inequities is a priority in the Region of the Americas, since there are vast social inequalities between rich and poor, people with different levels of education, urban and rural populations, and majorities and ethnic minorities.
The 2016 World Bank report on poverty and shared prosperity shows that, based on the trend in the Gini coefficient by region, the highest levels of inequality are found in Latin America and the Caribbean (). Inequality is the main obstacle to regional progress toward inclusive human development, poverty reduction, strengthening of the social unit, and better health.
With respect to health exclusively, despite economic progress in the majority of the countries, substantial numbers of people remain without effective access to comprehensive health services that serve their needs in a timely manner. Regarding the concentration of income and differences in health outcomes, when the average data are disaggregated by income, educational level, ethnicity, gender, and rurality, health inequities are revealed. Health outcomes have improved asymmetrically when considering the dimensions of gender, ethnicity, rurality, age, and educational level—all of which have health impacts that are not only different but unfair.
Some Member States have instituted changes in organization and management to provide a better response for vulnerable groups with low health indicators that are often preventable and unacceptable from the moral standpoint:
- Argentina. In 2016, the Health Program for Indigenous Populations was created under the Ministry of Health’s National Directorate for Community Care through Resolution 1036-E/2016. The aim of this program is to improve countrywide health coverage and indigenous communities’ access to the public health system through an intercultural approach. The program’s functions include formulating plans to reduce inequities in the health conditions of the target populations; supporting the reduction of morbidity and mortality in the indigenous population through health promotion and disease prevention programs; and training people from indigenous communities to facilitate access to the public health services, using an intercultural approach ().
- Venezuela. In 2015, Venezuela created the General Directorate for Intercultural Indigenous Health and Complementary Therapies under the office of the Vice Minister of Health. The General Directorate’s functions, established in the Organic Regulation of the Ministry of People’s Power for Health through Decree No. 1887 of 16 July 2015, are as follows: (a) to create mechanisms for linking the offices of the vice ministers, the Integrated Health Network, and health services and programs to strengthen and optimize the Ministry’s strategic policies; (b) to forge ties, develop strategies, and conduct activities with other public health service providers for the purpose of integrating and consolidating the Comprehensive Unified National Public Health System; (c) to develop and disseminate a management model that includes proactive engagement of the population and addresses social needs through the Joint Communal Health System, in order to strengthen communal social monitoring, comanagement, and self-governance in health; (d) to define, propose, and execute policies for monitoring and oversight of health management in national, state, and local entities, and to monitor due compliance with the regulations governing the public health structure in the Integrated Health Network; (e) to establish mechanisms for the creation of comprehensive community health areas (ASIC) as population-based technical and administrative health management units through the state health directorates, in conjunction with the office of the vice minister of the Outpatient Health Network; (f) to design mechanisms, in coordination with the offices of the vice ministers, to comprehensively examine the health profiles of the population, considering the social determinants and territory of residence; and (g) based on the policies of the competent agency for indigenous affairs, to establish and disseminate strategies for health promotion, disease prevention, treatment, and recovery of indigenous people and communities in the facilities of the Integrated Network, with due respect for traditional medicine and their culture () (see topic 2 of this chapter, “Access to Comprehensive, Equitable, and Quality Health Services”).
Progress toward solidarity-based health systems
The concept of solidarity describes support for a cause or project of third parties (Royal Spanish Academy). Its etymology refers to in solidum conduct, meaning that the destinies of two or more people are linked. Thus, someone who exhibits solidarity not only offers assistance but makes a commitment to the person he or she is attempting to help. Embracing solidarity as a core health value has the potential to transform society, since it implies that people will stop making decisions to maximize their own personal (or family) well-being and instead, consider the effect of those decisions on the well-being of other community members. Solidarity is a value that promotes a culture of appreciation for and commitment to social justice; hence, it is critical for guaranteeing the right to health and reducing inequities. Solidarity is realized through a planned effort to redistribute wealth through social development and social protection policies.
The Strategy for Universal Access to Health and Universal Health Coverage is based on solidarity as the underlying value for policies on financing. It also expresses a vision that contrasts with the traditional argument that based access on an individual’s and household’s ability to pay, asserting that: “Health strategies that ensure timely, quality access for all people, within the framework of universal access to health and universal health coverage, require solidarity in order to promote and provide financial protection. To this end it is necessary to pool resources and to advance toward the elimination of direct payments that constitute a barrier at the point of service.” The Strategy indicates that those direct payments should be replaced with pooling mechanisms: “Pooling resources means combining all sources of financing (social security, government budget, individual contributions, and other funds) in a single, pooled fund; i.e., all contribute according to their means and receive services according to their needs. In such a scheme, the public budget covers contributions for those individuals who do not have the means to contribute (poor and homeless people)” ().
Topic 5 of this chapter (“Health Financing in the Americas”) offers an extensive look at health financing in the Region and the rationale for a strategy centered on pooled resources. Here, we would simply emphasize that some countries have created pooled funds to supplement other sources of financing.
One of the expressions of solidarity in health is care for migrants, an effort consistent with recognition of the health-related rights of all people, including migrants, refugees, and other foreigners. Heavy migration flows in the Region have made it necessary to conduct a situation analysis of health access and coverage for these people. In 2016, the Member States of PAHO decided to bring the issue of migrants’ health issue before the Governing Bodies, which adopted a resolution in this regard (). According to that resolution, the Ministers made a commitment to lead “the effort to modify or improve regulatory and legal frameworks in order to address the specific health needs of migrant individuals, families, and groups [ … ] and advance towards providing migrants with access to the same level of financial protection and of comprehensive, quality, and progressively expanded health services that other people living in the same territory enjoy, regardless of their migratory status, as appropriate to national context, priorities, and institutional and legal frameworks” ().
The values of human rights, equity, and solidarity underpinning the Strategy for Universal Access to Health and Universal Health Coverage are leading to a more just society in which the search for the common good takes precedence over the search for individual benefit. Embracing these values and implementing the strategy can potentially influence not only health outcomes but human development outcomes as well.
Guaranteeing the right to health calls for greater equity, which can be attained only through public policies built on reliable information and social dialogue on areas that affect individual and community well-being. The information on different and unfair health outcomes is the point of departure for an analysis of their causes, which can then be used by the relevant decision-making bodies. The availability of information to establish baselines for the different variants of the inequity situation is key to obtaining relevant information to characterize the situation and lay the foundations for monitoring and evaluation systems for pro-equity initiatives.
Monitoring inequities and their determinants is a challenge for information systems, since it requires changes in the types of data collected and the way they are obtained and analyzed to inform public policy design. This means selecting a base of health indicators, appropriate stratification criteria, and good indicators of inequities and inequalities ().
The information produced by sound equity-monitoring systems, as well as the evaluation of initiatives to improve them, is essential for social participation and accountability to individuals and communities and for the design and implementation of pro-equity public policies.
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