ABSTRACT The region has made considerable progress implementing schemes aimed at expanding univer... more ABSTRACT The region has made considerable progress implementing schemes aimed at expanding universal health coverage in the past quarter-century. Measureable improvements in equity have been identified during the same period. Socioeconomic gradients are clearly present in health status, with the poor having worse observed health outcomes than the rich, but disparities have narrowed, particularly for early stages of the life course. Countries have reached high levels of coverage for maternal and child health services but, despite narrowing inequality, services remain pro-rich. Coverage of noncommunicable disease interventions is not as high as maternal and child health services and service utilization is skewed toward the better off, though these disparities continue to narrow as well. Primary care services are in general more equally distributed across income groups than is specialized care. Prevalence of noncommunicable diseases has not declined as expected given drops in mortality across these groups. Greater access to services, and hence diagnosis, among wealthier individuals may be masking differences in actual prevalence between income groups. Catastrophic health expenditures have declined in most countries, though the picture regarding equity is mixed due to measurement limitations.
Over the past quarter century, the countries of Latin America and the Caribbean (LAC) have experi... more Over the past quarter century, the countries of Latin America and the Caribbean (LAC) have experienced rising incomes, with corresponding reductions in levels of poverty. At the same time, countries have achieved improvements in health and well-being for all segments of the population: average life expectancy has risen significantly, more children live to see their first and fifth birthdays, and fewer mothers are dying from complications of childbirth. Nonetheless, health inequities persist between and within countries, and some health outcomes are still unacceptable, challenging health systems to develop innovative approaches that will improve responsiveness and address people's changing needs. Universal health coverage (UHC) has been at the center of the global public health agenda in recent years. As one of the overarching goals of health systems, UHC provides countries a way forward to address unmet needs and health inequities. The World Bank has embraced UHC as part of its mission to eliminate absolute poverty by 2030 and to boost shared prosperity. The Pan American Health Organization (PAHO) in October 2014 adopted a regional Strategy for Universal Access to Health and Universal Health Coverage, which expresses the commitment of PAHO Member States to strengthen health systems, expand access to comprehensive quality health services, provide financial protection, and adopt integrated, comprehensive policies to address the social determinants of health and health inequities. For the past two years, the World Bank and PAHO have engaged in a collaborative effort to examine policies and initiatives in LAC aimed at achieving UHC. This report is one product of that collaboration. It includes contributions from professionals from both institutions and it has received the support of researchers from several countries in the region. The report provides insight on different approaches and progress being made by selected countries over the past quarter century to increase population coverage, services covered, and financial protection, with a special focus on reductions in health inequities. The report shows that countries have made meaningful progress toward UHC, with increases in population coverage and access to health services, a rise in public spending on health, and a decline in out-of-pocket payments, which can result in catastrophic spending and impoverishment for many households. Expanded health services, including preventive, curative, and specialized services, have also been observed in most countries, and service utilization has become less
Despite notable scientific and medical advances, broader political, socioeconomic and behavioural... more Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic1,2. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches1, while maintaining proven preve...
Objective. To describe the methodology used to measure and explain income-related inequalities in... more Objective. To describe the methodology used to measure and explain income-related inequalities in health and health care utilization over time in selected Latin American and Caribbean countries. Methods. Data from nationally representative household surveys in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru were used to analyze income-related inequalities in health status and health care utilization. Health was measured by self-reported health status, physical limitations, and chronic illness when available. Hospitalization, physician, dentist, preventive, curative, and preventive visits were proxies for health care utilization. Household income was a proxy for socioeconomic status except in Peru, which used household expenditures. Concentration indices were calculated before and after standardization for all dependent variables. Standardized concentration indices are also referred to as horizontal inequity index. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. Results. Results of analysis of the evolution of income-related inequality in health and health care utilization in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru are presented in separate articles in this issue. Conclusions. The methodology used for analysis of equity in all six country research studies attempts not to determine causality but to describe and explain income-related inequalities in health status and health care utilization over time. While this methodology is robust, it is not free of errors. When possible, errors have been identified and corrected.
Revista panamericana de salud publica = Pan American journal of public health, 2018
This article reviews the evolution of regional proposals and agreements from the Declaration of A... more This article reviews the evolution of regional proposals and agreements from the Declaration of Alma-Ata (1978) to the Universal Health Strategy, highlighting how the core tenets of the primary health care strategy have come to be reflected in proposals to strengthen the primary level of care and establish integrated health services networks. Contextual aspects of implementing the strategy within the framework of complex national scenarios are also noted, through a review of some of the milestones of the last 40 years. Factors that hinder implementation of primary health care are described, as well as the advances and the emerging challenges that health systems face in several countries. This article reaffirms the need for a strong primary care level--with coordination and response capacity, close to and involved in the community, and accessible--in order to advance towards realizing the right to health for everyone. It also advocates for practical proposals to relaunch the primary ...
Two commonly used metrics for assessing progress toward universal health coverage involve assessi... more Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens’ rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already “reached” universal health coverage. Neither metric indicates, however, whether a country has achieved universal health coverage in the now commonly accepted sense of the term: that everyone—irrespective of their ability to pay—gets the health services they need without suffering undue financial hardship. We operationalized a framework proposed by the World Bank and the World Health Organization to monitor progress under this definition and then constructed an overall index of universal health coverage achievement. We applied the approach using data from 112 household surveys from 1990 to 2013 for all twenty Latin American countries. No country has achieved a perfect...
Este es un artículo de acceso abierto distribuido bajo los términos de la licencia Creative Commo... more Este es un artículo de acceso abierto distribuido bajo los términos de la licencia Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO, que permite su uso, distribución y reproducción en cualquier medio, siempre que el trabajo original se cite de la manera adecuada. No se permiten modificaciones a los artículos ni su uso comercial. Al reproducir un artículo no debe haber ningún indicio de que la OPS o el artículo avalan a una organización o un producto específico. El uso del logo de la OPS no está permitido. Esta leyenda debe conservarse, junto con la URL original del artículo.
In 1988, Brazilian Constitution definedhealth as a universal right and state responsibility. Prog... more In 1988, Brazilian Constitution definedhealth as a universal right and state responsibility. Progress towards universal health coverage (UHC) has been achieved through a Unified Health System (Sistema Único de Saúde, SUS) which was created in 1990. With successes and setbacks in the implementation of health programmes and organization of its health system, Brazil has achieved nearly-universal access to health services for her citizens. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale UHC in a health system in a highly-unequal country and relatively low resources. The analysis of the 30 years since the inception of SUS shows that innovations in the Brazilian health system extend beyond the development of new models of care and highlights the importance of establishing political, legal, organizational and management-related structures, and the role of the federal and local governments in the governance, planning, financing, and provision of health services. The expansion of SUS has allowed Brazil to rapidly address the changing health needs, with dramatic scaling up health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographic inequalities, insufficient funding, and the suboptimal private-public collaboration. Recent fiscal policies that ushered austerity measures, environmental, educational and health policies of the new administraion introduced in Brazil could reverse the hard-earned achievements of the SUS and threaten its sustainability and its ability to fulfil its constitutional mandate of providing 'health for all'. 2000 2010 2015 Births attended by skilled health staff (% of total) 87•6 98•6 98•9 99•1 Immunization, BCG (% of one-year-old children) 79 99 99 99 Immunization, measles (% of children ages 12-23 months) 78 99 99 96 Immunization, DPT (% of children ages 12-23 months) 66 98 99 96 Immunization, Hib3 (% of children ages 12-23 months) 90 99 96 Immunization, Pol3 (% of one-year-old children) 58 99 99 98 Immunization, HepB3 (% of one-year-old children) 94 96 96 Antiretroviral therapy coverage (% people living with HIV) 27 38 57
Two commonly used metrics for assessing progress toward universal health coverage involve assessi... more Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens' rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already…
A fi nes de la década de 1980, muchos países de América Latina comenzaron reformas en el sector s... more A fi nes de la década de 1980, muchos países de América Latina comenzaron reformas en el sector social para aliviar la pobreza, reducir las desigualdades socioeconómicas, mejorar los resultados de salud, y proporcionar protección ante el riesgo fi nanciero. Particularmente, a partir de la década de 1990, las reformas encaminadas a fortalecer los sistemas de salud para reducir las desigualdades en el acceso a la salud y en los resultados, se centraron en la expansión de la cobertura universal de salud, especialmente para los ciudadanos pobres. En América Latina, las reformas del sistema de salud han creado un acercamiento distinto a la cobertura universal de salud, apoyado en los principios de equidad, solidaridad y acción colectiva para superar las desigualdades sociales. En la mayoría de los países estudiados, el fi nanciamiento del gobierno permitió la introducción de intervenciones relacionadas con la oferta para ampliar la cobertura de seguro para los ciudadanos no asegurados —c...
Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Selected Countries, 2015
ABSTRACT The region has made considerable progress implementing schemes aimed at expanding univer... more ABSTRACT The region has made considerable progress implementing schemes aimed at expanding universal health coverage in the past quarter-century. Measureable improvements in equity have been identified during the same period. Socioeconomic gradients are clearly present in health status, with the poor having worse observed health outcomes than the rich, but disparities have narrowed, particularly for early stages of the life course. Countries have reached high levels of coverage for maternal and child health services but, despite narrowing inequality, services remain pro-rich. Coverage of noncommunicable disease interventions is not as high as maternal and child health services and service utilization is skewed toward the better off, though these disparities continue to narrow as well. Primary care services are in general more equally distributed across income groups than is specialized care. Prevalence of noncommunicable diseases has not declined as expected given drops in mortality across these groups. Greater access to services, and hence diagnosis, among wealthier individuals may be masking differences in actual prevalence between income groups. Catastrophic health expenditures have declined in most countries, though the picture regarding equity is mixed due to measurement limitations.
Starting in the late 1980s, many Latin American countries began social sector reforms to alleviat... more Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide fi nancial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government fi nancing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens-with defi ned and enlarged benefi ts packages-and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-fi nanced universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.
Objective. This study evaluates whether recent positive economic trends and pro-poor health polic... more Objective. This study evaluates whether recent positive economic trends and pro-poor health policies have resulted in more health equity and explores key factors that explain such change. Methods. This study focuses on the evolution of measures of health status (selfreported morbidity) and use of health care services obtained from the 2004 and 2008 rounds of the Peruvian National Household Survey (Encuesta Nacional de Hogares). It concentrates on health inequalities associated with socioeconomic status and uses interquintile differences (gradient), concentration indices with and without needs-based adjustments, and decomposition analysis. Results. Findings show a low level of inequality in measures of health status, with a slightly pro-poor inequality in self-reported health problems and a slightly pro-rich inequality in selfreported chronic illness. Inequity in the use of curative services declined significantly between 2004 and 2008, while inequity in the use of preventive services increased slightly. Use of hospital and dental services remained unchanged during the same period. Conclusions. Limitations of self-reported morbidity measures probably underestimate the results of health inequalities across socioeconomic groups. Improved equity in the use of curative health services can be explained by a number of positive factors that occurred concurrently during the analysis-namely, increased mean household income, reduced economic inequality, the Juntos conditional cash transfer program, and gradual expansion of public health insurance, Seguro Integral de Salud (SIS). Given that SIS expansion is the main public policy for promoting health equity in Peru, it is crucial that future steps in expansion come with a strategy to isolate its contribution to health equity improvements from that of other positive socioeconomic trends. Health inequalities; health insurance; Peru.
2008 were used to analyze inequalities in health and health care. Health was measured by self-rep... more 2008 were used to analyze inequalities in health and health care. Health was measured by self-reported health status, physical limitations, and chronic illness. Hospitalization and physician and dentist visits were proxies for health care utilization. Income was a proxy for socioeconomic status. Concentration indices were calculated before and after standardization for all dependent variables. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. Results. In all three periods analyzed, the poor reported worse health status, while the wealthy reported more chronic diseases; health care utilization was pro-rich for medical and dental services. Yet, income-related inequality in health care utilization has been declining. Private health insurance, education, and income are the major contributors to the inequalities identified. Conclusions. Income-related inequality in the use of medical and dental health care is gradually declining in Brazil. The decline is associated with implementation of pro-equity policies and programs, such as the Community Health Agents Program and the Family Health Program.
Objective. To describe the methodology used to measure and explain income-related inequalities in... more Objective. To describe the methodology used to measure and explain income-related inequalities in health and health care utilization over time in selected Latin American and Caribbean countries. Methods. Data from nationally representative household surveys in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru were used to analyze income-related inequalities in health status and health care utilization. Health was measured by self-reported health status, physical limitations, and chronic illness when available. Hospitalization, physician, dentist, preventive, curative, and preventive visits were proxies for health care utilization. Household income was a proxy for socioeconomic status except in Peru, which used household expenditures. Concentration indices were calculated before and after standardization for all dependent variables. Standardized concentration indices are also referred to as horizontal inequity index. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. Results. Results of analysis of the evolution of income-related inequality in health and health care utilization in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru are presented in separate articles in this issue. Conclusions. The methodology used for analysis of equity in all six country research studies attempts not to determine causality but to describe and explain income-related inequalities in health status and health care utilization over time. While this methodology is robust, it is not free of errors. When possible, errors have been identified and corrected.
ABSTRACT The region has made considerable progress implementing schemes aimed at expanding univer... more ABSTRACT The region has made considerable progress implementing schemes aimed at expanding universal health coverage in the past quarter-century. Measureable improvements in equity have been identified during the same period. Socioeconomic gradients are clearly present in health status, with the poor having worse observed health outcomes than the rich, but disparities have narrowed, particularly for early stages of the life course. Countries have reached high levels of coverage for maternal and child health services but, despite narrowing inequality, services remain pro-rich. Coverage of noncommunicable disease interventions is not as high as maternal and child health services and service utilization is skewed toward the better off, though these disparities continue to narrow as well. Primary care services are in general more equally distributed across income groups than is specialized care. Prevalence of noncommunicable diseases has not declined as expected given drops in mortality across these groups. Greater access to services, and hence diagnosis, among wealthier individuals may be masking differences in actual prevalence between income groups. Catastrophic health expenditures have declined in most countries, though the picture regarding equity is mixed due to measurement limitations.
Over the past quarter century, the countries of Latin America and the Caribbean (LAC) have experi... more Over the past quarter century, the countries of Latin America and the Caribbean (LAC) have experienced rising incomes, with corresponding reductions in levels of poverty. At the same time, countries have achieved improvements in health and well-being for all segments of the population: average life expectancy has risen significantly, more children live to see their first and fifth birthdays, and fewer mothers are dying from complications of childbirth. Nonetheless, health inequities persist between and within countries, and some health outcomes are still unacceptable, challenging health systems to develop innovative approaches that will improve responsiveness and address people's changing needs. Universal health coverage (UHC) has been at the center of the global public health agenda in recent years. As one of the overarching goals of health systems, UHC provides countries a way forward to address unmet needs and health inequities. The World Bank has embraced UHC as part of its mission to eliminate absolute poverty by 2030 and to boost shared prosperity. The Pan American Health Organization (PAHO) in October 2014 adopted a regional Strategy for Universal Access to Health and Universal Health Coverage, which expresses the commitment of PAHO Member States to strengthen health systems, expand access to comprehensive quality health services, provide financial protection, and adopt integrated, comprehensive policies to address the social determinants of health and health inequities. For the past two years, the World Bank and PAHO have engaged in a collaborative effort to examine policies and initiatives in LAC aimed at achieving UHC. This report is one product of that collaboration. It includes contributions from professionals from both institutions and it has received the support of researchers from several countries in the region. The report provides insight on different approaches and progress being made by selected countries over the past quarter century to increase population coverage, services covered, and financial protection, with a special focus on reductions in health inequities. The report shows that countries have made meaningful progress toward UHC, with increases in population coverage and access to health services, a rise in public spending on health, and a decline in out-of-pocket payments, which can result in catastrophic spending and impoverishment for many households. Expanded health services, including preventive, curative, and specialized services, have also been observed in most countries, and service utilization has become less
Despite notable scientific and medical advances, broader political, socioeconomic and behavioural... more Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic1,2. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches1, while maintaining proven preve...
Objective. To describe the methodology used to measure and explain income-related inequalities in... more Objective. To describe the methodology used to measure and explain income-related inequalities in health and health care utilization over time in selected Latin American and Caribbean countries. Methods. Data from nationally representative household surveys in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru were used to analyze income-related inequalities in health status and health care utilization. Health was measured by self-reported health status, physical limitations, and chronic illness when available. Hospitalization, physician, dentist, preventive, curative, and preventive visits were proxies for health care utilization. Household income was a proxy for socioeconomic status except in Peru, which used household expenditures. Concentration indices were calculated before and after standardization for all dependent variables. Standardized concentration indices are also referred to as horizontal inequity index. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. Results. Results of analysis of the evolution of income-related inequality in health and health care utilization in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru are presented in separate articles in this issue. Conclusions. The methodology used for analysis of equity in all six country research studies attempts not to determine causality but to describe and explain income-related inequalities in health status and health care utilization over time. While this methodology is robust, it is not free of errors. When possible, errors have been identified and corrected.
Revista panamericana de salud publica = Pan American journal of public health, 2018
This article reviews the evolution of regional proposals and agreements from the Declaration of A... more This article reviews the evolution of regional proposals and agreements from the Declaration of Alma-Ata (1978) to the Universal Health Strategy, highlighting how the core tenets of the primary health care strategy have come to be reflected in proposals to strengthen the primary level of care and establish integrated health services networks. Contextual aspects of implementing the strategy within the framework of complex national scenarios are also noted, through a review of some of the milestones of the last 40 years. Factors that hinder implementation of primary health care are described, as well as the advances and the emerging challenges that health systems face in several countries. This article reaffirms the need for a strong primary care level--with coordination and response capacity, close to and involved in the community, and accessible--in order to advance towards realizing the right to health for everyone. It also advocates for practical proposals to relaunch the primary ...
Two commonly used metrics for assessing progress toward universal health coverage involve assessi... more Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens’ rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already “reached” universal health coverage. Neither metric indicates, however, whether a country has achieved universal health coverage in the now commonly accepted sense of the term: that everyone—irrespective of their ability to pay—gets the health services they need without suffering undue financial hardship. We operationalized a framework proposed by the World Bank and the World Health Organization to monitor progress under this definition and then constructed an overall index of universal health coverage achievement. We applied the approach using data from 112 household surveys from 1990 to 2013 for all twenty Latin American countries. No country has achieved a perfect...
Este es un artículo de acceso abierto distribuido bajo los términos de la licencia Creative Commo... more Este es un artículo de acceso abierto distribuido bajo los términos de la licencia Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO, que permite su uso, distribución y reproducción en cualquier medio, siempre que el trabajo original se cite de la manera adecuada. No se permiten modificaciones a los artículos ni su uso comercial. Al reproducir un artículo no debe haber ningún indicio de que la OPS o el artículo avalan a una organización o un producto específico. El uso del logo de la OPS no está permitido. Esta leyenda debe conservarse, junto con la URL original del artículo.
In 1988, Brazilian Constitution definedhealth as a universal right and state responsibility. Prog... more In 1988, Brazilian Constitution definedhealth as a universal right and state responsibility. Progress towards universal health coverage (UHC) has been achieved through a Unified Health System (Sistema Único de Saúde, SUS) which was created in 1990. With successes and setbacks in the implementation of health programmes and organization of its health system, Brazil has achieved nearly-universal access to health services for her citizens. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale UHC in a health system in a highly-unequal country and relatively low resources. The analysis of the 30 years since the inception of SUS shows that innovations in the Brazilian health system extend beyond the development of new models of care and highlights the importance of establishing political, legal, organizational and management-related structures, and the role of the federal and local governments in the governance, planning, financing, and provision of health services. The expansion of SUS has allowed Brazil to rapidly address the changing health needs, with dramatic scaling up health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographic inequalities, insufficient funding, and the suboptimal private-public collaboration. Recent fiscal policies that ushered austerity measures, environmental, educational and health policies of the new administraion introduced in Brazil could reverse the hard-earned achievements of the SUS and threaten its sustainability and its ability to fulfil its constitutional mandate of providing 'health for all'. 2000 2010 2015 Births attended by skilled health staff (% of total) 87•6 98•6 98•9 99•1 Immunization, BCG (% of one-year-old children) 79 99 99 99 Immunization, measles (% of children ages 12-23 months) 78 99 99 96 Immunization, DPT (% of children ages 12-23 months) 66 98 99 96 Immunization, Hib3 (% of children ages 12-23 months) 90 99 96 Immunization, Pol3 (% of one-year-old children) 58 99 99 98 Immunization, HepB3 (% of one-year-old children) 94 96 96 Antiretroviral therapy coverage (% people living with HIV) 27 38 57
Two commonly used metrics for assessing progress toward universal health coverage involve assessi... more Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens' rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already…
A fi nes de la década de 1980, muchos países de América Latina comenzaron reformas en el sector s... more A fi nes de la década de 1980, muchos países de América Latina comenzaron reformas en el sector social para aliviar la pobreza, reducir las desigualdades socioeconómicas, mejorar los resultados de salud, y proporcionar protección ante el riesgo fi nanciero. Particularmente, a partir de la década de 1990, las reformas encaminadas a fortalecer los sistemas de salud para reducir las desigualdades en el acceso a la salud y en los resultados, se centraron en la expansión de la cobertura universal de salud, especialmente para los ciudadanos pobres. En América Latina, las reformas del sistema de salud han creado un acercamiento distinto a la cobertura universal de salud, apoyado en los principios de equidad, solidaridad y acción colectiva para superar las desigualdades sociales. En la mayoría de los países estudiados, el fi nanciamiento del gobierno permitió la introducción de intervenciones relacionadas con la oferta para ampliar la cobertura de seguro para los ciudadanos no asegurados —c...
Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Selected Countries, 2015
ABSTRACT The region has made considerable progress implementing schemes aimed at expanding univer... more ABSTRACT The region has made considerable progress implementing schemes aimed at expanding universal health coverage in the past quarter-century. Measureable improvements in equity have been identified during the same period. Socioeconomic gradients are clearly present in health status, with the poor having worse observed health outcomes than the rich, but disparities have narrowed, particularly for early stages of the life course. Countries have reached high levels of coverage for maternal and child health services but, despite narrowing inequality, services remain pro-rich. Coverage of noncommunicable disease interventions is not as high as maternal and child health services and service utilization is skewed toward the better off, though these disparities continue to narrow as well. Primary care services are in general more equally distributed across income groups than is specialized care. Prevalence of noncommunicable diseases has not declined as expected given drops in mortality across these groups. Greater access to services, and hence diagnosis, among wealthier individuals may be masking differences in actual prevalence between income groups. Catastrophic health expenditures have declined in most countries, though the picture regarding equity is mixed due to measurement limitations.
Starting in the late 1980s, many Latin American countries began social sector reforms to alleviat... more Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide fi nancial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government fi nancing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens-with defi ned and enlarged benefi ts packages-and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-fi nanced universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.
Objective. This study evaluates whether recent positive economic trends and pro-poor health polic... more Objective. This study evaluates whether recent positive economic trends and pro-poor health policies have resulted in more health equity and explores key factors that explain such change. Methods. This study focuses on the evolution of measures of health status (selfreported morbidity) and use of health care services obtained from the 2004 and 2008 rounds of the Peruvian National Household Survey (Encuesta Nacional de Hogares). It concentrates on health inequalities associated with socioeconomic status and uses interquintile differences (gradient), concentration indices with and without needs-based adjustments, and decomposition analysis. Results. Findings show a low level of inequality in measures of health status, with a slightly pro-poor inequality in self-reported health problems and a slightly pro-rich inequality in selfreported chronic illness. Inequity in the use of curative services declined significantly between 2004 and 2008, while inequity in the use of preventive services increased slightly. Use of hospital and dental services remained unchanged during the same period. Conclusions. Limitations of self-reported morbidity measures probably underestimate the results of health inequalities across socioeconomic groups. Improved equity in the use of curative health services can be explained by a number of positive factors that occurred concurrently during the analysis-namely, increased mean household income, reduced economic inequality, the Juntos conditional cash transfer program, and gradual expansion of public health insurance, Seguro Integral de Salud (SIS). Given that SIS expansion is the main public policy for promoting health equity in Peru, it is crucial that future steps in expansion come with a strategy to isolate its contribution to health equity improvements from that of other positive socioeconomic trends. Health inequalities; health insurance; Peru.
2008 were used to analyze inequalities in health and health care. Health was measured by self-rep... more 2008 were used to analyze inequalities in health and health care. Health was measured by self-reported health status, physical limitations, and chronic illness. Hospitalization and physician and dentist visits were proxies for health care utilization. Income was a proxy for socioeconomic status. Concentration indices were calculated before and after standardization for all dependent variables. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. Results. In all three periods analyzed, the poor reported worse health status, while the wealthy reported more chronic diseases; health care utilization was pro-rich for medical and dental services. Yet, income-related inequality in health care utilization has been declining. Private health insurance, education, and income are the major contributors to the inequalities identified. Conclusions. Income-related inequality in the use of medical and dental health care is gradually declining in Brazil. The decline is associated with implementation of pro-equity policies and programs, such as the Community Health Agents Program and the Family Health Program.
Objective. To describe the methodology used to measure and explain income-related inequalities in... more Objective. To describe the methodology used to measure and explain income-related inequalities in health and health care utilization over time in selected Latin American and Caribbean countries. Methods. Data from nationally representative household surveys in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru were used to analyze income-related inequalities in health status and health care utilization. Health was measured by self-reported health status, physical limitations, and chronic illness when available. Hospitalization, physician, dentist, preventive, curative, and preventive visits were proxies for health care utilization. Household income was a proxy for socioeconomic status except in Peru, which used household expenditures. Concentration indices were calculated before and after standardization for all dependent variables. Standardized concentration indices are also referred to as horizontal inequity index. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. Results. Results of analysis of the evolution of income-related inequality in health and health care utilization in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru are presented in separate articles in this issue. Conclusions. The methodology used for analysis of equity in all six country research studies attempts not to determine causality but to describe and explain income-related inequalities in health status and health care utilization over time. While this methodology is robust, it is not free of errors. When possible, errors have been identified and corrected.
Over the past three decades, many countries in Latin America and the Caribbean have recognized he... more Over the past three decades, many countries in Latin America and the Caribbean have recognized health as a human right. Since the early 2000s, 46 million more people in the countries studied are covered by health programs with explicit entitlements to care. Reforms have been accompanied by a rise in public spending for health, financed largely by general revenues that prioritize or explicitly target the population without capacity to pay. Political commitment has generally translated into larger budgets as well as passage of legislation that ring-fenced funding for health. Most countries have prioritized cost-effective primary care and have adopted purchasing methods that incentivize efficiency and accountability for results and that give stewards of the health sector greater leverage to steer providers to deliver on public health priorities. Despite progress, disparities remain in financing and quality of services provision across health subsystems. Delivering on the commitment to universal health coverage will require concerted efforts to improve revenue generation in a fiscally sustainable manner and to increase the productivity of expenditures.
In Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Select Countries, the authors show that evidence from an analysis of 54 household surveys corroborates that investments in extending coverage are yielding results. Although the poor still have worse health outcomes than do the rich, disparities have narrowed considerably—particularly in the early stages of life. Countries have reached high levels of coverage and equity in utilization of maternal and child health services. The picture is more nuanced, and not nearly as positive, regarding adult health status and prevalence of chronic conditions and illnesses. Coverage of noncommunicable disease interventions is not as high, and service utilization is still skewed toward those who are better off. Prevalence of noncommunicable diseases has not behaved as expected given the drop in mortality; better access to diagnosis among wealthier individuals may be masking changes in actual prevalence.
Catastrophic health expenditures have declined in most countries. The picture regarding equity, however, is mixed, pointing to limitations in the measure. Although the rate of impoverishment owing to health expenditures is low and generally declining, 2–4 million people in the countries studied still fall below the poverty line after health spending.
Efforts to systematically monitor quality of care in the region are still in their infancy. Nonetheless, a review of the literature reveals important shortcomings in quality of care, as well as substantial differences across subsystems. Improving quality of care and ensuring sustainability of investments in health remain an unfinished agenda.
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Papers by Gisele Almeida
In Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Select Countries, the authors show that evidence from an analysis of 54 household surveys corroborates that investments in extending coverage are yielding results. Although the poor still have worse health outcomes than do the rich, disparities have narrowed considerably—particularly in the early stages of life. Countries have reached high levels of coverage and equity in utilization of maternal and child health services. The picture is more nuanced, and not nearly as positive, regarding adult health status and prevalence of chronic conditions and illnesses. Coverage of noncommunicable disease interventions is not as high, and service utilization is still skewed toward those who are better off. Prevalence of noncommunicable diseases has not behaved as expected given the drop in mortality; better access to diagnosis among wealthier individuals may be masking changes in actual prevalence.
Catastrophic health expenditures have declined in most countries. The picture regarding equity, however, is mixed, pointing to limitations in the measure. Although the rate of impoverishment owing to health expenditures is low and generally declining, 2–4 million people in the countries studied still fall below the poverty line after health spending.
Efforts to systematically monitor quality of care in the region are still in their infancy. Nonetheless, a review of the literature reveals important shortcomings in quality of care, as well as substantial differences across subsystems. Improving quality of care and ensuring sustainability of investments in health remain an unfinished agenda.