Hospital in Cienfuegos, Cuba. AP Photo/Franklin Reyes. All rights reserved.
In recent decades, progress in Latin American societies has been
shifting the focus of public debate from the fight against authoritarian
regimes, the lack of freedom and crises related to extreme poverty,
exploitation and underdevelopment, towards the consolidation of democratic
transitions, the conquest and defense of social and civil rights, and the
construction of a developing welfare state, a typical feature of advanced societies
which is here an established aspirational goal. Although structural weaknesses
in the region are still plentiful, the discussion on healthcare systems, their
universalization and accessibility has been gaining ground among the political
priorities of multilateral agencies and national governments, local political
actors, human and civil rights activists, and different actors from organized
civil society and the economic and business world.
Even though Latin America carries the weight of some constitutive
problems that hinder the development of its societies, in the last decade some
progress has been reported which certainly needs consolidating and
strengthening, but leads us to believe that the debate on health in the region,
which the Barcelona Institute of Global Health (ISGlobal) and DemocraciaAbierta
are proposing through a series of forthcoming articles, is particularly
relevant at this point in time and may hopefully have some impact on the debate
on the development of a healthcare ecosystem throughout the continent.
Three areas of action
We propose to approach a series of reflections in three major areas: the
issue of inequality and its impact on health systems, the debate on universal
coverage, and issues related to access and quality of healthcare services,
including those related to indigenous peoples, gender equality, and the
vulnerability of excluded people in rural areas and large urban suburbs.
The gender question, and the access to sexual and reproductive health in
a region where violence, sexism and historical inequality are inbred in the
cultural context, deserve special attention. Linked to all of the above, the
problems associated with epidemics (such as the recent case of Zika virus) and
infectious diseases have also a continental dimension.
Ultimately, we seek to contribute elements of analysis and reflection to
an informed and plural but not necessarily expert audience, to help answer the
question of what future for healthcare in Latin America and the Caribbean do
the actors and the populations want, as the answer to this question will also
depend on the quality of their democratic systems of government and the
governance of the common good.
Inequality
Even though some goals in healthcare have improved, Latin America
remains the most unequal region in the world: in 2014, 71% of the wealth of the
region belonged to the richest 10% of the population. Inequities exist not only
among Latin American countries, but also within each of them. As underlined by several
regional analyses, particularly those carried out by the
Economic Commission for Latin America and the Caribbean (ECLAC), inequality
in healthcare is due not only to the lack of socio-cultural and geographical
accessibility, but also to income inequalities which generate living
conditions that are inadequate for anticipating and meeting the healthcare
needs of the population.
The poor are more likely than the rich to develop health problems and
are less able to use basic services such as preventive care, which is key to
early detection of diseases and appropriate intervention. A recent study by the
World
Bank conducted in 9 countries in the region indicates that, while the
current rate of impoverishment is relatively low and is gradually declining due
to public spending on health protection systems, two to four million people
remain below the poverty line once their spending on healthcare is discounted.
At the same time, the changing demographic and epidemiological profile
of the region, particularly the aging population, is shifting the burden of
morbidity towards chronic diseases, which have increased in all population
groups. This means greater and more widespread demand for healthcare services
and an expected rapid increase of the budget burden.
As a demographic dependency factor, the aging population is a crucial
element to consider for the dynamics of the protection systems and the welfare
regimes. In the poorest families, care for dependents is something that can
hardly be met by the market and is largely provided by women in family
environments, which entails gender effects for the individual development and
labour-market integration of women.
In too many places in Latin America and the Caribbean access to quality
healthcare services is restricted to high-income earners. In addition, the
commodification of these services makes them more expensive and drives them
away from poverty and vulnerability areas. Thus a vicious cycle is put into
motion that affects the quality of life and the process to guarantee human,
political and social rights for millions of people.
Inequality affects both the social determinants that influence health
and access to healthcare. Healthcare inequality, in turn, causes more poverty,
and diverts communities from the path towards the progressive realization of a
basic right.
Universal Health Coverage
Universal Health
Coverage implies that all individuals and communities, without discrimination,
have access to comprehensive, quality healthcare according to their needs, and
to quality drugs that are safe, effective and affordable, and that the use of
these services does not result in financial difficulties for their users,
particularly the vulnerable groups. Reference to this is to be found in Estrategia para la
Cobertura Universal en Salud (PAHO/WHO).
After years of
debate and work on healthcare approach in the national and international
development agendas, last September the United Nations General Assembly
approved the Agenda 2030, broken down in
17 sustainable development goals (SDGs), among them SDG 3 which aims to
achieve Universal Health Coverage and provide drugs and vaccines that are safe,
effective and affordable to all.
Several paths
have been tried in Latin America and the Caribbean, with varying degrees of
success, in relation to universal coverage. Some countries have experienced
similar results to the Organization for Economic Cooperation and Development
(OECD) countries, despite the fact that they launched their programs and
policies to improve population coverage, access to healthcare services and
financial protection much later. However, there are still millions of people in
the region who lack access to comprehensive healthcare services and thus cannot
lead healthy lives and prevent disease, or receive healthcare service
assistance when sick, including palliative care in the terminal phase of an
illness.
After nearly a
quarter of a century's experience with reforms to further the Universal Health
Coverage in Latin America and the Caribbean, it is particularly relevant to
analyse not only the concept and its composing elements from a Latin American
perspective, but also the ways to protect them against regressive policies that
threaten, ultimately, the fulfilment of the Right to Health.
Service (access and quality)
Deficient quality in healthcare shows itself in many ways: limited
access to healthcare services, ineffective and inefficient services, medical
complaints, high costs, dissatisfaction on the part of both users and health
professionals, low credibility of the healthcare institutions and the health
sector as a whole. Worse still, as
PAHO notes, poor quality in the provision of healthcare services comes to mean the
loss of human lives.
So, this is not a problem that has to do only with financing, and other
issues need to be addressed, for example the management capacity of the
healthcare systems to provide quality services when, in many countries in the
region, their control and governance is not in state hands.
Some of the questions we will be
discussing in the series are: Is progress being made in Latin America towards
healthcare models centred on people, especially the most vulnerable, and based
on their needs? While providing a range of guaranteed benefits, is due
attention being paid to the quality of the healthcare services? How is the
challenge of accessing diagnosis and treatment of the "poverty
diseases" to be addressed?
In the most unequal region in the world, progressively consolidated
democratic aspirations cannot be met without comprehensively addressing the
causes of the precarious health of the population and expanding further public
health policies. Electoral democracy is not enough if it does not guarantee
services linked to fundamental human rights such as access to health services.