Quality and health care reform in Latin America and the Caribbean]

Improving the quality of basic health services, together with the search for equity, efficiency, sustainability, and social participation, has been one of the guiding principles of health sector reform initiatives ever since the I Summit of the Americas was held in 1994. This article addresses some basic concepts, examines the status of quality control within health systems and services in Latin America and the Caribbean, and analyzes the most important trends observed in the Region in the establishment of quality assurance programs. Finally, ways of improving and monitoring quality continuously and sustainable are recommended.     

Gender equity in health sector reform policies in Latin America and the Caribbean]

Gender equity is increasingly being acknowledged as an essential aspect of sustainable development and more specifically, of health development. The Pan American Health Organization's Program for Women, Health, and Development has been piloting for a year now a project known as Equidad de género en las políticas de reforma del sector de salud, whose objective is to promote gender equity in the health sector reform efforts in the Region. The first stage of the project is being conducted in Chile and Peru, along with some activities throughout the Region. The core of the project is the production and use of information as a tool for introducing changes geared toward achieving greater gender equity in health, particularly in connection with malefemale disparities that are unnecessary, avoidable, and unfair in health status, access to health care, and participation in decision-making within the health system. We expect that in three years the project will have brought about changes in the production of information and knowledge, advocacy, and information dissemination, as well as in the development, appropriation, and identification of intersectoral mechanisms that will make it possible for key figures in government and civil society to work together in setting and surveying policy on gender equity in health.     

Rethinking social protection in health in Latin America and the Caribbean]

Despite what is written in the constitutions and other basic document mandates of the countries of the Region, exclusion from social protection in health (SPH) affects an important proportion of the population (at least 20%, which represents, in absolute figures, between 80 and 200 million people). These estimates are obtained through a series of theoretical (social security coverage) and practical indicators that encompass structural indicators (poverty, ethnicity, and geographical barriers) as well as process indicators (non-institutional births, compliance with vaccination schedules, and access to basic sanitation). Exclusion levels in a society are affected by the degree of segmentation of the health system. Traditionally, most countries of the Region have had a public, a social security and a private subsystem in health. Lack of attention to the problem has resulted in the formation of a community-based subsystem. The coexistence of many subsystems, along with poor regulation on the part of health authorities, has resulted in high levels of exclusion and inefficient resource allocation within the sector. The organization of social dialogue processes focusing on SPH within the context of health sector reform initiatives in each country is recommended. The process, which should be participatory, should include a full diagnosis of the situation (how many are excluded, who are they, and why, and what mechanisms are the most appropriate for tackling the issue in each country). It should also provide a political and technical feasibility analysis of the most suitable options for each society, and a determination of whether or not conventional subsystems have exhausted their potential. The process should culminate in a program for implementing the specific proposals made in each society, in an effort to maximize SPH.     

Organization of the public health services in Latin America and the Caribbean]

The organisation of veterinary public health (VPH) services in countries of Latin America and the Caribbean has resulted from an historical process which has consolidated the structure of these services and the concept of VPH. This concept comprises five principal plans of action: promotion of animal health in order to increase the production of protein of animal origin; protection of foods for human consumption; vigilance, prevention, control and eradication of zoonoses; promotion of environmental protection, together with the development of biomedical models. These plans of action serve the purpose of improving human health and well-being, which is essential for the socioeconomic development of populations. Within this context, the authors describe the organisation of VPH services for health and agriculture, which have a part to play in intersectorial collaboration and in social participation. Finally, an account is given of progress in the control of rabies, brucellosis and tuberculosis, and the organisation of integrated programmes for food protection and also the control and eradication of foot and mouth disease. Technical cooperation with the Pan American Health Organisation (PAHO) assists these activities and intersectorial coordination, principally between health and agriculture.     

The economic crisis and its impact on health and health care in Latin America and the Caribbean

The economic crisis that struck most Latin American and Caribbean countries beginning in 1982 has caused sharp reductions in domestic investment and in imports; domestic consumption has been less affected, while public sector spending has responded in different degrees in different countries. In general, public spending on health decreased, sometimes quite dramatically, but some countries were able to maintain the real value of noninvestment spending for health by central governments. It is much harder to tell what may have happened to output of health services, and still harder to know how health status has been affected. Scattered evidence suggests two conclusions. First, worsened economic conditions can seriously damage health status, with effects on infant mortality and on the patterns of disease and death, especially for children. Second, these repercussions do not have to occur, and public programs designed specifically to maintain basic health services and to assure adequate nutrition are effective in offsetting the worst consequences of economic hardship.     

Social scenarios in Latin America and the Caribbean]

A wide range of sources have pointed out the magnitude and depth of the social problems that trouble Latin America and the Caribbean and the risks that these problems pose for democracy. Although there are other issues that merit consideration, this article briefly outlines nine key social problems: 1) the increase in poverty, 2) the impact of poverty, 3) unemployment and informal employment, 4) deficiencies in public health, 5) problems in education, 6) the newly poor, 7) the erosion of the family, 8) increasing crime, and 9) the perverse cycle of socioeconomic exclusion. Solving these problems must not be delayed. It is urgent to move to a comprehensive view of development that achieves a different balance between economic and social policies, and that recognizes the indispensable role of these policies in achieving truly sustainable development. At stake are problems that not only concern resources, but also priorities, levels of equity, and the organization of society. Facing up to this poverty and inequity requires an in-depth assessment of these economic policies' social consequences, of the crucial subject of Latin American inequity--the greatest in the world--and of the role of social and public policies.     

Emergency contraception in Latin America and the Caribbean]

Introducing the post-coital birth control method in the family-planning services of Latin American countries has not been an easy task. Catholic and other conservative groups with great influence in the political arena have time and again stopped it from being adopted as an alternative method and have even succeeded in having it removed from official directives after formal acceptance by health authorities. The main objections are triggered by the erroneous supposition that "emergency contraception" pills are abortifacients. However, a large dose of cultural discrimination against women seems also to be involved. It has been extremely difficult to register dedicated products and make them available in drug-stores and even more difficult to distribute them without charge at public health centers. They are hard to find, expensive, and unavailable to adolescents at risk for unwanted pregnancies and to most low-income women, especially in rural areas. Dissemination of appropriate information has been scarce and slow and there are still great numbers of people that do not understand how or why the method works. Brazil has been the only exception, as its open society has readily accepted this method of contraception. The Latin American Consortium on Emergency Contraception founded in the year 2000 and its regional conference two years later had an important impact on the situation, as they encouraged the coordination of efforts by governmental and nongovernmental entities with those of women's groups to fight for sexual and reproductive rights. A number of studies have shown that the more people learn about emergency contraception, the more they find it acceptable and necessary, and radio spots and other media techniques have begun to educate the public about this matter. In spite of the many difficulties encountered, in the last few years several countries have made strides to include this method in their public health guidelines. However, because of the powerful forces against it, accessibility and distribution of the emergency pills are not always implemented as planned and there are still many areas that require work. Details are given on the situation in Argentina, Bolivia, Chile, Colombia, Ecuador, Honduras, Mexico, Paraguay, and Peru.     

Unwanted pregnancy: impact on health and society in Latin America and the Caribbean]

Engaging in sexuality and reproduction should always be something that is wanted and planned. Unfortunately, when that is not the case, one result can be unwanted pregnancy. Unwanted pregnancies have consequences for women, their families, and their countries. This document reviews the causes and results of unwanted pregnancy, emphasizing the impact that this problem has on Latin America and the Caribbean (LAC). Four reasons why unwanted pregnancy is a continuing problem in LAC are: 1) people's growing desire to have smaller families, 2) the unmet need for family planning, 3) the fact that contraceptive methods are not 100% effective, and 4) unwanted sexual relations. Unwanted pregnancies especially affect adolescent women, single women, and women over 40 years of age. Given their desperate situation with an unwanted pregnancy, some women opt for an unsafe abortion, which can lead to their death. Other women can go so far as to commit suicide, or be murdered by a family member or other person who is unhappy that the pregnancy has occurred. It has been found that women who decide to continue with the pregnancy have higher risks of suffering an illness, and the same is true for the child. Reducing unwanted pregnancies and treating post-abortion complications are key to lowering maternal mortality and morbidity. This necessitates developing mass communication programs that address gender issues, education programs for girls, and sex education programs. It is also vital to make available to all persons reproductive health services that include family planning methods. In the countries of LAC with laws that specify grounds for legally ending a pregnancy, it is necessary that health care be organized to actually provide this service, and that health care programs obtain the safest, most effective technologies now available for ending a pregnancy.     

Health sector reform and reproductive health in Latin America and the Caribbean: strengthening the links

Many countries in Latin America and the Caribbean (LAC) are currently reforming their national health sectors and also implementing a comprehensive approach to reproductive health care. Three regional workshops to explore how health sector reform could improve reproductive health services have revealed the inherently complex, competing, and political nature of health sector reform and reproductive health. The objectives of reproductive health care can run parallel to those of health sector reform in that both are concerned with promoting equitable access to high quality care by means of integrated approaches to primary health care, and by the involvement of the public in setting health sector priorities. However, there is a serious risk that health reforms will be driven mainly by financial and/or political considerations and not by the need to improve the quality of health services as a basic human right. With only limited changes to the health systems in many Latin American and Caribbean countries and a handful of examples of positive progress resulting from reforms, the gap between rhetoric and practice remains wide.     

Mental disorders in Latin America and the Caribbean: a public health priority]

OBJECTIVE: The growing burden of mental disorders in Latin America and the Caribbean has become too large to ignore. There is a need to know more about the prevalence of mental disorders and the gap between the number of individuals with psychiatric disorders and the number of those persons who remain untreated even though effective treatments exist. Having that knowledge would make it possible to improve advocacy, adopt better policies, formulate innovative intervention programs, and apportion resources commensurate with needs. METHODS: Data were extracted from community-based psychiatric epidemiological studies published in Latin America and the Caribbean from 1980 through 2004 that used structured diagnostic instruments and provided prevalence rates. Estimates of the crude rates in Latin America and the Caribbean for the various disorders were determined by calculating the mean and median rates across the studies, by gender. In addition, data on service utilization were reviewed in order to calculate the treatment gap for specific disorders. RESULTS: Nonaffective psychosis (including schizophrenia) had an estimated mean one-year prevalence rate of 1.0%; major depression, 4.9%; and alcohol use abuse or dependence, 5.7%. Over one-third of individuals with nonaffective psychosis, over half of those with an anxiety disorder, and some three-fourths of those with alcohol use abuse or dependence did not receive mental health care from either specialized or general health services. CONCLUSIONS: The current treatment gap in mental health care in Latin America and the Caribbean remains wide. Further, current data likely greatly underestimate the number of untreated individuals. The epidemiological transition and changes in the population structure will further widen the treatment gap in Latin America and the Caribbean unless mental health policies are formulated or updated and programs and services are expanded.     

Agricultural occupational health and health education in Latin America and the Caribbean

Agricultural diseases and injuries are major sources of healthconcern in Latin America and the Caribbean. To help alleviatethis situation, health education programs directed at workersat risk have been implemented. This paper discusses the factorsinherent to agricultural work that need to be considered inthe design, planning, implementation, and evaluation of healtheducation activities, such as the characteristics of agriculturalwork and occupational health problems. In addition, it presentsa case study of health promotion for Argentine Hemorrhagic Feverdirected to agricultural workers in the endemic area of thisdisease.     

Toward a model of communications in public health in Latin America and the Caribbean]

OBJECTIVE: So far, there have been no bibliometric or scientometric studies that make it possible to examine, with quantitative, retrospective, and comprehensive criteria, the scientific output on public health in Latin America and the Caribbean (LAC). Further, the weakness of the existing information systems makes it impossible to examine the relevance, quality, and impact of this scientific output, with a view to evaluating it in terms of societal needs and existing patterns of scientific communication. This article presents the results of a bibliographic analysis of the scientific output in the area of public health in Latin America and the Caribbean. The ultimate goal of the analysis is to build a model of scientific communication in this field, to help researchers, managers, and others working in the area of public health to make decisions and choose actions to take. METHODS: We conducted a literature review in order to identify the distribution of publications on public health that were produced by LAC researchers and published in each of the LAC countries from 1980 through 2002. The review used the Literatura Latino-Americana e do Caribe em Saúde Pública (LILACS-SP) (Latin American and Caribbean Literature on Public Health) bibliographic database. That database is operated by the Latin American and Caribbean Center on Health Sciences Information (BIREME), which is in S?o Paulo, Brazil. We processed the LILACS-SP data using two software packages, Microsoft Excel and Bibexcel, to obtain indicators of the scientific output, the type of document, the language, the number of authors for each publication, the thematic content, and the participating institutions. For the 1980-2002 period, there were 97,605 publications registered, from a total of 37 LAC countries. RESULTS: For the analysis presented in this article, we limited the sample to the 8 countries in Latin America and the Caribbean that had at least 3,000 documents each registered in the LILACS-SP database over the 1980-2002 study period. In descending order of the number of publications registered, the 8 nations were: Argentina, Brazil, Chile, Colombia, Cuba, Mexico, Peru, and Venezuela. Those 8 countries were responsible for 83,054 publications (85.10% of the total of 97,605 registered documents produced by the 37 LAC countries). Of those 83,054 publications from the 8 countries, 56,253 of them (67.73%) were articles published in scientific journals and 24,488 were monographs (29.48%). The proportion of works produced by two or more coauthors was relatively high (56.48%). The 56,253 articles appeared in a total of 929 different journals. Of the 929 journals, 91 of them published at least 150 articles over the study period. In descending order, LAC journals with the largest number of articles on public health were: Revista de Saúde Pública (Brazil); Cadernos de Saúde Pública (Brazil); Revista Médica de Chile; Archivos Latinoamericanos de Nutrición (Venezuela); and Salud Pública de México. The 91 journals that published at least 150 articles represented 29 different specialties. The most common of the specialties for the 91 journals were general medicine (18 journals) and pediatrics (10 journals). In descending order, the populations that the publications dealt with primarily were human beings in general, females, males, and adults; and, in descending order, a relatively small number of publications dealt with pregnant women and middle-aged or elderly persons. The topics most often covered in the publications were risk factors, health policy, and primary health care, as well as family doctors in the case of Cuba. CONCLUSIONS: This research produced a preliminary model of communications in public health in LAC countries that will hopefully help lay the groundwork for further research to develop a model of scientific communication in LAC nations.     

Equity and health systems reform in Latin America

The aim of any health care system is to help improve the people's health, and to do so as efficiently as possible. In order to improve the efficiency and equity of health services provision, many countries around the world have implemented reforms, including several Latin American nations. However similar the objectives may appear, the various ways societies implement such reforms reflect different values and concepts. This article analyzes the egalitarian and neoliberal values underlying different concepts of equity in health care. The authors develop criteria to interpret selected health services funding and provision strategies in Latin American health system reforms. These criteria are then applied to health care financing and delivery policies under the reforms currently being implemented in Colombia and Costa Rica.     

Health care technology transfer in Latin America and the Caribbean.

The greatest problem concerning health care technology for developing countries is that they are dependent upon the industrialized world for technology. The only short-term solution to this problem is to improve the choices that are available to them. This goal will require changes in the structure and processes of policy making. A particular difficulty for these countries is the lack of trained personnel in fields related to technology assessment.     

Perspectives for workplace health promotion in Latin America and the Caribbean

The Latin American and Caribbean region is witnessing the emergence of discussion on workplace health promotion (WHP). The authors propose WHP as an equitable collective action targeting primarily work hazards and their determinants. It has its economic-political "macro" level and a downstream "micro" level. On the macro level, neoliberalism, privatization, and deregulation threaten equitable health and labor issues. Effective labor and health legislation and a fair degree of social redistribution of resources support WHP. Micro-scale WHP is important for contextual reasons and social diffusion, and can literally save lives. Worker involvement, free association of workers, public health affiliation, the precautionary principle, sensitization and training, employer responsibility for healthy working conditions, coalitions between workers and health professionals, and preference for reduction of direct work hazards over modification of personal lifestyles are basic tenets of WHP.     

Managed care in Latin America: the new common sense in health policy reform

This article presents the results of the comparative research project, "Managed Care in Latin America: Its Role in Health System Reform." Conducted by teams in Argentina, Brazil, Chile, Ecuador, and the United States, the study focused on the exportation of managed care, especially from the United States, and its adoption in Latin American countries. Our research methods included qualitative and quantitative techniques. The adoption of managed care reflects the process of transnationalization in the health sector. Our findings demonstrate the entrance of the main multinational corporations of finance capital into the private sector of insurance and health services, and these corporations' intention to assume administrative responsibilities for state institutions and to secure access to medical social security funds. International lending agencies, especially the World Bank, support the corporatization and privatization of health care services, as a condition of further loans to Latin American countries. We conclude that this process of change, which involves the gradual adoption of managed care as an officially favored policy, reflects ideologically based discourses that accept the inexorable nature of managed care reforms.     

Urban air pollution in Latin America and the Caribbean: health perspectives

In the last few years, air pollution has become a major issue in some countries of Latin America and the Caribbean because of urban development and growing industrialization. In addition to industrial processes often concentrated in the cities, vehicle emission and stationary-source fuel combustion are the primary sources of air pollution. Although air-quality standards have been established in some Latin American countries, these are frequently exceeded. Adverse health effects of air pollution have been mainly associated with the following pollutants: sulfur dioxide and particulate matter, photochemical oxidants, nitrogen dioxide and carbon monoxide, and lead. Short-term as well as long-term effects can be expected at levels exceeding WHO guidelines. The Latin American urban areas most affected by anthropogenic pollutant emissions are: the area of S?o Paulo (Brazil), the city of Santiago (Chile) and the metropolitan area of Mexico City. However, situations similar to those prevailing in these cities could well occur in other cities of Latin America and the Caribbean. The population exposed to air-pollutant levels exceeding WHO guidelines can be estimated to 81 million or 26.5% of the total urban population of Latin America and 19% of its total population. These estimates correspond to 30 million children (0-14), 47 million adults (15-59) and 4 million elderly people (60+). To date a very limited number of epidemiological studies have been carried out to determine the potential health effects of air pollutants in Latin America. To obtain a rough estimate, a scenario was hypothesized in which subjects living in cities would be exposed to a given level of air pollutant, using data from the international literature to extrapolate the expected number of events in different strata of the hypothetical population. The estimated health effects are considerable and warrant priority control intervention. This is true although epidemiological studies are needed to evaluate the health impact of specific pollutant compounds as well as their interactions in Latin American populations exposed to high levels of pollution.