The resilience of Latin America’s Health System

Latin America is faced with a deteriorating economy, economic recession, and significant political changes. How can it preserve what has been achieved in terms of public health and social inclusion? Interview. Español

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Francesc Badia i Dalmases Leire Pajín
2 November 2016

XV Ibero-American Conference of Ministers of Health in Cartagena de Indias. Secretaria General Iberoamericana. All rights reserved.

Francesc Badia i Dalmases: Latin America is experiencing a cycle of political change after more than a decade of economic growth and social and political progress that has also resulted in improvements with regard to issues affecting health. Are there reasons to keep on being optimistic?

Leire Pajín: I think that in recent years the region has offered a number of good news. One has to do, quite obviously, with economic growth and social inclusion. The latest United Nations Development Program’s (PNUD) Human Development Index for Latin America and the Caribbean show that it is the world region where poverty and inequality has been reduced the most in comparative terms. The good news is that economic growth has helped to diminish poverty and inequality. The bad news, however, is that inequality is still the great challenge of Latin America, for we have not managed to break unequal access to services and the most basic rights. A minority of the population still concentrates a very disproportionate share of total wealth to the detriment of a vast majority who has no access to minimum resources. The challenge now, and the PNUD Index makes it very clear, is not to lose what has been gained in recent years. In this cycle of economic slowdown the region is currently going through, those who have escaped poverty, and even the lower middle class, are very vulnerable and can easily fall back into exclusion and total poverty.

FB: How fragile are the gains of the economic and political cycle that is coming to an end? How does the cycle change affect health policies?

LP: Objectively, economic growth, plus a series of ambitious and progressive policies that have been developed in the region in recent years, including very specific social programs aimed at breaking inequality, have improved social inclusion. Now, we are faced with a deteriorating economy, greater economic recession, and also significant political changes. What remains to be seen is how much resilience is there to preserve what has been achieved so far. This is the big challenge.

What Latin American reality shows is that poverty is a multidimensional phenomenon. Poverty is not measured only in terms of income, but also in terms of health, gender equality, and social protection. Health is key to determining the development of the region and the challenges it faces, at a time when the Millennium Development Goals are giving way to the Sustainable Development Goals. The good news is that in recent years we have managed to significantly increase life expectancy in Latin America through massive vaccination policies which have reduced infant mortality. The other piece of good news is that maternal mortality, though still very high, has been reduced by almost 52%. Clearly, progress has been made. But I must say that the number of women dying in Latin America from maternity-related causes is still unbearably high.

FB: This has to do also with ideological issues related to reproductive rights, does it not?

LP: This has to do with two factors. On the one hand, the lack of equal access to healthcare services in general, which particularly affects women. The burden of vulnerability for indigenous women and women of African descent is twice as heavy, for they are discriminated against not only on this, but also socially and economically. On the other hand, the challenge is to ensure minimum sexual and reproductive rights for women, which means access to new generation contraceptives, and to accurate and effective information, and also to the exercise of fundamental rights.

The data are far from being positive in the case of teenage pregnancies. Young women, mostly teenagers, account for 26% of childbirths in Latin America. This is a worrying figure. It is no coincidence that both the Ibero-American Conference of Ministers of Health and the Conference on Reproductive Rights have called for powerful political and social action in this area. We cannot keep on accepting the current level of unwanted pregnancies among teenage women, who see their lives truncated in terms of employment, rights, and economic and social inclusion. Girls and teenagers have to face this reality on their own and this perpetuates poverty, inequality and exclusion. This is a major issue.

FB: You just mentioned multilateral summits. How do regional organizations such as UNASUR, which seems quite weakened at the moment, influence decisions? Or is this something that depends mainly on the World Health Organization (WHO)?

LP: I think the effort that is being done with the Ibero-american  Conference of Health Ministers (which took place early September in Colombia)  to gather in the same space and with the same aims, in one collective effort, the political will, the private sector, academia, research and activist society, indicates that working separately has not had positive results. We can see what these results are: we have failed to reduce teenage pregnancies adequately, so now we must redouble our efforts and organize in a coordinated and complementary way. The region has understood that this is both a particular and a shared challenge – a regional challenge.

But there are other elements to take into consideration. Seven out of the nine most restrictive countries in the world as regards the voluntary termination of pregnancy are in Latin America. This is a reality that is not unrelated to other health challenges facing the region at this point in time. For example, if we consider Zika-related microcephalia, the situation of women living in countries where they are allowed to continue, or not, with their pregnancy once the serious effects of the disease on the fetus have surfaced is clearly quite different – and unequal – from the situation of women living in countries where this possibility does not exist. But beyond reproductive rights, the region has to deal with epidemics and the effects of other types of virus.

FB: In a context of political crisis, in Brazil for example, it does not seem that legal progress on issues such as abortion is on the agenda - quite the opposite, in fact. Do you think that what has been achieved so far is strong enough to resist the onslaught of regression?

LP: Well, history has taught us that progress, unfortunately, especially when it has to do with social rights, especially women rights, can wither away rather quickly. There are clear examples of this in Europe, and particularly in Spain, where concern is widespread about losing progress made in recent years as a result of weak structures. The foundations of healthcare in Latin America are indeed very weak. While it is true that much has been achieved in recent years - many more people have access to healthcare, especially through health insurance schemes -, we are still very far from universal health coverage in the region. Besides, what do we mean by coverage? What do we mean by quality, and equity? What access is being guaranteed? Health insurance is not enough, for the insurance model in many countries in Latin America perpetuates social inequality: there are first class and second class insurances. It is important that we should be clear as to what we mean by universal coverage.

FB: There are also geographical gaps, central and peripheral urban communities, and also highly isolated rural communities...

LP: We must also take into account multiculturalism. Many indigenous and Afro-American populations live in rural areas, and this means that they are already cut-off from access to healthcare services, but there is also, in their case, a cultural and language factor that further hinders their access to health. It is therefore very important to work closely with the communities, especially in the case of indigenous communities. It is important to understand that it is essential to work with the people who are dealing with health issues in the communities, ensuring access to information and adequate reach.

FB: Another issue of epidemic proportions that has made the headlines this year, mostly in Latin America, is the so-called war on drugs. How do you view the situation in the region after UNGASS? Do you think Latin American countries will they keep on with the reform agenda in this field?

LP: I think that in Latin America people are very conscious of the damage and the tragedy of drug trafficking and consumption, particularly as regards the young. This is definitely one of the most important challenges in the region. For the first time in many years, however, there is an open and rigorous debate about the results of the policies based merely on prohibition and restriction, and about the possibility of adopting more open models and viewing the problem of drugs in terms of public health - which is how it should be viewed.

Some countries, like Uruguay, have been brave and have passed laws that change course and show the way to a new type of policies. The debate is on the table and it must be supported from the international arena. The policies that have been implemented so far show a dismal lack of results, and this should prompt us to change our responses. There is no easy answer, though, because many social elements have to be taken into account, such as violence and organized crime. But we have come to understand that we should give different answers, as has been discussed at the mentioned Conference of Ibero-American health ministers. Other equally important issues are youth violence and road accidents, which are two of the biggest causes of death in Latin America.

FB: Violence and firearm-related deaths have epidemic proportions in Latin America too.

LP: This is indeed an extremely serious matter. But Latin America is also a region with vector-borne endemic diseases such as Zika, Dengue or Chikungunya, and where malaria is still a serious problem. To this should be added the additional challenge of chronic and non-transmissible diseases such as overweight, which affects 26% of the under-19 population.

FB: There are also some reasons for hope, however, such as the fact that the WHO has declared the Americas free from measles, thanks to policies of massive and systematic vaccination.

LP: It is a fact that collaborative work in vaccination has achieved very positive results. But we are still a long way from dealing effectively with other diseases. Several ongoing epidemics show that although the region has some positive results to show, there are still many challenges ahead, especially related to regional coordination, training and joint response to early detection.

FB: Zika has been very much in the media, due to microcephalia and its awful consequences, particularly on vulnerable populations. What are the prospects?

LP: We still do not know the real impact and the reach of Zika in the region. But it is a disease that is here to stay, such as Dengue or Chikungunya. The true extent of its impact is unknown because we do not know what the social effects of microcephalia are, and we will only see them much later. But we are beginning to see that the impact goes well beyond health, and that it will have important socio-economic consequences. This is something that must be analyzed. Besides, there are several island countries in the region, which are more vulnerable to viruses: this is another, sometimes forgotten element that must be taken into account.

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