By Daniela C. Rodríguez, Mariana Calderón Jaramillo, Mathieu JP Poirier, Ariel Frisancho, Gisele Almeida, Daniel Maceira, Pablo Gaitán Rossi, Ana Lorena Ruano
Despite years of economic development, Latin America and the Caribbean still struggles with deep and persistent inequalities across many socio-demographic dimensions. Many efforts at health sector reforms have been attempted over the years, yet health systems remain deeply fragmented and face persistent challenges to deliver quality health services. A new Special Collection from the International Journal for Equity and Health begins to capture insights from the region for the field of health policy and systems.
To showcase this Special Collection, Health Systems Global hosted a webinar ‘Inequities in health and health systems in Latin America and the Caribbean’ on 18 March with presentations from authors. In addition, the webinar featured critical reflections from regional panelists and a discussion about what we know, what is still missing, the impacts of COVID-19, and what the future holds for health policy and systems research (HPSR) in Latin America. This blog post provides an overview of and reflections from the webinar.
Exclusion from health systems and future lessons
The first paper from Mariana Calderón Jaramillo and colleagues tackles sexual and reproductive health services for transgender people in Colombia, identifying barriers to access, such as out-of-pocket costs, bureaucracy, stigma and discrimination among providers, and limits to available services. These barriers are normalized, which increases mistrust from transgender patients. Unmet needs around sexual and reproductive health touch on both general services (e.g. birth control, sexual education, gynecology) as well as transgender-specific needs (e.g. endocrinology, reassignment services). To address these challenges, the authors propose improved training and sensitization of health workers, more research, and advocacy.
Mathieu JP Poirier presented his comparative analysis of equity of conditional cash transfer (CCT) programs in Bolivia, Colombia, Ecuador and Peru exploring the difference of targeting recipients based on socio-economic status (SES) and/or health status. He finds higher CCT coverage in sub-regions with higher vaccination coverage, and higher rates of underweight, stunting and child deaths; meanwhile policymakers appear to be guided by relative SES within a subregion rather than absolute poverty. Surprisingly, capital regions are under-targeted resulting in vulnerable women and children in these areas missing out on CCT programs. From a policy perspective, these findings suggest that a universal rollout of CCT with means testing performs better than geographic targeting.
Ariel Frisancho presented his work with colleagues comparing citizen-led accountability to address social exclusion in Guatemala and Peru, where socially excluded groups are seeing decreasing rights and entitlements. Indigenous community leaders as health facility monitors demonstrated that social exclusion is embedded in state and public health facilities, including discrimination and abuse, disrespectful treatment, charging of illegal fees and denial of services. Civil society and pro-accountability actors need support to implement governance approaches that address inequal power relations and push institutionalized accountability. At the same time, a shift in rhetoric from universal health insurance to universal health coverage is needed to increase the focus on access and quality.
Gisele Almeida from the Pan American Health Organization then reflected on the panelists’ work by drawing attention to historical drivers in the region, such as how CCTs have been a response to income inequality exacerbated by the externally-driven economic reforms of the 1980-90s. Likewise, marginalized groups — such as transgender people and indigenous people — experience multiple, intersecting vulnerabilities, while fragmented services and segmented financing continue to limit access and quality, and perpetuate poor outcomes. Inclusive, people-centered services are possible, but they require strong governance, intersectoral action on social determinants of health, and health information systems that do not hide excluded groups under averages.
In relation to COVID-19, the Latin America and Caribbean region has suffered mightily under the weight of its unresolved health sector problems and persistent inequalities. Despite strong health coverage indicators pre-pandemic, weak governance resulted in a failed health system response and near collapse in countries around the region, with people dying in the streets suffering from lack of hospital beds, intensive care services and oxygen. As elsewhere, the crisis hit vulnerable and excluded groups the hardest as they are served the least and reached last. Sexual, reproductive and other health services were de-prioritized as not urgent, and severe economic and social crises resulting from extended, rigid lockdowns jeopardized the living conditions of the most vulnerable.
What is next?
This Special Collection touches on governance and accountability, services and impacts on vulnerable and marginalized populations, health financing, health service delivery and planning, and includes a number of comparative papers, all of which showcase the robust HPSR that is happening in the region.
The Special Collection remains open and is actively seeking submissions in order to further advance conversations about HPSR in settings of persistent inequity. If interested, submit your manuscript to the International Journal for Equity and Health and asked to be added to the Special Collection. The collection and this webinar also set the stage for the next Global Symposium on Health Systems Research taking place in Bogotá, Colombia in 2022. The theme for the 2022 Symposium is currently under development, so active participation is welcome.