Health Inequalities in the Americas by ida17629

VIEWS: 19 PAGES: 38

									                                                           2005




                   Health in The Americas :

               From Health for All to the Millennium
                      Development Goals

                         Mirta Roses Periago
                  Director, Pan American Sanitary Bureau

Pan American
Health
Organization                Ottawa, May 2005
                                                                                                             2005
       the political scenario of population health in the Americas
                                              WIDENING DISPARITIES
                                                RISING EXCLUSION
 Bipolar world                                                                                     Unipolar world
 Cold War                                                                                        War on terrorism
                                                     GLOBALIZATION
 Capitalism vs Socialism                          & New Economic Order                       Capitalism hegemony
 Anti-colonialist          DEMOCRATIZATION                                                           Globalization
 movement                   & decentralization                                                       Unilateralism
                                                    Economic & State Reforms
 Third World
                                                    Health Sector Reforms                     Human insecurity &
 Multilateralism       Welfare State &                                                              vulnerability
                     Social Security Crisis
                                                                         MDG
         HFA


1975                                             1990                     2000                                2015

   DEMOGRAPHIC TRANSITION: population growth, urbanization, population ageing
                    EPIDEMIOLOGIC POLARIZATION: opposite risk & disease profiles coexistence
                                                 ENVIRONMENTAL & ECOLOGIC overburdening impact
            Pan American
            Health
            Organization
                                                                                 PAHO/WHO; DPM/SDH & DPM/GPP; 2005
                                                                                  2005


     the call for equity in ―Health for All‖ (1977-2000)


   political commitment to achieve universal access to health services

   recognition of health as a fundamental human right

   ethical basis for international commitments

   recognition of health as a pre-requisite to economic & human
    development

   recognition of role and responsibilities of the State in the
    protection of population health

   health systems have an essential role: Primary Health Care is the
    strategy for its transformation


    Pan American
    Health
    Organization
                                                      PAHO/WHO; DPM/SDH & DPM/GPP; 2005
                                                                 the legacy of HFA to the population of the Americas                                                        2005


                                                               decomposition of 1980-2000 life expectancy changes by cause and age
                                                                            0.40
                                                                1.6
                                                                                              acute diarrheal diseases
years of life expectancy gained 1980-2000 (regional average)




                                                                1.4
                                                                            0.30

                                                                1.2
                                                                                                    acute respiratory infections

                                                                1.0         0.20


                                                                                                            immunopreventable diseases
                                                               0.8

                                                                            0.10
                                                               0.6
                                                                                                                         nutritional deficiencies

                                                               0.4
                                                                            0.00
                                                                                   <1   1-4       5-9       10-14   15-19      20-24
                                                                                                                                                              residual
                                                               0.2                                  age (years)                                               violence
                                                                                                                                                              perinatal
                                                               0.0
                                                                                                                                                              cardiovascular
                                                                                                                                                              cancer
                                                               -0.2
                                                                                                                                                              communicable
                                                               -0.4

                                                                  Pan American
                                                                  Health
                                                                  Organization
                                                                                                                                   PAHO/WHO: Health in the Americas, Edition 2002
                                                                                 2005


         the major forces in the Pan American context

Return to Democracy
     representative democracy
     democracy under economic pressure
     ―low intensity democracies‖


The Washington Consensus, 1990
    one agenda for economic market-oriented reforms
    neoliberal approach: market fundamentalism


Globalization
     inter–dependency of countries/markets
     threats, risks and economic vulnerability
     limits to policy jurisdiction and enforcement by national states


    Pan American
    Health
    Organization
                                                     PAHO/WHO; DPM/SDH & DPM/GPP; 2005
                                                                          2005


        IMPACT OF MARKET-ORIENTED REFORMS ON
            WELFARE STATE IN THE NINETIES


                                         • Labor Flexibility

                                         • Low quality employment
                                           and high unemployment
SOCIAL JUSTICE              EQUITY
                 SOCIETY
                                         • Low salaries
                    STATE                • Informal labor market
                            EFFICIENCY
  ECONOMIC
   GROWTH        MARKETS                 • Low coverage of social
                                           services
                                         • Social inequities and social
   CRISIS OF SOCIAL PROTECTION             exclusion
     REGIME BASED ON LABOR
   CONTRACT, HIGHLY SEGMENTED            • Rising social segmentation
          LOW COVERAGE

     Pan American
                                         • Institutional fragmentation
     Health
     Organization
                                                                                                                                                       2005

                                                               disparities in economic growth in the Americas
                                               14,000                                                                           upper tercile



                                               12,000
ppp-adjusted average GNP per capita (int. $)




                                               10,000




                                                8,000




                                                6,000                                                                           mid tercile




                                                4,000




                                                                                                                                Lower tercile
                                                2,000




                                                    0
                                                        1978      1980   1982   1984   1986   1988   1990        1992        1994             1996   1998
                                                    Pan American
                                                    Health
                                                    Organization                                            PAHO/WHO: Health in the Americas, Edition 2002
                                                                                                                                             2005

the depth of income inequality in the Americas, 2003
                                      1.0



                                      0.9



                                      0.8
    income (cummulative proportion)



                                      0.7



                                      0.6



                                      0.5



                                      0.4



                                      0.3



                                      0.2



                                      0.1



                                      0.0
                                            0.0   0.1      0.2    0.3   0.4    0.5    0.6   0.7    0.8      0.9      1.0

Pan American                                                        population ranked by income
                                                        poorest                                   richest
Health                                                               (cummulative proportion)
Organization
                                                                                                                  CD145/7; PAHO Program Budget Policy
                                                                                                                                              2005

inequalities in life expectancy. The Americas, 1990-2000
                                          80




                                          75
life expectancy at birth (1990s); years




                                                                                                                       regional
                                          70                                                                           median




                                          65




                                          60
                                                                                                                       income gap

                                                                                                                            narrow gap

                                          55                                                                                 wide gap
                                                         low income                  high income
                                          Pan American
                                          Health                      income level
                                          Organization                                             PAHO/WHO: Health in the Americas, Edition 2002
                                                                                                                                                    2005
inequalities in access to water & sanitation. The Americas, 1998
                                                 100

                                                                                                                               urban
                                                                                                                              median
                                                  90                                                                          regional
   median access to waer & sanitation 1998 (%)




                                                  80



                                                  70                                                                            rural
                                                                                                                              median
                                                                                                                              regional

                                                  60


                                                  50



                                                  40


                                                  30                                                                                 urban


                                                  20                                                                                 rural
                                                        low-narrow       low-wide       high-narrow      high-wide
                                                 Pan American    income level-income gap country group
                                                 Health
                                                 Organization                                            PAHO/WHO: Health in the Americas, Edition 2002
                                                                                                                        2005
                   Infant Mortality Rate (per 1,000 live births)
                       and access to water systems, 1998
         100



           80




           60



           40




           20



             0

                        EUA CUB CHI COR URU VEN ARG PAN COL MEX DOR HON ECU ELS BRA GUT NIC PER HAI

Infant mortality    7    8   10   14   14    20   23   24   25   28   34   42   43   44   44   47   48   52   55   86

Access to water    100 100   91   91   100   89   79   65   84   75   83   73   77   55   53   69   67   62   66   39

   Pan American
   Health Source: SHA/PAHO
   Organization
                                                                                                                                                                             2005
       ethnic diversity and social exclusion: a case from Panama
  Quartile of Human                                                        Panama
                                                          Province
  Development, 2002                                                          HDI                                                20
                                                          Ngöbe Buglé       0.363




                                                                                             physicians per 10.000 pop
Lowest                                     wIDH = 0.383   Emberá Wounaan    0.392
                                                                                                                                15
                                                          Kuna Yala         0.448
                                                          Darién            0.504
Low                                        wIDH = 0.594   Veraguas          0.600                                               10
                                                          Bocas del Toro    0.619
                                                          Coclé             0.650
High                                       wIDH = 0.679   Herrera           0.690                                                5
                                                          Chiriquí          0.692
                                                          Los Santos        0.710                                                0
Highest                                    wIDH = 0.755   Colón             0.715
                                                                                                                                     lowest     low       high     highest
                                                          Panamá            0.764
 wIDH = weighted Panama's Human Development Index 2002
                                                                                                                                         quartile of human development

                                          15                                                                                    80
          premature death (% <40 years)




                                                                                             life expectancy at birth (years)
                                                                                                                                75
                                          10

                                                                                                                                70

                                           5
                                                                                                                                65


                                           0                                                                                    60
                                          lowest       low       high    highest                                                     lowest     low       high     highest
                                   Pan American
                                   Health     quartile of human development                                                              quartile of human development
                                   Organization
                                                                                    PAHO/WHO; Governance & Policies, DPM/GPP/GP & PWR Panama; 2004
                       ethnic diversity & social exclusion: a case from Panama
                                                                                                                                                                  2005


                                 effect of US$ 100 of increment in the annual household income
                      25.0                                                                                   90.0
                                    Ngöbe Buglé
                                                                                                             80.0




                                                                           chronic child malnutrition (%)
                      20.0                                                                                   70.0         Emberá–Wounaan
low birthweight (%)




                                                                                                             60.0
                      15.0
                                            Herrera                                                          50.0

                                                                                                             40.0
                      10.0
                                                                                                             30.0                          Colón

                       5.0                                                                                   20.0

                                                                                                             10.0

                       0.0                                                                                    0.0
                             0       1000      2000        3000         4000                                        0    1000         2000          3000          4000
                                     average annual income (US$)                                                        average annual income (US$)

          province                       income       absolute change                                       province               income         absolute change
         Ngöbe Buglé                        $141      21.5%        17.3%                                    Emberá Wounaan            $413        61.1%          48.4%
       Herrera                           $1,765        9.2%        8.2%                                     Colón                   $2,151        14.2%          12.6%
                             Pan American
                             Health
                             Organization                                                                               PAHO/WHO; Policies & Strategies, DPM/GPP/SP; 2004
                                                                                      2005


     health equity in the social & development agendas

   lack of equity was seen as a health problem in 1977; now it is
    clear that equity is a social, political, and developmental issue.

   health is increasingly seen as a pre-requisite for good governance,
    social stability, and sustainable development.

   a new health debate is also in place:

                                       i.     security issue;
                                       ii.    foreign policy issue;
              health as a:             iii.   macro economic issue;
                                       iv. human rights issue; and,
                                       v.     global public good

    Pan American
    Health
    Organization
                                                          PAHO/WHO; DPM/SDH & DPM/GPP; 2004
                                                                                            2005

 The thrust for social justice: MDG‘s collective intentionality

MDGs have brought the investment in people‘s health to the very center
of the global development agenda, opening new opportunities for the
health sector and health organizations to gain wide support for the
health agenda:
       gaining access to the political system;
       legitimizing critical social issues, such as health disparities;
       giving a voice to unattended groups and issues

There is a close match between the challenges set by the MDGs and
PAHO‘s new strategic priorities and directions:
       address health determinants;
       protect health as a public good and human right;
       create a synergy of actors;
       ensure fairness of distribution.
     Pan American
     Health
     Organization
                                                                PAHO/WHO; DPM/SDH & DPM/GPP; 2005
                                                         2005


Implementation of the MDGs in the Region: gaps to fill


• the operational gap in scaling-up health systems and
  public health infrastructure;
• the structural gap in extending social protection in
  health;
• the governance gap in involving wide segments of
  government and society in a truly intersectoral and
  participatory effort;
• the equity gap in addressing the health needs of the
  poorest



  Pan American
  Health
  Organization
                                                                          2005
      PAHO framework for technical cooperation


                        addressing the
                          unfinished
                           agenda



                          national
                           health
                        development

           protecting                    facing new
         achievements                    challenges
            in health                     in health


Pan American
Health
Organization                                   PAHO/WHO; DPM/SDH & DPM/GPP; 2005
                                                                                                                                                                            2005

                                                     maternal mortality‘s unfinished agenda in the Americas

                                                     1000
maternal mortality (ratio per 100,000 live births)



                                                              USA                  HAI                                                                                  CAN
                                                                                                     LAC
                                                     900     trend
                                                                                           BOL
                                                                                                     PAR
                                                     800                                   PER
                                                                                                     PAN
                                                                                                 BRA
                                                                                                     TRT
                                                     700                                         GUT
                                                                                                     DOR
                                                                                                 NIC
                                                                                                     ELS
                                                     600
                                                                                                                VEN
                                                                                                            COL
                                                                                                                BAR
                                                     500                                                    ECU
                                                                                                                JAM
                                                                                                            HON
                                                                                                                MEX
                                                     400
                                                                                                                ARG           BAH
                                                                                                                              COR
                                                     300                                                                                  CUB
                                                                                                                                          CHI
                                                     200                                                                                  URU

                                                     100

                                                       0
                                                            1900     1910   1920       1930       1940       1950        1960       1970        1980       1990       2000


                                                       Pan American                 Centers for Disease Control & Prevention. Achievements in Public Health 1900-1999: Healthier
                                                       Health                                                                  Mothers and Babies; 48(38):849-58; Atlanta, 1999.
                                                       Organization                WHO Maternal Mortality in 2000: estimates developed by WHO, UNICEF & UNFPA; Geneva, 2002
                                                                                                                                                                                             2005

                                                 maternal death risk in LAC: 2005-2015 scenarios

maternal mortality rate in 2005                                                                                     burden of mortality to avert 2005-2010
by health needs-based country groups                                                                                            by health needs-based country groups

                                                                                                                                                                             G1 G2
                                           300
maternal death risk (MMR per 100,000 lb)




                                                                                                                                                       G6                    3% 3%
                                                                                                                                                      21%                               G3
                                           250                                                                                                                                         16%

                                           200


                                           150                                                                                                  G5
                                                                                                                                               15%
                                           100

                                                                                                                                                                                  G4
                                           50
                                                                                                                                                                                 42%

                                            0
                                                                                                                                          total number of preventable deaths: 38,000
                                                  G1      G2         G3              G4               G5              G6


                                                                PHNI Group 0 (lowest health needs)    Canada, USA, Puerto Rico, France, Netherlands, and UK territories
                                                                                    PHNI Group 1      Argentina, Bahamas, Barbados, Chile, Costa Rica, Uruguay
                                                                                    PHNI Group 2      Colombia, Mexico, Panama, Trinidad & Tobago, Venezuela
                                                                                    PHNI Group 3      Belize, Brazil, Jamaica, Saint Lucia, Saint Vincent & the Grenadines
                                                                                    PHNI Group 4      Cuba, Dominican Republic, El Salvador, Paraguay, Peru, Suriname
                                                                PHNI Group 5 (highest health needs)   Bolivia, Ecuador, Guatemala, Guyana, Haiti, Honduras, Nicaragua
                                                 Pan American
                                                 Health
                                                 Organization                                                                    PAHO/WHO; Governance, Policies & Partnerships; 2005
                                                                                                         2005

                                 Measles vaccine coverage, 2001
              Chile

         Ho nduras

         Nicaragua

            B o livia

            M exico

         A rgentina

              P eru

           Uruguay

        Co sta Rica

            Guyana

              B razil

        El Salvado r

        Guatemala

         B arbabo s

         Co lo mbia

           P anama

             B elize

           Trinidad

           Jamaica

          P araguay

Do minican Republic

           Ecuado r

              Cuba

         Venezuela

          Suriname                                                               Regional average: 91%
               Haiti


                        0   10     20      30      40      50     60   70   80           90              100
                 Pan American
                 Health
                 Organization
                                   Source: PAHO Core Data, 2003
                                                              %
                                                                                                                                                                                    2005

                                              infant death risk in LAC: 2005-2015 scenarios

infant mortality rate in 2005                                                                                  burden of mortality to avert 2005-2010
by health needs-based country groups                                                                                       by health needs-based country groups
                                       35

                                                                                                                                                  G6                     G1
infant death risk (IMR per 1,000 lb)




                                       30                                                                                                        21%                    17%

                                       25                                                                                                                                     G2
                                                                                                                                                                              4%
                                       20
                                                                                                                                          G5
                                       15                                                                                                12%
                                                                                                                                                                               G3
                                                                                                                                                                              21%
                                       10


                                       5                                                                                                                 G4
                                                                                                                                                        25%
                                       0
                                            G1       G2         G3              G4               G5               G6            total number of preventable deaths: 257,000


                                                           PHNI Group 0 (lowest health needs)    Canada, USA, Puerto Rico, France, Netherlands, and UK territories
                                                                               PHNI Group 1      Argentina, Bahamas, Barbados, Chile, Costa Rica, Uruguay
                                                                               PHNI Group 2      Colombia, Mexico, Panama, Trinidad & Tobago, Venezuela
                                                                               PHNI Group 3      Belize, Brazil, Jamaica, Saint Lucia, Saint Vincent & the Grenadines
                                                                               PHNI Group 4      Cuba, Dominican Republic, El Salvador, Paraguay, Peru, Suriname
                                                           PHNI Group 5 (highest health needs)   Bolivia, Ecuador, Guatemala, Guyana, Haiti, Honduras, Nicaragua
                                            Pan American
                                            Health
                                            Organization                                                                    PAHO/WHO; Governance, Policies & Partnerships; 2005
                                                                               2005


challenges to the National Health Development in the Americas


       inadecuate governance and conflict of interests

       uneasy economic adaptation to globalization

       ample infrastructure, but with social exclusion

       antiquate structures & incomplete decentralization

       manpower & resources reduction in public sector




       Pan American
       Health
       Organization
                                                   PAHO/WHO; DPM/SDH & DPM/GPP; 2005
                                                 2005




               The ―missing middle‖

 – Strengthening Public Health Infrastructure

 – Extending social protection in health

 – Developing the health workforce

 – Developing the operative capacity of health
   services



Pan American
Health
Organization
                                                                                2005

             a new agenda for health sector reforms

   strengthening reduction of health inequity

   solidarity in financing

   population health‘s oriented interventions

   health promotion and prevention-based health care models

   adequate performance of essential public health functions

   integral and sustainable human resources development

   emphasis on the steering role

   extension of social protection in health



    Pan American
    Health
    Organization                                  PAHO/WHO; DPM/SDH & DPM/GPP; 2005
                                                                                     2005

               ESSENTIAL CHARACTERISTICS OF
                     A HEALTH SYSTEM
                                                                           FINAL
                                            INTERMEDIATE                 OBJECTIVES
                                             OBJECTIVES
                                                                          Improve
RESOURCES                                                              Health Situation
                          FUNCTIONS
                                            Cost-effective
 Financial                                                              Promote and
                      Steering Role         interventions
 Materials                                                                preserve
                        Financing
Organization                                                              healthy
                       Insurance            Quality of Care
                        Provision                                       environments
                                              Access to
                                             Services by                 Contribute to
                                                needs                  Overcome illness
                                                              HEALTH     and disability
                                                               CARE
                                                               MODEL


                              HEALTH WORKERS



                      VALUES AND PRINCIPLES

                  EQUITY, UNIVERSAL ACCESS, SOLIDARITY
     Pan American
     Health    INTEGRAL   CARE, EFFECTIVITY, QUALITY, EFFICIENCY
     Organization
                                                                                              2005

                   main challenges to health systems


   guarantee social protection in health to all citizens

   contribute to the elimination of inequities in access to health
    services

   guarantee quality health services

   assure excluded social groups equal opportunity to receive integral
    health care

   satisfy the population‘s health needs and demands

   eliminate the inability to pay as a barrier to access to health care


    Pan American
    Health
    Organization                             PAHO/WHO XLIII Directing Council, Washington DC 2002
                                                                                   2005

The Commission on Social Determinants of Health (CSDH)

The Commission aims to level policy change by turning existing public
health knowledge into actionable goals and national policy agendas. It
will:


       compile evidence on successful interventions and formulate policies that
        address key social determinants, particularly for low-income countries;
       raise societal debate and advocate for implementation by Member
        States, civil society, and global health actors of policies that address
        social determinants;
       define a medium- and long-term action agenda for incorporating social
        determinants of health interventions/approaches into planning, policy,
        and technical work within WHO.


    Pan American
    Health
    Organization
                                                                             2005


how do we should tackle the social determinants of health?
           CSDH positioning on the Mahler-Grant problem

    by leading a far-reaching structural critique based on a social justice
     vision, a ‗Copernican revolution‘ in thinking and action on health
     policy, aimed at significant changes to states‘ existing governance
     and budget structures and their relationships with IFIs and donors;

or

    by developing and promoting a ‗ toolkit‘ of tightly focused effective
     interventions that states can implement swiftly and may produce
     short-term results, but risk leaving the deeper causes of avoidable
     suffering and health inequities untouched.



     Pan American
     Health
     Organization
                                                                         2005

       why policy action on social determinants of health
                 has lagged in most settings?

   The blockage is a problem of knowledge. Action to address SDH has
    been weak because the evidence base on which to build such action
    is inadequate, or existing evidence has not been effectively
    communicated to those in a position to effect change.

   The blockage is a problem of power. The most important barriers to
    action on SDH lie in the political-economic dimension of power and
    profit. Policy failure on SDH is not primarily a symptom of ignorance,
    but a logical consequence of existing power relations.

    The CSDH will focus on both avenues, the scientific evidence and the
    political strategy to generate the concrete change it seeks.


     Pan American
     Health
     Organization
                                                                                 2005
       access to information & the digital divide




                      In 2001, the number of internet users (UNDP, 2003) was:
                               396.9 per 1,000 people in high income countries
                             36.8 per 1,000 people in middle income countries
                                   1.8 per 1000 people in low income countries

Pan American
Health
Organization
                                                                                                                                     2005

                 the scientific voice from The Americas‘ South

distribution of scientific papers by                                     distribution of scientific papers from
principal author‘s country of origin                                  Latin America & the Caribbean by area
MEDLINE 2000-02 (n = 1.1M)                                           MEDLINE & LiLACS 2000-02 (n = 0.1M)

                           3%                                                61%


39%                                                                                                                              10%
                                                            47%




                                                                                                                          14%
                                                                                         8%           2% 2% 3%
                    8%          3%



                                                                     Clinical Medicine                  Biomedical Sciences
 United States of America            Canada                          Basic Sciences                     Pharmacology
 rest of developed countries         Latin America & the Caribbean   Food Sciences                      Social Sciences & Social Welfare
 rest of developing countries                                        Public Health & Health Systems

       Pan American
       Health
       Organization
                                                                                                      PAHO/WHO; IKM/RU & DPM/GPP; 2004
                                                   2005



HEALTH EXPENDITURE AS % OF GNP IN LAC, 1997-2000




  Pan American
  Health
  Organization
                                       2005

       NATIONAL HEALTH EXPENDITURES:
           PUBLIC VERSUS PRIVATE




Pan American
Health
Organization
                                                                               PAHO/WHO new program budget policy:                                                                 2005


                                                                               distributive impact on regional income inequality
                                                                               1.0



   PAHO resources (cummulative proportion)                                     0.9



                                                                               0.8
                                             income (cummulative proportion)



                                                                               0.7



                                                                               0.6



                                                                               0.5



                                                                               0.4



                                                                               0.3



                                                                               0.2



                                                                               0.1



                                                                               0.0

Pan American                                                                         0.0   0.1      0.2    0.3   0.4    0.5    0.6   0.7    0.8       0.9    1.0
Health                                                                                                       population ranked by income
Organization                                                                                     poorest                                   richest
                                                                                                              (cummulative proportion)
                                                                                                                                                  CD145/7; PAHO Program Budget Policy, 2004
                                                        2005




                Reaching the neediest


• The equity perspective must be present in the
  analysis and monitoring of the actions to reach the
  MDGs and their targets, as well as of the level of
  their current level of completion.
• Need for disaggregating the indicators so
  geographical areas and neglected social groups that
  should be targeted for special interventions can be
  identified.
• Importance of PAHO/WHO‘s work on supporting the
  development of expanded social protection systems
  in the Region
 Pan American
 Health
 Organization
                                                          2005



        Strategic Goals to Support Countries

• Engage and increase cooperation with other
  partners—particularly at the country level—to obtain
  results.
• Increase health literacy and community
  empowerment to reach the MDGs.
• Improve measurement of progress through high-
  quality disaggregated health data at regional,
  subregional, and country levels.
• Initiate research to strengthen the evidence base and
  generate new knowledge.


   Pan American
   Health
   Organization
                                                                        2005




                             Health For All




                                 Health Promotion




                                                    Social Protection
               Health Care
                Primary




                  Information & Knowledge
Pan American
Health
Organization                 Human Rights
                                            2005




               PAHO in the 21st Century

                        one team, one goal:



      ...to improve the health of the Americas

Pan American
Health
Organization

								
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