Equity
&
Health
Views from the
Pa n A m e r i c a n S a n i t a r y B u r e a u
Pan American Health Organization
Occasional Publication No. 8
Occasional Pub. No. 8
EQUITY
&
HEALTH
Views from the
Pan American
Sanitary Bureau
Pan American Health Organization
Regional Office of the
World Health Organization
525 23rd Street, N.W.
Washington, D.C. 20037 U.S.A.
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Table of Contents
PAHO Library Cataloguing in Publication Data
Pan American Health Organization
Equity and Health: Views from the Pan American Sanitary Bureau
Washington, D.C: PAHO, © 2001.- (Occasional Publication No. 8)
ISBN 92 75 12288 1
1. Title
1.
2.
3.
4.
5.
6.
II. Series
EQUITY IN HEALTH CONDITIONS
POVERTY
SOCIOECONOMIC FACTORS
HEALTH FINANCING
HEALTH STATUS INDICATORS
AMERICAS
LC HC79.P187e 2001
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TABLE OF CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiv
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
PART 1. CONCEPTUAL AND CONTEXTUAL ASPECTS
OF HEALTH EQUITY IN THE AMERICAS
Equity and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
George A. O. Alleyne
Assessing Equity in Health: Conceptual Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alexandra Bambas and Juan Antonio Casas
Health Disparities in Latin America and the Caribbean: The Role of Social and
Economic Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Juan Antonio Casas, J. Norberto Dachs, and Alexandra Bambas
Poverty, Human Development, and Public Expenditure: Developing Actions for
Government and Civil Society . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Eduardo Doryan
Poverty, Equity, and Health: Some Research Findings . . . . . . . . . . . . . . . . . . . . . . . . .
Adam Wagstaff
Equidad, Minorías Étnicas y Derechos Humanos Fundamentales . . . . . . . . . . . . . . .
Pilar Córdova
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22
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PART 2. PRIORITIES FOR INCORPORATING EQUITY INTO TECHNICAL
COOPERATION IN HEALTH IN THE AMERICAS
La Medición de las Desigualdades en Salud: Algunos Ejemplos
de la Región de las Américas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
George A. O. Alleyne, Carlos Castillo-Salgado, Cristina Schneider,
Oscar J. Mujica, Enrique Loyola, y Manuel Vidaurre
Noncommunicable Diseases and Risk Factor Surveillance . . . . . . . . . . . . . . . . . . . . . .
Sylvia Robles, Jeannette Vega, and Stephen Corber
Health Equity and Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ernesto Pate, Carol Collado, and José Antonio Solís
Health Equity in Relation to Safe Drinking Water Supply . . . . . . . . . . . . . . . . . . . . . .
Horst Otterstetter, Luiz A. C. Galvão, Vicente Witt, Peter Toft,
Sergio Caporali, Paulo C. Pinto, Luis C. R. Soares, and Carlos Cuneo
Access to Financing of Health Care: Ways to Measure Inequities and
Mechanisms to Reduce Them . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Daniel López Acuña, César Gattini, Matilde Pinto, and Bernt Andersson
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115
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Table of Contents
PART 3.
MAKING HEALTH EQUITY WORK AT THE COUNTRY LEVEL
Equity and Health: A Caribbean Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Richard A. Van West-Charles
Análise de Eqüidade – Saúde: Brasil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jacobo Finkelman
Equidad en Materia de Salud y Oportunidad de Vida
en Venezuela y Colombia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hernán Malaga, Marisela Perdomo, Angela González,
y Helena Restrepo
Agua Para Todos en el País de la Fantasía . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Paulo C. Pinto
Ética, Equidad y Práctica en las Instituciones de Salud . . . . . . . . . . . . . . . . . . . . . . . . .
Fernando Lolas Stepke
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PREFACE
Over the last several years, the concept of equity has emerged as a primary guiding
principle for the work of the Pan American Health Organization (PAHO). In particular,
PAHO has been gathering information on, and examining issues related to, disparities in
health in the Americas, especially as they relate to socioeconomic factors. Research findings from this effort have important implications for the Organization’s work, in that
they provide an empirical basis on which to build claims of health inequities and move
toward a more equitable distribution of the determinants of health outcomes. The development of a robust interpretation of the concept of equity is crucial for the advancement
of its application in the provision of appropriate technical cooperation by the Organization. The articles gathered in this publication represent an important step in that direction, in the measure in which they represent the status of the issues and dilemmas faced
by the PAHO Secretariat in making equity an operational concept for its work in the
Region. The challenge immediately before the authors is to show how this principle and
the insights it yields into the distribution of health—dependent as this is on differences
in education, income, class, ethnicity and race, geographic location, gender, and other
distinctions—can underpin the Organization’s work at the operational level and be incorporated into technical cooperation activities.
George A. O. Alleyne
Director
v
INTRODUCTION
In October 1999, PAHO held its first Organization-wide technical discussion of equity,
sharing perspectives developed by different Organizational divisions and among those
working at the country level. This publication includes the presentations made at that
meeting and is intended to provide a broad basis for discussion as well as to stimulate
future thought. The collection stands as an initial effort to interpret the concept of equity
for application to the various areas of PAHO’s work.
The individual articles were developed independently and reflect different approaches
to the interpretation of health equity. Many of the perspectives expressed in the collection extend from the conceptual work developed by other scholars and researchers or
emerge from PAHO’s ongoing work with collaborating institutions. Present project partners include the Rockefeller Foundation, the World Bank, UNDP, and CARICOM, as
well as several universities and professional and academic associations in the Region.
This diversity has presented challenges of its own. The job of the editors has been to
clarify the authors’ ideas and otherwise encourage dialogue that will eventually result
in conclusions, recommendations, and actions to be taken. A common understanding of
how to translate the concept would allow us to apply it to PAHO’s programs and technical cooperation, and to identify concrete and practical interventions and establish priorities which will contribute to increased equity in health in the countries of the Americas.
This collection is organized into three sections: “Conceptual and Contextual Aspects
of Health Equity,” “Priorities for Incorporating Equity into Technical Cooperation in
Health,” and “Making Health Equity Work at the Country Level.”
In the introductory chapter, Sir George Alleyne, the Director of PAHO, provides a
context for discussing equity and health, including the philosophical tenets of the concept and its recent historical development within the international health arena. In particular, he emphasizes the contribution of the “Black Report” and the “Acheson Report,”
especially in their emphasis on social determinants of health. Further, Dr. Alleyne links
past concerns with poverty to current equity and health projects, noting that current
research indicates that not only absolute levels of poverty but also relative deprivation
appears to affect health disparities. Finally, Dr. Alleyne provides suggestions for the role
that organizations such as PAHO and WHO can play in promoting equitable health situations, focusing on information collection and technical cooperation.
In “Assessing Equity in Health: Conceptual Criteria,” Bambas and Casas build and
expand on the definition of equity for health developed by Margaret Whitehead. They
explore the implications of Whitehead’s criteria for establishing health disparities as equitable or inequitable, including avoidability and choice, but also including a much overlooked criterion of responsible agency. The discussion provides a more detailed explication of each of the criteria and explains why they are relevant to the issue, demonstrating
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Introduction
how they can then be applied to specific situations in order to gauge the level of equity
or inequity present. This model provides a basis on which subsequent discussions of
equity that present empirical information on disparities among populations can be guided
and interpreted.
The second chapter, “Health Disparities in Latin America and the Caribbean: The Role
of Social and Economic Determinants,” by Casas, Dachs, and Bambas, provides an overview of the current empirical information available on various aspects of socioeconomic
inequalities in the Region. The authors first establish the general social and economic
context of Latin America and the Caribbean, including changes in the distribution of
income and education, both within and between countries and regions. After discussing
the present paucity of information in the Region, the article reviews the data available
for distributions of health between countries, and focuses on disparities within countries: among groups with different levels of income and education, populations living in
different geographic locations, among ethnic groups, between men and women, among
those with different levels of physical and financial access to health services, and for
migrants. Finally, strategic areas for the Organization are suggested, as are conclusions
and issues for further investigation.
The next two articles examine how to craft policies to promote equity in health. Using
the concept of “developmental cocktails” to create intersectoral synergy, Eduardo Doryan
raises key issues in combining an equity approach with attention to poverty to create
policy that accelerates the pace of human development in underdeveloped countries.
The question, as he poses it, is how to invest resources to simultaneously create growth
and decrease inequality. Doryan then ties the discussion into the three core issues of the
upcoming World Development Report—empowerment of the disadvantaged; security, livelihood, and risk management policies for nations; and opportunity for investment and
sustainable economic development. These core issues, he says, can be used as a crosssectoral framework for human development.
Adam Wagstaff demonstrates how to use empirical findings to link research to policymaking in order to further two of the broad goals of the health sector: 1) income protection,
specifically out-of-pocket payments and income loss due to illness and 2) focusing on the
health of the poor through access to health care and the non-medical determinants of health.
Intercountry comparisons show how the architecture of systems creates differential financial burdens between income groups through regressivity of payments, threat of poverty
due to out of pocket payments, and the availability of private insurance vs. publicly funded
systems. Wagstaff then provides a methodology for predicting the health impact of specific interventions, such as reducing travel time for the poor to medical facilities, broadening insurance coverage, and improving the quality of medical services.
Framing the discussion within social, economic, and cultural human rights and modern concepts of social justice, Piedad Córdova makes a cogent argument that the State is
the responsible agent for ensuring fair background conditions and institutions as well as
addressing those social factors that affect health equity. Córdova emphasizes how factors that especially affect women and ethnic minorities, such as violence, exclusion,
marginalization, and discrimination, generate inequitable social conditions that can eventually manifest as health inequities. The State has the duty to recognize social factors of
inequity and progressively address them and create fair background institutions in which
the population can direct political will. Further, the egalitarian construction of political
power; reduction of corruption; and support for economic, social, and cultural rights can
increase resources available for the equitable construction of a society. Córdova suggests
Introduction
ix
that, based on this discussion and the need to strengthen social institutions and political
processes, international cooperation should focus on information gathering and dissemination, and training, so that countries may attain the capacity to make their own development plans.
The book’s second section focuses on equity in relation to several priority areas for the
Organization, including establishing measuring methodologies as well as addressing 1)
risk factors in disease prevention and control, 2) maternal mortality, 3) safe drinking
water, and 4) access to and financing of health services. These articles present current
information from LAC on the issue, including statistics and measuring practices, as well
as methodological problems and additional information needed in order to establish
equity in health.
“La Medición de las Desigualdades en Salud” (“The Measurement of Health Inequalities”) discusses the use of several indicators of health disparities, as well as the purposes
of and complications involved in using them. Measurement indicators of inequality can
help to determine when there is equity in health, and how to identify equity gaps. The
authors discuss relative and absolute measures of inequality, population attributable risk,
the slope index of inequality and relative index of inequality, and the Gini coefficient and
concentration index. The article also explains the problems of taking into account only
extremes of privilege and deprivation, and concludes by emphasizing that measuring
and documenting inequalities is imperative for establishing a basis on which to develop
policies and interventions.
The next chapter, “Noncommunicable Diseases and Risk Factor Surveillance,” deals
with how to address equity concerns in the area of risk factors for noncommunicable
diseases, which tend to be linked to both behavior and biology, two factors with seemingly different implications in terms of avoidability and choice. For instance, behaviors are
usually thought of as chosen, but the concentration of risky behaviors among those in
lower socioeconomic groups raises questions as to the degree of choice actually at work
within this population group. As our perceptions of choice change, so do specific senses
of avoidability, e.g. behaviors are avoidable in a different sense if they are based on sociological/cultural phenomena such as advertising rather than individual autonomous
choice. Other risk factors for disease, such as exposure to health hazards, also are discussed, as are limitations of the measurements, quality of registries, and the difficulties
of mixing data sources. The authors provide suggestions for reducing inequalities and
give an example of how to use information on the prevalence of risk factors among socioeconomic groups to guide program planning.
In the area of health promotion and protection, maternal mortality is strongly concentrated among those women in low socioeconomic positions. Because maternal mortality
has a significant impact on the affected women and their families and is also highly
avoidable, addressing this health problem presents great potential for reducing one area
of health inequity. “Health Equity and Maternal Mortality” provides a brief overview of
the magnitude and causes of maternal mortality, the context of delivery practices in the
Region, and the causes of insufficient attendant care at birth. The authors then review
typical measures of maternal mortality, including maternal mortality ratio and rate, as
well as lifetime risk. The discussion then turns to limitations of the measures and difficulties with surveillance before reviewing some of the disparities in health expectancies,
including maternal mortality, for different socioeconomic and geographical groups. The
authors conclude with recommendations for action to reduce maternal mortality, as well
as an argument for why the topic is a priority area for health equity.
x
Introduction
“Health Equity in Relation to Safe Drinking Water Supply” focuses on access to safe
drinking water and demonstrates the potential health impact and high stratification of
access according to geographic location and income. While the health equity argument
turns on the basic need of all people for safe drinking water, the authors expand their
discussion to include the necessity of broad population access to quality water for economic development. Because many governmental sectors as well as subpopulations have
an interest in broad population access to quality water, the health sector must act in
tandem with other sectors to advocate for infrastructure development.
The next chapter, “Access to and Financing of Health Care,” addresses how to assess
equity in access to and financing of personal health care services. The chapter provides
some empirical information on disparities in access to health care services and the differential burdens of financing among subpopulations in the Region. The authors also address measurement and surveillance issues related to access to services and the financial
burdens of access, and discuss geographical, economic, and cultural barriers to access.
The discussion concludes with a proposal to reduce such inequalities.
In the publication’s third section, several authors comment on their national-level perspectives of equity and health. Richard Van West-Charles ties equity to human development by drawing in concepts of deprivation and vulnerability as key factors. He contends that although health systems generally focus on curative medicine to address
population health needs, the medical model is not a sufficient paradigm for the health
system. Further, technology should benefit all segments of the population, and equity
analyses should take into account both public and private sector resources. Van WestCharles ends his remarks with comments on financing and consumer choice, three facets
of access to care, and the complimentarity of efficiency/effectiveness and equity.
Hernán Málaga describes the relationships between material living conditions and
the health status of populations in both Venezuela and Colombia, as well as the potential
benefit of the healthy communities strategy in the effort to decrease inequalities and
inequities. He provides specific examples of interventions developed in Colombia to
address health problems declared as important by the communities themselves, and notes
the basic principles that are guiding the country’s health sector reforms. This analysis of
the situation leads him to the formulation of eleven guidelines for technical cooperation
in health in Colombia.
Finkelman provides a framework of reference for Brazil by analyzing the Constitution and the consequent legal instruments related to health, as well as the main aspects
of health sector reforms and the health care system organization, as they relate to equity.
He then relates this frame of reference to the deep inequalities in Brazilian society, and
presents evidence of these inequalities in material living conditions, health status, resources and coverage of health care services, and the financing of health care. By confronting the reality of inequality with the existing legal framework, he suggests a set of
possible guidelines for technical cooperation in health in Brazil to address the problem
of inequity.
“Agua para todos en el país de la fantasia” is a fable on the modernization of the State,
the privatization of water services in developing countries, and the consequences for
vulnerable populations in these countries. In this chapter, Paúlo César Pinto describes a
possible scenario of what might happen in this process for both the economically betteroff (i.e. improvements—with higher costs) as well as for the poor (an even smaller likelihood of access to quality water services in the near future). He ends by posing nine
Introduction
xi
questions to be answered in relation to how to expand the provision of safe water to
economically depressed areas and population groups.
Finally, Fernando Lolas expounds on the necessity of good theory for practical action
in “Ethics, Equity, and Practices in Health Institutions.” Theory “unmasks reality” and
shows the infinite variety of circumstances, thereby strengthening our ability to transform values into policy and action. And while theory requires time for reflection, the
urgency of work for those in the health field can create barriers for the integration of
theory and practice. After an explication of the general usefulness of ethical theory to
practical action, Lolas addresses the role of social institutions as conduits of justice, because, as he says, they convert ideals into practical principles and ideas into action.
Although equity in health has begun to flow freely into the mainstream literature,
there is much work left to be done. “The Black Report” and the “Acheson Report” as
well as the work of Margaret Whitehead, which were developed for the context of the
United Kingdom, remain seminal conceptual and operational documents. But the concepts, values, and assumptions of these documents should be tested against the cultural
context of other countries, which have different organizational and technical abilities
and levels of development.
The articles presented here do not pretend to be the last word on the subject of equity
and health in the Region of the Americas, but are meant to bring awareness to those
working in different areas of health equity of each other’s work and perspectives. PAHO
expects that as the topic continues to develop, communication and sharing knowledge
on the topic will become a main priority for health equity in its own right. To this end,
PAHO, through the Division of Health and Human Development, in association with
the International Society for Health Equity, has established an equity email listserv that
regularly distributes documents, news, and other relevant information on the development of this emerging and rapidly growing field of research and advocacy. We welcome
comments on the perspectives presented in this publication, which can be sent to
HDP@paho.org.
The Editors
EQUITY AND H EALTH
George A. O. Alleyne1, 2
According to Aristotle’s Eudemian Ethics,
the following quotation was inscribed over the
temple of Lelo at Delos: “Justice is fairest and
Health is best. But to win one’s desire is the
pleasantest.”
I have always been inspired by this and
have come to believe that the practice of medicine, especially that related to the medicine of
groups of people, provides the ideal opportunity to combine the concerns about health and
justice and win one’s desire. Just about the
time I joined the Pan American Health Organization (PAHO) nineteen years ago, my interest in the relation between justice and health
was stimulated further by a small book written by Alastair Campbell, from the Department of Ethics of the University of Edinburgh,
entitled Medicine, Health and Justice.
Campbell dealt with the issue of ethics and
priorities in medicine and stressed the value of
individual freedom and needs. If patients were
consumers and health care workers were providers, then there was a possibility that injustice
could be committed if health care was relegated
to being an ordinary commodity that was exchanged between providers and consumers in
the market place. Equity for him was a matter
of distributive justice, and those with the same
needs or capacities should be treated equally. Of
course, it was difficult to find adequate standards
for needs. But the part that struck me most forcibly was his treatment of justice as fairness in
relation to health in the context of a “balance of
freedom, equality and fraternity.”
He went on to describe John Rawls’ Theory
of Justice as it bore on health, referring to the
social contract theory of justice in which the
“Original Position” is derived by rational individuals devising a society under “a veil of
ignorance.” The two basic principles that
Rawls formulated are that each person should
have rights to maximum liberty compatible
with a similar system of liberty for all and that
inequalities are to be arranged so that they
benefit maximally the least advantaged. These
basic liberties were described as the “equal liberties of citizenship” which must be tempered
by equality in a good society. I have always
wondered why these liberties or basic values
did not include specifically, as appears in several other declarations on rights and liberties,
the right or liberty to have access to those
measures necessary to ensure health.
Health must be one of the ends or states that
society will pursue. Health, however produced, is an essential aspect of human development, and I will resist any disciplinary arrogance that would induce me to claim that it
is the best. However, health, as is material
wealth, is important for enhancing the possibility a human being has to flourish and enjoy life’s options. Without it, human beings are
limited in the life paths that can be followed.
If one believes that it is intrinsic to our condi-
Director, Pan American Health Organization.
Adapted from a presentation originally made at the
XI World Congress of Psychiatry on “Psychiatry on New
Thresholds,” Hamburg, Germany, 6–11 August 1999.
1
2
3
4
Equity and Health
tion that we have the same life chances, then
one may conclude that it is morally correct to
seek health equality as far as possible.
I have emphasized repeatedly in PAHO that
the two basic value principles that should
guide our work and our technical cooperation
are the search for equity in health and a Pan
American approach that sees the countries of
the Americas joining hands in the kinds of
enterprises that lead to Health For All. I am
not alone in this, as the European Region of
the World Health Organization (WHO) has
placed Equity in Health as the second of thirtyeight targets within its new Policy for Health
for All. The target is described thus: “By the
year 2020, the health gap between socioeconomic groups within countries should be reduced by at least one-fourth in all Member
States, by substantially improving the level of
health of disadvantaged groups.”
In its first policy, published in 1985, equity
was accorded the first place among the targets, and I must recognize the sterling work
of persons like Margaret Whitehead ensuring
that equity is a point of major interest in this
Region.
We are not original in this concern, as the
issue of equity in health and in other areas of
human experience has been the subject of debate by philosophers for many years; more
recently, economists have bent their minds to
unraveling some of its implications and making proposals to measure and perhaps achieve
such equity. As Director of PAHO, and being
neither a philosopher nor an economist, it has
not been an easy task to try to grasp the essentials of the two sets of propositions—that
is, those of the philosophers and the economists—and at the same time devise some practical applications for an organization that is
committed to cooperating with countries that
have a wide range of social, economic, and
health conditions, but are all united in the belief that human action can improve the health
of all, particularly the disadvantaged.
The issue for me is not only equity in health
outcomes, but also equity in the various determinants of health. There is wide acceptance
of the view that equity refers to differences that
are unnecessary or reducible and are unfair
and unjust. The concept of fairness obviously
involves a moral judgment and is, therefore,
intrinsically difficult. As is the case with health
outcomes, the inequities in health determinants are those that should not exist. Every
person should, in terms of equity, have the
opportunity to access those sanitary and social measures necessary to protect, promote,
and maintain or recover health.
Because of biological constraints, there are
differences or inequalities in health outcomes
or health status that are unavoidable or irreducible. By the same token, there are myriad
examples of differences or inequalities in
health outcomes that are unnecessary and,
therefore, represent inequities. There are differences between rural and urban areas and
between ethnic groups, differences on the basis of gender, intergenerational differences,
and, the most marked of all, are the differences
between rich and poor both between and
within countries. One of the starkest and most
egregious examples of unjust differences in
our Region is with regard to maternal mortality. A pregnant woman in the poorest country
of our hemisphere has about a fifty times
greater risk of dying as a result of her pregnancy than a woman in the rich countries. This
may be related to the fact that whereas almost
all women in the rich countries are attended
by a trained attendant during childbirth, this
happens in just about 50% of the time in the
poorest countries. To take another example,
the population attributable risk for dying from
acute respiratory infections was calculated to
show that if all countries had the same mortality rate for children under 5 years old as
does North America, there would be 93%
fewer deaths from these infections in this age
group in Latin America and the Caribbean.
Although almost every country in the world
has data showing the differences in health
outcomes, I refer frequently to the United
Kingdom where there is a tradition of more
than 150 years of collecting and analyzing
health data. The famous Black Report of 1980
Alleyne
was a seminal work on the inequalities in
health and the policies necessary to promote
and restore health. Even though the report
caused little positive domestic reaction at the
time, it was and continues to be the stimulus
for debate and research in the international
arena on the inequalities of health outcome
and the means to address them.
More recently another study on inequalities
in health in the UK has been conducted, and
the findings have been published in what is
known as the Acheson Report, after the chairman, Sir Donald Acheson. The report documents the persisting inequalities in health and
states, “… for many measures of health, inequalities have either remained the same or
have widened in recent decades.” This still
comes as a surprise to many of us who had
imagined that universal access to health care
services, as obtains in the National Health Service, would have served to decrease the inequalities as the overall mortality continued
to fall. The report “adopts the socioeconomic
model of health and its inequalities” and posits that the capacity of the personal behavior
and lifestyles of individuals to affect health is
significantly modulated by the social and community influences in which a given individual
operates. In addition, there is a wide range of
living and working conditions that can positively or negatively affect the health outcomes,
and the health care services are included
among these conditioning factors, but are not
given any primacy in affecting outcome.
The data clearly show the impact of social
class on health. In spite of criticisms of the formulation of the social classes, there is now
overwhelming evidence of the influence of
social hierarchy on health. In the classic work
Why Some People Are Healthy and Others Not
by Evans and his colleagues, Renaud makes a
most definitive statement:
The lower one is situated in the social hierarchy as defined by work, lodging, education,
income or whatever; the lower one’s probability of staying in good health and the lower
one’s life expectancy. This is the most frequent
5
and most pervasive of all the observations
made in the history of public health.
The fact that health outcomes are to a large
measure socially determined gives hope that
these social conditions, if altered, can lead to
improved health. The Acheson Report notes
that in order to reduce health inequalities,
“further steps should be taken to reduce income inequalities and improve the living standards of poor households.” This recommendation is remarkably accurate in that it
addresses both the aspect of difference in income and the absolute level of income that is
associated with poverty. There has often been
debate as to whether it is income distribution
or poverty that has the major impact on health.
The answer is that the predominance of one
or other depends very much on the economic
status of the population examined.
The relation of poverty to ill health has been
known for centuries, and the classic work of
medical historians such as Sigerist outlines the
evolution of that relationship. He describes the
major lines of thought of the eighteenth century when activists like Johann Peter Frank
recognized poverty as a major cause of disease and advocated for a police function in
public health. The industrial revolution accentuated the appalling health living conditions
of the poor and led to the utilitarian approaches of reformers like Chadwick towards
improving the health of the poor in the nineteenth century.
It is appropriate here to point out the role of
one of my medical heroes, Rudolf Virchow,
whose leadership of the health reform movement in this country has left a remarkable legacy
in terms of social security that includes health
benefits. It was about 150 years ago that he investigated an outbreak of relapsing fever in
Silesia and came to the conclusion that the causes
were essentially social. According to Sigerist, he
recommended prosperity, education, and liberty,
which can develop only on the basis of complete
and unrestricted democracy.
The impact of poverty on health is still evident today, and in every country it will be the
6
Equity and Health
poor who are the most disadvantaged, both in
terms of health outcomes and in access to the
factors that make for good health. Poverty is
associated with mental as well as physical illness, and there are good data to show that low
socioeconomic status is associated with higher
rates of psychopathology. But as the Report on
World Mental Health points out, “although
poverty is linked to mental ill health, economic
prosperity does not translate directly into either personal or social well-being.”
An analysis by Kawachi and his colleagues
describes lucidly the two approaches to the
economic situations associated with ill health.
There is the focus on absolute poverty, with
the need that is expressed so often today of
eliminating or eradicating poverty. These expressions borrow from the image of disease
control and eradication but, although attractive as slogans, are not usually useful in operational terms. The other focus is on relative
deprivation, where it is the difference in income between groups perhaps at any level of
wealth that is a major determinant of health
outcome. It is important to make this differential. Poverty affects the individual’s capacity to maintain or recover his or her health and
in addition impacts on the societal environment that itself will affect health. Relative deprivation or, in its commonly assessed expression, maldistribution of income is not an
individual characteristic, but is very much a
structural aspect of the society or group in
which the individual has to function.
The relationship between income and measures of health such as life expectancy is curvilinear. The poorer the group, the sharper and
clearer the relationship, but above a certain
level of income the curve flattens and the effect of income on health is progressively muted.
In terms of country level comparisons, we can
note that the effect of income on life expectancy,
for example, is stronger in the developing than
in the more developed countries.
In a classic series of data produced 25 years
ago, Preston developed a family of curves for
the relationship between income and life expectancy for different decades of this century.
The curves remain qualitatively the same, but
over time—as countries prosper—the curves
shift, and there is a higher life expectancy for
the same income level. This is a most important observation, in that it leads to the view
that there are exogenous factors such as technology, both hard and soft, that have contributed to this increase in life expectancy at similar income levels. It is the advent of this
technology that has been implicated in the
finding of the relatively more rapid improvements in health in many of the developing
countries.
As indicated above, it is not only absolute
deprivation that is important. As Wilkinson’s
seminal work has proven, income inequality
has an equally and sometimes more powerful
influence on such health outcomes as infant
mortality rate and life expectancy. Particularly
in the developed and richer countries, it is
income distribution rather than individual
measures of wealth such as per capita GNP
that are important. Income maldistribution is
associated not only with health outcome
but with a whole range of social pathologies. In societies that have more income inequality, there is increased criminal activity,
for example.
It has been suggested that it is not only difference in outcomes, such as mortality rates,
that can be affected by maldistribution of income. Income differentials result in or are derived from different work opportunities, and
these employment differentials are said to
create a situation in which the self-worth and
autonomy of the lower paid worker are so affected as to lead to varying degrees of psychosocial stress. The spread of information that
shows what can be achieved elsewhere makes
the appreciation of the gap between aspirations and reality so great that there can be
outcomes measured in terms of physiological
abnormality. The television images of the rich
and famous are seen in the most remote parts
of the world, and miracles of modern technology appear to be there simply for the asking.
Blood pressure, for example, increases when
there is incongruity between what the indi-
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vidual perceives to be an acceptable or conventional lifestyle and that to which he or she
is subjected or relegated because of material
deprivation.
It also has been proposed that when material deprivation is such that the expectations
of the individual cannot be fulfilled, a situation develops similar to the anomie described
by Durkheim. As he first conceived it, anomie
refers to a state in which the usual norms are
no longer clear or observed, and later he used
the concept to describe anomic suicide. The
competition between individuals and the incongruence between aspirations and possible
satisfaction favored the impulse towards suicide. It is not farfetched to relate the increase
in criminal activity and social stress attendant
upon income inequality to the anomie of
Durkheim.
I was intrigued by the possibility that there
might be a relationship between income distribution and the rates of suicide. However,
in some preliminary analyses of data from our
Region, it appears that suicide and death from
self-inflicted injury increase as income distribution improves. Countries with more equitable income distribution have higher mortality rates from suicide. This preliminary finding
merits more research, as it would seem to run
counter to accepted beliefs.
The competitiveness of modern western
society stresses and glorifies difference. Wealth
may be important not only for its own sake
and because it increases options but as a mark
of having surpassed others. It satisfies the basic and almost primal drive for recognition.
As John Stuart Mill is supposed to have said:
“. . . men do not desire to be rich, but to be
richer than other men.”
I am tempted to assume that there is almost
no limit to the degree of income inequality that
may occur, and there is evidence that this is
worsening, certainly in our hemisphere. Indeed, as Kaus puts it in a provocative book,
The End To Equality, it may be pointless to seek
to reduce income inequality, as there are too
many forces pulling in the opposite direction
in the liberal, market-based societies that seem
7
to be overtaking the world. He proposes that
it may be more feasible to look for equality in
certain civic areas among which he includes
health care.
But there are good grounds for believing
that there is some theoretical minimum gap
in health outcomes for which we can strive in
the search for equity. It is possible that health
interventions of one or other type may contribute to narrowing this gap. Victora has put
forward an interesting thesis based on data
collected in Brazil, which show the impact of
interventions by the health system in reducing inequities. Any intervention that is likely
to improve health will be picked up and used
by wealthier groups, with an attendant improvement in their health status. Only after
that group has reached what may be considered the maximum plateau will the technology have an effect in improving the health of
the poor, thereby closing the gap. There are
several factors that contribute to this differential use of the interventions, and they include
ease of access to services and the availability
and use of information.
It is an interesting phenomenon that the
health care interventions that are more equitably used and result in health outcome equity are those that depend on supply and not
on demand. The coverage by vaccines is universally high in the Americas, and the success
in eliminating diseases such as poliomyelitis
has been due to the ability to deliver vaccines
to virtually all children. The coverage for polio vaccine in the Americas is about 90% and
for BCG, more than 90%. The prospect of
eliminating measles by the end of next year is
very good because of the possibility of delivering the vaccine to all those who are susceptible. Yet the usage of family planning contraceptives is low—only about two-thirds of the
women of childbearing age in Latin America
and the Caribbean regularly use contraceptives. The former is essentially supply-driven
while the latter is very much dependent on
induced demand.
Although we agree that traditional health
care services are only partly responsible for
8
Equity and Health
health status of the population as a whole, they
consume a very large fraction of the nation’s
health budget and are held to be valuable by
all the population. While there is general
agreement that in some way there should be
equity in terms of health care, there is little
agreement as to what that means and how it
is to be achieved. Wagstaff is one of the economists who have contributed most perceptively
to the debate on equity and health, particularly health care. He points out the need to
separate the wish for health care based on altruism from that rooted in a concern for social
justice. In exploring the latter, he separates the
libertarians, who are concerned with a minimum standard of care for everyone, from the
egalitarians, who argue that health care should
not be determined by ability to pay, and care
should be allocated on the basis of need. It is
unlikely that there will ever be consensus, and
he argues that there is incompatibility between
the three interpretations of equity in health
care—”equality of access, allocation according to need and equality of health outcomes.”
I confess to being philosophically an egalitarian with a preference for allocation of health
care according to need as being the best option for ensuring equity of health outcome.
Having said that, I am very conscious of the
difficulty, if not the impossibility, of finding a
definition of a population’s needs that is universally acceptable, and I am also aware of the
contradiction that sometimes surfaces between the egalitarian posture and the need for
efficiency. In addition, even if one adopts a
minimalist approach in the sense of a requirement to meet a minimum standard, there is
the compounding problem of finding good
indicators.
Equity in health care financing is equally
complex, and the differentiation is made between vertical equity (whereby payment for
care is made according to ability) and horizontal equity (whereby those with the same
ability pay the same amounts). I am not sure
this distinction is useful in operational or
policy terms. The various approaches to financing health care—at least in our Latin
American and Caribbean countries—have focused on the need to abolish the segmentation of the funding sources and opt for a more
universal system in which the provision of
care is separated from the financing. In Latin
America there are traditionally three systems
of financing health care. There are the ministries of health, the social security institutions,
and the private for-profit sector, and there
would be general agreement that this arrangement does not lend itself to equitable access
to the services that are needed. Perhaps surprisingly, the majority of the expenditure is in
the private sector. One of the most thorny issues in our Region is ensuring that health care
includes those persons in the informal sector
who do not normally pay direct taxes. This
informal sector in some countries is larger than
the formal one and usually embraces the majority of the poor and especially poor women.
Some 25% of the population of Latin America
and the Caribbean lack access to basic health
services and thus, by definition, there is no
universal equity in health care.
We are currently exploring the possibility
of micro-insurance schemes for the informal
sector, and these will comprise grassroots organizations in areas and populations that are
not normally incorporated into the government or private-operated insurance. These
schemes, which are usually adapted to the local working or trade situations, are voluntary
and preferably run locally, although I believe
that their success will depend on at least some
initial funding from the state. One of the ways
to success of this approach is through having
these micro schemes link up in such a manner that there is reasonable sharing of risk.
I have paid more attention to the influence
of income or material wealth and health services to equity in health outcomes. This must
not be interpreted that I am insensitive to the
possibility that differences in other living and
working conditions will also impact on health,
or that the relative strengths of the various
social networks will condition the ability of
the individual to retain or recover the healthy
state. I am very aware that trying to separate
Alleyne
into neat and discrete categories those social
factors whose unequal distribution influence
health may lead me to fall into the trap of reductionism. We have learnt only too well both
in the biological and the social sciences related
to health that the systemic approach is the
most apt.
If health is universally regarded as a good
and there is general agreement on a philosophical level as to the desirability of having
equity in terms of health outcomes and equity
in terms of access to determinants of health,
particularly the health services, why is this so
difficult to achieve? First, there would be debate as to whether there can ever be equity in
terms of health outcomes and the work of
Evans et al discusses in detail the basic reasons for there being some differential that can
probably never be erased in any society. I have
referred to this above. But if the services are
organized by human institutions, why is there
inequity in terms of availability and access?
Birdsall and her colleagues analyzed this
unequal distribution of resources for health
in developing countries and described efforts
to correct it as “swimming against the tide.”
She contends that it is based on the distribution of power in these developing societies,
although I suspect her analysis is applicable
to all societies. If it is governments that are
primarily responsible for the allocation or direction of resources, their policies will follow
the dictates of rational public choice. This thesis predicates that political decision-makers
do not operate simply as individuals seeking to maximize their utility function and to
satisfy the perceived needs of individuals.
They act to increase the interest, power, and
permanence of the group to which they belong, and this approach may be incompatible with equity in access to health services.
The recipe for ensuring the reallocation of financing so that the poor benefit equitably
from services includes sustained economic
growth, political conditions such that there
is genuine participation, and gradualism in
reallocation to ensure that the resources for
the most powerful and articulate groups are
9
not abruptly reduced. I would lay particular
stress on the second condition.
What is the role of organizations such as
PAHO and WHO in promoting and making
operational the concept of equity in health,
especially when our capacity to change the
social ecology is limited? I believe that the first
and most important task is to promote the
collection of the appropriate data and transform them into useful information. It is useless to begin to speak of equity without first
having some good measures of the differences
that occur. Countries like the United Kingdom,
with its long tradition of collection of vital statistics and other health data, are the envy of
many of the countries of the developing world.
But in addition, we are plagued with the many
different systems of data collection that are to
be found. A plethora of national institutions
may be collecting the same data from individuals without any thought of making them
compatible or perhaps organizing fewer systems that are interconnected. It is not uncommon to see the drive of technology producing
data in such quantity and of such varying
quality that the capacity of the country to analyze them is overwhelmed. Our emphasis is
also to stimulate our countries to disaggregate
their data so that they may be analyzed in
terms of geography, because a country, even
the smallest one, is almost a virtual space, and
national averages hide the differences that
occur. It is critical to have this disaggregation,
as it provides information that will permit targeting those areas or groups that are in need,
as evidenced by the health data. We are making every effort to stimulate more interest in
the traditional vital statistics, which in many
places have fallen into neglect, although they
were one of, if not the oldest, form of health
data to be collected. In addition, it is becoming clearer that any focus on equity demands
that the country data sets must go beyond vital statistics and include measures of the performance of the health services as well as other
variables such as gender and ethnicity, and a
range of social indicators that are usually collected by specific surveys. There has been sig-
10
Equity and Health
nificant progress, and almost every country
of the Americas is now producing basic core
data on health as a tool for the planning in the
health sector.
Our forte is technical cooperation, which
must go beyond assisting in the collection of
good data. If we are to help to reduce inequity, we must identify the gaps that occur and
target our own technical cooperation towards
the application of technologies that may reduce those gaps. In the case of specific diseases, it is conceptually easy to define the gaps
or differences between areas or groups and cooperate in the application of the technology
that can reduce the gap. As noted above, this
is easier with supply-driven interventions, and
different tools have to be used in those areas
that are essentially demand-driven. Marketing tools and social communication techniques are coming to the fore as behavior
change of individuals or groups becomes more
and more necessary to impact on the major
health problems of our Region. The whole
concept of equity of access to the services does
not always take account of the fact that accessibility does not necessarily imply usage. The
motivation for the socially disadvantaged or
excluded to make use of theoretically accessible services may not be the same as for the
more fortunate groups, even apart from the
difference in transactional costs. The socially
disadvantaged are apparently more resistant
to changing risk behaviors than others.
I am conscious of the inequity that applies
to mental illness. The forms of organization
of our mental health services are a manifestation of the frank discrimination against the
mentally ill that has its roots and origins in
the fear of and ignorance about mental illness.
Mental health is rarely included in considerations of public health, perhaps because public health has been linked historically to disease eradication. When I review the many
schemes for health sector reform that are currently occupying the attention of our countries, I rarely if ever see any mention of any
specific interventions for mental health that
ought to be included in the basic or essential
package of services that should be made available to all. Perhaps the myth still persists that
there are not efficient population-based interventions that can affect the burden of mental
illness. In this case the inequity is between
groups of persons rather than based on such
determinants as place, sex, or race. We believe
that this can be changed. We estimate, for example, that the twenty-four million persons
in Latin America and the Caribbean with treatable depression who are not receiving regular
therapy is evidence of a gap that can be closed.
We are convinced that it is perfectly possible
to institute treatment schemes at the primary
care level that will go some way towards closing this gap.
As those who work for health step forward,
I hope that you will make or retain as one of
the canons of your faith that it is imperative
to advocate as loudly as you can for there to
be reduction of those unnecessary and unjust
differences that represent inequity. I hope you
will see that the widening of the gaps, especially in the areas of social concern, represents
a recipe for an unstable world.
BIBLIOGRAPHY
Acheson D. Independent inquiry into inequalities in health.
Report. London: The Stationary Office; 1998.
Aron R. Main currents in sociological thought. Basic Books,
Inc; 1967.
Birdsall N, Hecht R. Swimming against the tide: strategies
for improving equity in health. Washington, D.C. InterAmerican Development Bank; 1995. (IDB Working
Papers Series No. 305).
Birdsall N, James E. Efficiency and equity in social spending.
Washington, D.C.: World Bank (Working Papers 1990;
Series No. 274).
Black D, et al. Inequalities in health: report of a research working group. London: London DHSS; 1980.
Campbell AV. Medicine, health and justice: the problem of
priorities. Churchill, Livingstone, Edinburgh, London
and New York; 1978.
Desjarlais R, Eisenberg L, Good B, Kleinman A. World
mental health: problems and priorities in low income countries. New York, Oxford: Oxford University Press;
1995.
Dror DM, Jacquier C. Microinsurance: extending health insurance to the excluded. International Social Security
Review; 1999;52(1):71–97.
Kawachi LS, Miller M, Lasch K, Amich B III. Income inequality and life expectancy—theory, research and policy.
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Boston: Harvard School of Public Health; 1994. (Society and Health Working Paper Series No. 94-2).
Kohn R, Dohrenwend BP, Mirotiznik J. Epidemiological
findings on selected psychiatric disorders in the general population. In: Adversity, stress and psychopathology. New York: Oxford University Press; 1998.
Preston SH. The changing relationship between mortality and
level of economic development population. London; 1975;
231–248.
Renaud M. The future: hygeia versus panakeia? In: Why
some people are healthy and others not? The determinants
of health of populations. Evans RG, Barer ML, Marmor
TR. eds. New York: Aldine de Gruyter; 1994.
Rice T. Can markets give us the health system we want? J
Health Politics Policy and Law. 1997; 22:383–425.
Sigerist HE. Medicine and human welfare. New Haven: Yale
University Press; 1941.
Victora CG. Reducing health inequalities: can health interventions make an impact? Paper presented at the
ninth annual Public Health Forum. London School
of Hygiene and Tropical Medicine; April, 1999.
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Wagstaff A, Van Doorslaer E. Equity in health care and
financing. In: Culyer AJ, Newhouse JP, eds. North
Holland Handbook of Health Economics; 2000.
Wagstaff A, Van Doorslaer E. Equity in the finance and
delivery of health care: concepts and definitions.
In: Van Doorslaer E, Wagstaff A, Rutten F, eds. Equity in finance and delivery of health care: an international perspective. London: Oxford University Press;
1993.
Whitehead M. The concepts and principles of equity and
health. Copenhagen: World Health Organization Regional Office for Europe; 1990.
Whitehead M. The health divide. In: Townsend P, Whitehead M, Davidson N, eds. Inequalities in health: the
Black report and the health divide. 2nd ed. London: Penguin; 1992.
Wilkinson RG. Socio-economic determinants of health:
health inequalities: relative or absolute material standards? Br Med J 1997; 314:591–595.
Wilkinson RG. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996.
ASSESSING EQUITY IN H EALTH : CONCEPTUAL CRITERIA
Alexandra Bambas1 and Juan Antonio Casas1
INTRODUCTION 2
national or social origin, property, birth or other
status.3
Fifty years ago, the framers of the Universal Declaration of Human Rights (UDHR) established a benchmark of standards against
which to assess equity in health, both in terms
of equity in health and well-being and in access to medical care. They wrote:
Article 2. Everyone is entitled to all the rights
and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour,
sex, language, religion, political or other opinion,
Unfortunately, those ideals for human
health and well-being set forth in that document have not become a reality for every citizen in the world. In fact, given the competition for resources among different aspects of
human well-being, attaining these standards
is unfeasible for the present. Consequently, we
must now attempt to develop a more organic
process for assessing fairness in the distribution of resources for health that takes into consideration our organizational and technical
abilities, personal autonomy, and reasonable
expectations for action.
In recent decades, important authors have
devoted themselves to study, define, and interpret the concepts of equity and social justice, as well as that of health equity. The works
of John Rawls,4 Amartya Sen,5 and Margaret
Whitehead6 stand out. In our Region, several
authors and public health leaders have con-
1
Division of Health and Human Development, Pan
American Health Organization.
2
This paper is based on a larger work by Alexandra
Bambas, entitled “An Interpretation of Equity in Health
for Latin America and the Caribbean” (working title),
which examines conceptual and programming issues for
equity in health in the context of the Region. The paper
was also supported by the Division of Health and Human Development’s Health Equity Interprogrammatic
Group, with inputs from various other PAHO technical
units.
3
The full text of the Universal Declaration of Human
Rights is available at: http://www.ifs.univie.ac.at/intlaw/
konterm/vrkon-en/html/doku/humright.htm#1.0.
4
Rawls J. A theory of justice. Cambridge: Harvard University Press; 1971.
5
Sen A. Inequality reexamined. Cambridge: Harvard
University Press; 1992.
6
Whitehead, M (1991) The Concepts and Principles of
Equity and Health. World Health Organization, Regional
Office for Europe. (Who document EUR/ICP/RPD 414.
Unpublished.)
Article 25. Everyone has the right to a standard of
living adequate for the health and well-being of
himself and of his family, including food, clothing,
housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old
age or other lack of livelihood in circumstances
beyond his control.
The UDHR also states:
12
Bambas and Casas
tributed to the understanding of health equity
as a public health issue,7 and since 1995, under the leadership of its Director, Sir George
Alleyne, the Pan American Health Organization has identified the reduction of health
inequities as the main goal of its technical cooperation.8 Other leading development institutions, such as the Rockefeller Foundation9
and the World Bank,10 also have launched important initiatives that consider health equity
as a priority issue for human development.
The persistence of infectious diseases
among the poor; the growing proportion of
the burden of disease that is due to non-infectious, behavior-related causes; and the growing inequalities within and between countries
that have accompanied the globalization process and its worldwide expansion of free trade,
market economies, and liberal democracy,
have added urgency to the need to address
the growing health inequalities. As a result,
national and international health authorities
have increasingly addressed the macrodeterminants of health inequities. The issue of
health inequities and their relation to living
conditions is now in the mainstream of public
health thinking. And yet, although the technical aspects of measuring inequalities in
health have evolved, insufficient attention is
given to the explanation of why inequalities
in health or health resources might be unfair
or what the larger implications of labeling
them as unfair might be. Moreover, the term
“equity” often is used loosely, making it un7
These Latin American public health figures include,
but are not limited to, Jaime Breilh, Juan Cesar Garcia,
Asa Cristina Laurell, Cristina Possas, Mario Testa, Naomar
de Almeida Filho, Pedro Luis Castellanos, Juan Samaja,
Carlos Montoya, Jeanette Vega, among others.
8
See for example, Pan American Health Organization.
Annual report of the Director, 1995: In search of equity. Official document No. 277. Washington, DC: 1996; and
Alleyne G.A.O. “Equity and Health,” speech presented
at the XI World Congress of Psychiatry, Hamburg, Germany, August 1999.
9
Rockefeller Foundation. Global health equity initiative report. In press.
10
The current work by Davidson Gwatkin and Adam
Wagstaff in the Poverty and Health Interprogrammatic
Group in the World Bank is of particular importance.
13
clear as to how the term should be interpreted
in a given context.
Many of the discussions about health equity make reasonable claims that there are inequalities in health status and access to care
for different categories of people, whether
identified by social class (as measured by income, wealth, and/or formal education), spatial distribution, gender, or ethnicity. Those
who work in the public policy sector take this
a step further, often referring to these inequalities in health as inequities, casually using the
term as shorthand for describing differences
between better- and worse-off groups. Implicit
to these discussions is an assumption that any
difference is unacceptable and requires attention and intervention, but such discussions
rarely provide an explanation for that value
judgment or make distinctions between different kinds and levels of inequalities.
Asserting that these inequalities are inequities makes a forceful claim about justice—
the normative implication of the word is useful. Confusing “equity” with “equality,” a
common implication of comparisons between
the best-off and worst-off, can result in a much
higher standard than we might agree to under a more careful examination, however. The
failure to distinguish between philosophical
and pragmatic decisions regarding equity concerns in health could confuse the assessment
of resource allocation or other policy decisions.
This, in turn, would undermine the transparency of the process, making it difficult to generate public support.
At least three emerging empirical findings
commonly drive the claim that inequalities in
health between socioeconomic groups should
be a development issue, and specifically a
public health concern, particularly in Latin
America and the Caribbean.
1. The poor use fewer public resources than
middle and upper income groups.
2. There are vast and patterned health inequalities between socioeconomic groups,
as well as between gender and ethnic origin categories, suggesting links between
14
Assessing Equity in Health: Conceptual Criteria
health outcomes and a variety of material
and social living conditions.
3. Inequalities in the impact of these macrodeterminants on health and overall wellbeing are growing.
These observations are often associated with
the effects of globalization, and imply that intervention is required to prevent market distributions of resources from creating large discrepancies in health. These concerns also
suggest that past interventions have not sufficiently compensated for these market effects.
DEFINITIONS OF EQUITY
Dictionary definitions of “equity” are fairly
consistent. The term is defined as “justice according to natural law or right; specifically,
freedom from bias or favoritism,” or “the state,
ideal, or quality of being just, impartial, and
fair.”11
“Inequity,” then, is the linguistic opposite:
the state, ideal, or quality of being unjust, partial, or unfair. Most importantly, notice that
not equality of distributions but rather fairness
of distributions is central to the definition. Although “equality” and “equity” are often
conflated, the words have two distinct meanings and are conceptually very different.
Equality is sameness, and equity is fairness.
In any particular situation, equal may not be
equitable, or equal may be precisely equitable,
but we must present an ethical justification for
why a certain distribution constitutes an
inequity.
Vertical and Horizontal Equity
In describing an equitable situation, distinctions must be made between the appropriateness of equal and unequal distributions—or
horizontal and vertical equity—either of
which may constitute “even-handed treat11
Webster’s New Collegiate Dictionary; American Heritage Dictionary.
ment,” depending on the situation. Equity simultaneously requires that relevantly similar
cases be treated in similar ways, and relevantly
different cases be treated in different ways. As
noted in the Dictionary of Philosophy, controversy arises from the delineation of relevant
similarity—horizontal equity is the allocation
of equal or equivalent resources for equal need;
vertical equity is the allocation of different resources for different levels of need.
These two conceptions of equity have dramatically different policy implications and
cannot be applied randomly to problems.
Rather, their application must appeal to some
principle or special feature of the problem that
justifies the choice of one over the other. For
example, a universal health care plan might
appeal to horizontal equity on the basis that
everyone needs health care at some point. On
the other hand, targeted programs for the poor
would appeal to vertical equity. The distinction between these situations turns on the interpretation of need: in the first case, the justification is that everyone needs health care in
the biological sense, while the second case
appeals to a sense of financial need of the poor
which doesn’t apply to the non-poor.
Vertical equity has a higher potential for redistributing resources, and therefore often faces
more political obstacles. However, in the current political climate, which challenges the legitimacy of public provision of services in areas thought to have market potential, vertical
equity has gained momentum as a mechanism
for constraining claims of need to those based
on severe financial deprivation. For instance,
where market mechanisms have been introduced into national health systems in the process of health sector reform, publicly funded
basic packages or focalization strategies were
instituted to provide for the needs of the worstoff. This approach has been criticized as having an overly narrow interpretation of need,
which left large segments of the population
vulnerable once again. On the other hand, some
focalized strategies based on vertical equity are
seen as quite reasonable and successful, such
as in immunization programs.
Bambas and Casas
EQUITY IN ACCESSTO
HEALTH CARE SERVICES
An operational definition of health equity
that focuses on need as the appropriate distribution mechanism specifically addresses equity in access to health care services. Aday’s
definition,12 which has pervaded thinking in
the health field, often is taken for granted and
seldom questioned. Aday et al. define an “equitable distribution of health-care services” as
“one in which illness (as defined by the patient and his family or by health-care professionals) is the major determinant of the allocation of resources.”
The crux of the argument is that health resources are special goods that should not be
distributed strictly as normal market commodities according to economic resources,
because their social worth is significant. But
this service-oriented approach has been found
to be insufficient in reducing inequalities in
health status and access to health between socioeconomic groups, a finding cited by the
widely influential Black and Acheson Reports
of the United Kingdom. These reports examined the British National Health System, a
prime example of universal coverage in health,
and concluded that the effect of approaching
health using a medical services strategy did
not address concerns of reducing health inequalities and achieving fairness.
“Access to medical services” historically
has been used as a measure of fair distribution, partly because it is easier to measure and
to improve access to services than to achieve
more ambitious goals—say, securing a certain
level of well-being in a population—and because of the historical compartmentalization
of the social sectors within government, which
provide focal advantages, but may at times
limit the activities seen as appropriate for any
one sector.
Additionally, there is an implicit assumption that services are a means to improve the
Aday LA and Andersen RM (1981). Equity of access
to medical care: a conceptual and empirical review. Med
Care 1981; 19 (12), Suppl. pp. 4–27.
12
15
population’s health, an assumption that has
not been sufficiently confirmed.13 Recent attention to inequalities in health status, especially with regard to socioeconomic categories, underlies a certain dissatisfaction with
approaches strictly focused on access to services. This is due in part to the recognition
that medical services may not be the most
important determinant of health status and
certainly are not the only means to improving health status. Insofar as access to services
is supposed to be a means to higher level
goals, such as better health, or even more
opportunities in life, it is a limited measure
of health equity. Various other sectors and
aspects of life affect one’s health status, including living conditions, working conditions, environmental issues such as air quality, education level, and access to cultural,
social, and political participation.
By limiting our evaluation of health equity
to “access to medical services,” we ignore the
importance of other sectors in determining
health, and effectively exclude their incorporation into an equity strategy. Such an approach tends to value these services for their
own sake, rather than emphasizing the role of
medical services as one of many means to attain
health.
If our consideration of health equity is widened to include inequalities in health outcomes, it becomes necessary to measure health
status directly (rather than using only access
to services) and to incorporate the analysis of
access to other basic services and the level of
satisfaction of other basic needs into the assessment of equity in health. The shift from a
medical services approach to a health outcomes approach involves the recognition that
people do not get sick randomly, but in relation to their living, working, environmental,
social, and political contexts, as well as with
regard to biological and environmental factors
that are unevenly distributed in the popula13
McKeon T. The role of medicine: dream, miracle or
nemesis? Nuffield Provincial Trust; 1976 (also available
in Spanish, under the title, “El papel de la medicina: sueño,
espejismo o nemesis.” México: Siglo XXI; 1982).
16
Assessing Equity in Health: Conceptual Criteria
tion. This broader concept is also much more
conducive to considering the improvement of
health status as part of the larger work of human development.
EQUITY IN HEALTH OUTCOMES
Based on the broad concept of health equity,
as developed by Margaret Whitehead and
adopted by EURO/WHO, the government of
the United Kingdom has taken the policy position that all health differences between the
best-off and worst-off in different socioeconomic groups constitute inequities in health.
Whitehead defines health inequities as “differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.”14
If this were the complete definition, people
with different life perspectives and even different political ideologies might be able to
agree to it in principle, which would make it
useful in the larger political forum to generate a working consensus on the matter. However, it entails reaching agreement on two
potentially controversial parameters, i.e., determining what is unnecessary and unfair visà-vis what is inevitable and unavoidable.
Whitehead goes on to specify seven determinants of health inequalities that can be
identified:
1. Natural, biological variation.
2. Health damaging behavior that is freely
chosen, such as participation in certain
sports and pastimes.
3. The transient health advantage of one group
over another when that group is first to
adopt a health-promoting behavior (as long
as other groups have the means to catch up
fairly soon).
14
Whitehead M (1991) The Concepts and Principles of
Equity and Health. World Health Organization, Regional
Office for Europe (WHO document EUR/ICP/RPD 414.
Unpublished); p. 5.
4. Health damaging behavior in which the
degree of choice of lifestyles is severely
restricted.
5. Exposure to unhealthy, stressful living and
working conditions.
6. Inadequate access to essential health and
other basic services.
7. Natural selection or health-related social
mobility involving the tendency for sick
people to move down the social scale.
Health inequalities determined by the first
three categories would not be considered unfair nor unjust, while the last four would be
“considered by many to be avoidable and the
resultant health differences to be unjust.”15
Although Whitehead’s definition includes
adequate access to health services as a condition of justice, it extends far beyond that—and
beyond the more procedural standard related
to access to services—to a much broader set
of conditions that can affect health and establish a health advantage of one group over
another. It’s a robust concept of equity, encompassing a range of situations including outcomes, exposures, risks, living conditions, and
social mobility.
CRITERIA FOR ASSESSING
HEALTH EQUITY
The burden of proof lies in demonstrating
that a situation is inequitable (rather than equitable), because making a social argument to
change the present order requires justifying
the allocation of public resources for interventions to redress the inequality. But to make this
claim, we must give contextual and concrete
meaning to the operational definitions of equity to determine when the judgment would
apply. These meanings are reflected in the criteria that are repeatedly referred to in discussions regarding fair distributions of goods.
15
Whitehead M (1991) The Concepts and Principles of
Equity and Health. World Health Organization, Regional
Office for Europe (WHO document EUR/ICP/RPD 414.
Unpublished); p. 6.
Bambas and Casas
To establish a situation as inequitable, differences in distributions of a good, such as health
resources or even the larger determinants of
health status, must satisfy each of the criteria:
• The differences in distribution must be
avoidable,
• must not reflect free choice, and
• the claim must link the distribution to a responsible agent.
As the claimants, we must be able to argue
how these criteria relate to particular claims
of inequity.
Although these criteria might be applied to
either individual distributions or to social distributions, their implications will take on
somewhat different tones with each. For the
purposes of policy development, we are concerned with social distributions, and therefore
the interpretation of each of these criteria will
relate not to equity judgments of any particular person’s situation, but to trends in the
health of the population and its subgroups.
Some might argue that distributions are politically necessary—that sufficient support cannot be generated to support redistribution. But
political will should be driven by justice; it
should not constrain justice. If political will is
lacking but equity criteria are present, mobilizing civil society to create political pressure
becomes a technical issue.
Avoidability
“Avoidability” is a key criterion for equity,
because if a distribution is not avoidable, it
cannot be interpreted to be unfair in a social
sense. While we emotionally respond by feeling that the universe or life is not just—and
we may even have a will to intervene to
change such distributions—to make a social
claim based on equity is quite a different matter in that it requires action.
A proposal for redistribution, whether it be
of health services or of macro-determinants of
health, must show the current distribution to
be avoidable in several senses.
17
It must be technically avoidable because current scientific and organizational knowledge
provides a solution for successful intervention.
It must be financially avoidable because sufficient resources exist either within the public
sector or more generally to satisfy fair conditions.
And it must be morally avoidable because the
proposed redistribution would not violate
some other, greater, sense of justice.
The subcategories of avoidability are highly
relevant to claims of socioeconomic health inequities. Certainly there are individual cases
of “technically unavoidable” health differences, such as in the case of health harms
linked to naturally occurring genetic variations. But unless given reason to believe the
contrary, we would not expect such occurrences to be patterned according to socioeconomic groups, thereby eliminating one source
of “technically unavoidable” health inequalities and strengthening claims that patterned
distributions of health may constitute inequities. Assuming that genetically related differences in health are not used to define our
groups, the health standard of best-off groups
demonstrates that those health indicators are
indeed technically feasible. That is, in technical terms there is no reason why all groups
could not achieve health levels similar to those
of best-off groups.
However, the setting of standards according to best-off groups may be prohibitively expensive, at least above a certain level of health.
Diminishing margins of utility certainly do not
argue against any redistribution or investment,
but may place a limit on what might be financially possible in reducing health inequalities
given resource constraints. Therefore, such
studies contribute significantly to our understanding of financial avoidability, and therefore to reasonable and fair differences, even if
absolute equality proves unfeasible. Finally,
the evaluation of financial feasibility and the
effect of re-distributions cannot be restricted
to current public spending levels, but must
necessarily include an economic evaluation of
the availability of external resources based on
18
Assessing Equity in Health: Conceptual Criteria
the potential to increase fiscal base, since the
question at issue is whether the financial resources exist at a macroeconomic level, not
only within the institutional confines of the
health sector.
At some point, we may determine that a
certain redistribution level is technically and
financially feasible, but impinges on other social values to the extent that the redistribution
itself becomes unjust, either by severely restricting civil liberties or by prioritizing health
to the unjustifiable detriment of other social
goods. Analyses must therefore include not
only studies of diminishing margins of utility, but also the larger social effect of such redistributions. Hypothetically, if, for a given
country, we found that we could bring inequalities of infant mortality rates, maternal
mortality rates, and communicable diseases
within “an acceptable range” only by instituting tax rates of 90% of income, we may decide that personal freedoms would be compromised to an extent that the social injustices
created are greater than those that existed
under conditions of larger health inequalities.
If we accomplished the task by directing public spending for health activities by virtually
eliminating other important national programs, not only might we find greater injustices than health inequalities, but also the
actions might prove counter-productive if certain other programs (such as education or environmental protection) were to be affected.
If an argument that inequities exist is able
to respond to each of these issues, it has succeeded in establishing that such inequalities
are in fact avoidable, perhaps the most difficult of the criteria to secure.
Choice
Choice is particularly relevant to interpreting justice in health in terms of the protection
of individual autonomy. Therefore, health behaviors are better at indicating possible choice
issues than are health outcomes. The application of choice as a criterion might range from
an individual electing to (1) engage in an ac-
tivity, to (2) buy a product, and to (3) prioritize needs. We hope that given sufficient information and opportunity, people will opt for
activities and behaviors that enhance their
health. Even when such activities and behaviors may not always be chosen, justifying
health-enhancing interventions may be limited by concerns for autonomy and the preservation of civil liberties.
Free choices may, in fact, create acceptable
differences between individuals’ health, as
some persons may choose behavior that leads
to worse health outcomes. But if the choice
was in fact made under perfect, or even reasonably high conditions of choice, including
adequate information and free will, claims of
an injustice would be more difficult to sustain.
Particularly in the context of populationbased analyses, however, protecting autonomy and promoting health often are more
complimentary goals rather than competing
interests. While individuals might make free
choices based on their own particular wants
or needs, we would not expect to see strong
patterns of such behavior stratified in socioeconomic groups, unless an additional correlation that explains the concentration of risky
behavior were presented.
A case for socioeconomic inequities in health
must be built on the presumption that population groups would not freely choose lesser levels of health. In fact, some studies have shown
that health behaviors do not differ significantly
between population groups, and when they do,
such as in the case of high fat diets among some
minority groups in the United States or the urban poor in Latin America and the Caribbean,
culture and lack of health information can be
seen to clearly diminish the role of free choice.
Further, when health behaviors are controlled
for income, differences between groups dissolve, and income is not usually considered a
“chosen” socioeconomic category. Consequently, choice as a justification for health differences tends to fall away in population studies. Therefore, when we do see such patterns,
there is reason to believe that low levels of
choice, or a thin sense of choice, might better
Bambas and Casas
describe those behaviors or decisions. Investigation into causality, whether through physical or social science, can bolster the argument
that choice is limited.
Opponents of redistribution sometimes try
to limit the scope of challenges to choice by
depending on claims of economic choices in
prioritizing goods or procedural interpretations of legal entitlement (in the case of public programs) as sufficient conditions for establishing free choice. Such conclusions
generally rely on assumptions of equal opportunity for individuals within a society, at least
at some level, although little attention is given
to elaborating on the conditions of equal opportunity or a practical demonstration that
such opportunity exists. Failure of the poor to
“protect their health,” for instance, is seen as
due to their own negligence or to the life situation that they have put themselves in (e.g.
“choosing” to work in a dangerous factory),
rather than any larger social, economic, or
political disadvantages over which they had
little control.
Some might argue that the poor or other
vulnerable groups “choose” poor health, particularly when they fail to seek care when they
are ill. However, the priorities that intervene
to prevent such utilization of care are often
not only equally basic and necessary for survival, but also often contribute to the family’s
health in some other way, as when financial
resources are used to purchase food or support the survival of the family business. Such
arguments gain by conflating “decision making,” which can include prioritizing certain
needs over other needs, with a richer meaning of “free choice.” Further, if we can demonstrate that health is strongly linked to other
social sectors, the argument that the poor can
“choose” to invest in health by financially prioritizing health care services over, say, housing or nutrition, loses its weight, since the areas are interrelated, and that “choice” simply
becomes a decision, with little real meaning
in terms of improving one’s well-being.
Insofar as access to health services is concerned, proponents of resource redistribution
19
have succeeded in expanding the narrow, but
commonly used interpretation of “choice”—
the legal right to utilize resources. They include
more socially embedded issues that are
needed to access health resources, such as support services, including transportation. Recognizing the social context of a situation demonstrates how real “choices” can be thwarted
by the reality of people’s daily lives. Removal
of those barriers, then, actually enhances individual autonomy in a meaningful sense,
rather than detracting from it.
Transportation is only one of many barriers
to free choice. While individuals often do
make choices about their own health, decisions also are made by groups at the national,
community, and family levels. Such situations
can be used against the politically disenfranchised in a democracy, if the assertion is made
that all citizens have agreed to certain conditions, and therefore have “chosen” those conditions. The recognition of macrodeterminants
of health, including social and economic factors that influence health status, has greatly
broadened the social meaning of health resources, and consequently has expanded the
list of relevant resources involved in the choice
claim. Lack of access to education and access
to information, for instance, can ground a
health inequity claim related to choice.
Though more difficult to empirically demonstrate, psychological issues also are basic to a
conception of choice. Elements of social control and influence, actual and perceived locus
of control, and the larger implications of certain health-related choices on one’s life become
very important to identify in order to establish that choice is more limited than it might
appear.
Agency
The third criterion for establishing that an
inequity exists is that the claim be linked to a
responsible agent. To make this determination,
either of two meanings of “responsible” may
be used. We may establish that there is a culpable entity who caused direct or indirect
20
Assessing Equity in Health: Conceptual Criteria
harm, as we might apply in cases of damage
to health due to environmental degradation
or occupational hazards. One of the difficulties in identifying and establishing the culpable agent is that culpability can be masked.
The externalization of health harms in industry or manufacturing, for instance, would first
have to be recognized, then traced. In the absence of empirical studies linking problems to
their sources, our ability to perceive the culpability of a particular agent will be impaired,
even if there is a very direct cause/effect relationship. Further, for the purposes of socioeconomic differences in health, discrete instances of culpability are less relevant than
larger systematic patterns of harms that would
be generated through responses to policy, or
its absence.
Alternatively, we might make a claim that
there is an accountable entity, one who is responsible for rectifying the unfair distribution.
In the case of health equity, claims often center on the responsibility of the government to
ensure certain rights or provide a certain
amount of protection to all citizens, which justifies state intervention. A claim of lax or unenforced government regulations, or governmental assistance in externalizing health
harms, makes a particularly strong claim. Although a government might not be responsible for creating a health-harming situation,
once an issue has been publicly discussed, lack
of response by government must be interpreted as a decision affecting the public to
which it, as a presumably just institution, must
be held accountable. The level of governance
then, will also affect perceptions of the responsibility (and the ability to respond) of the
government.
demonstrating that these criteria apply, thereby greatly strengthening the political claim
that inequities also exist. Because scientific
knowledge is constantly growing, our interpretation of whether criteria apply to specific
issues also changes over time. For instance, in
relation to “free choice,” alcoholism and smoking are not seen as much as lifestyle choices as
they once were, because of increasing evidence
on the biological basis of addiction. Social science research also contributes to our interpretations, as when we attend to the effect of targeted advertising on alcohol consumption and
smoking rates.
When we make the claim that differences
in health are inequitable, the strength of the
evidence or the argument, according to the
above criteria, will determine the level of inequity. We might think of this as a spectrum,
with each of the criteria moving our assessment of the situation either closer to “misfortune” or to “inequity.”
Misfortune
Inequities
(Fair differences)
(Unfair differences)
Avoidable Differences
Chosen Differences
Responsible Agent
To be sure, we must be willing to recognize
some differences as “fair” differences; otherwise, the criteria would not be meaningful.
Genetic birth defects and deaths due to “old
age” may be very unfortunate but not necessarily unfair if little could have been done to
prevent them; that is, they were not avoidable.
Therefore, it will also be important for a clear
analysis to identify those differences that do
not fit into the criteria.
The Spectrum of Inequalities
CONCLUSION
If any one of these criteria is absent, or is
present only weakly, the argument that a difference is an inequity begins to lose power. In
addition to the empirical verification that inequalities in health status or access to resources exist, scientific research can assist in
The framework presented here must now
be supplemented with quantitative and qualitative information that applies each of these
criteria to the health conditions and broader
societal abilities and resources in order to set
Bambas and Casas
priorities and targets for equity in health. Research must be supported not only by traditional epidemiological studies but also by social health research, including methodologies
that are continuing to be developed. The particular resources and challenges will differ
among countries, and the quest for health equity should be recognized as a development
process, and one that must alter its goals on
occasion to adjust to the changing environment.
An equity-driven approach in health policy
requires a broad vision of the determinants of
population health and an understanding of
how both health policy and wider social policy
will affect those determinants. To the extent
that health and other socioeconomic factors
are interdependent, health policy must consider how other sectoral policies and actions,
as well as societal trends, can be directed to
promote health equity. Similarly, health policy
must take into consideration how health
21
policy can contribute to broader equity goals
in health development.
Finally, the pursuit of equity is necessarily
linked to issues of governance, which include
accountability, transparency, decision-making
procedures, and the ability of the political
arena to allow for broad representation and
the effective exercise of choice by all social
groups and members of society.16 Leadership
in health equity requires both a high capability for managing resources and developing
policy and a strong political society. Once a
society embraces a political foundation of
egalitarianism, whereby all citizens of a country are due equal regard under the law and
have equal political voices, societies themselves become the ultimate arbitrators of equity, in health or any other sphere.
16
Gilson L. In defence and pursuit of equity. Soc Sci
Med 1998; 47: 1891–1896.
HEALTH DISPARITIES IN LATIN AMERICA AND THE CARIBBEAN:
THE ROLE OF SOCIAL AND ECONOMIC DETERMINANTS
Juan Antonio Casas,1 J. Norberto W. Dachs,1 and Alexandra Bambas1
The Latin American and Caribbean (LAC)
region demonstrates the greatest disparities in
income and in other socioeconomic determinants of health. Although research in many
developed countries has provided strong evidence on the extent and strength of the relationships between these determinants and
health, relatively little has been established on
this relationship in the context of the countries
in LAC. Nevertheless, available evidence
shows that the distributions of health status and
access to health services among different socioeconomic groups follow patterns that place
the most vulnerable groups in situations of continuing and often growing disadvantage.
Evidence also shows that such social and
economic advantages are more strongly related to health outcomes than are need-based
allocations of health services. This is a particular problem in LAC, where disparities in socioeconomic factors have continued to increase since 1980. Although general health has
improved in LAC countries, gains in health
status have not been made equally among
various socioeconomic groups. Overall health
improvement does not imply diminishing dis-
parities either between or within countries.
Rather, improvements appear to be disproportionately weighted toward those who already
have a greater share of social and economic
advantages in society, while the health of disadvantaged groups improves less consistently
and at much more modest rates.
1
Division of Health and Human Development, Pan
American Health Organization. The authors wish to acknowledge other members of PAHO’s Division of Health
and Human Development who made significant comments to this paper, including Elsa Gómez, Edward
Greene, Cristina Torres, and Raúl Molina.
2
There are exceptions in a few countries, specifically in
the groups between 20 and 39 years of age for males, due
to AIDS and violent deaths.
3
Murray CJL, Chen LC. In search of a contemporary
theory for understanding mortality change. Soc Sci Med
1993; 35 (2): 143–145.
HEALTH AND THE SOCIAL AND
ECONOMIC CONTEXT OF LATIN
AMERICA AND THE CARIBBEAN
National health statistics in LAC have shown
improvement over the past 35 to 50 years for
almost all health indicators, including life expectancy, infant mortality, the incidence of
many communicable diseases, and vaccination
coverage, to name a few. For example:
• Life expectancy over the last 35 years has
followed the worldwide trend for the 20th
century, rising from 56.9 to 68.5 years, an
increase of almost 12 years.2 During this
time, specific mortality rates for almost all
age groups and in all countries showed significant reductions.3
22
Casas, Dachs, and Bambas
The range of national health levels among
countries around the world broadened for
most health statistics, however, revealing a
growing gap between the extremes of the global social ladder. Improvements in life expectancy in the LAC region are not keeping pace
with those of other regions. If we compare
LAC countries to East Asian countries, their
relative life expectancies at the beginning of
the 1960s were 56.9 and 51.4, respectively; currently these values are 68.5 and 69.7. In other
words, whereas LAC enjoyed a five-year advantage in life expectancy over East Asia thirty
years ago it now lags by 1.2 years.5
Improvements in health also have been uneven within LAC and do not correspond to
the region’s economic development level. Successes in the reduction of infant mortality by
countries such as Costa Rica, Cuba, and Chile,
which have diverse political and economic
circumstances, demonstrate that most LAC
countries have not yet tapped their potential
to improve population health.6
The level of population health, particularly
over long periods of time, tends to be associated with a level of economic growth and overall availability of resources, as is evident when
a health indicator such as the infant mortality
rate is correlated with per capita income (see
Figure 1). Countries and social groups that
have higher incomes usually have better
health conditions and better overall living con4
United Nations. World population prospects, 1998 revision. New York, NY: UN; 1998.
5
United Nations. World population prospects, 1996 revision. New York, NY: UN; 1996.
6
Pan American Health Organization. Health statistics
from the Americas, 1992 edition. Washington, DC: PAHO;
1992.
FIGURE 1. Correlation between the infant
mortality rate and the per capita income (PPP),
selected countries in the Americas, 1996.
80
Infant mortality rate
• Although life expectancy in LAC in 1990–
1994 (68.5) was still below that of North
America (76.2) and Western Europe (80.2),
it was above the world average of 64.3 years
and above that of Africa (51.8) and Asia
(64.5), but below that for eastern Asia (69.7).
• Similarly, the infant mortality rate in LAC
has dropped from 125 per 1,000 live births
in 1950–1955 to 36 in 1995–2000.4
23
60
40
20
0
7
8
9
10
Log of income per capita
Source: Pan American Health Organization/Division of Health
and H uman D evel opment and U ni ted N ati ons D evel opment
Program/Human Development Report, 1997
ditions since they have more economic and
technological resources to fulfill basic needs.
The political context also is an important determinant of health. With few exceptions,
those countries in the world that developed
institutions of democratic governance and
strong civil societies usually have established
long-term social policies that tend towards a
broader distribution of income and social benefits. Interestingly, the countries that applied
social policies providing their populations
with better access to education, basic health
services, nutrition, and basic sanitation have
achieved low mortality rates compared to
countries of equal or even better economic
performance, but where large disparities of
income and resources persist.7
These epidemiological transitions have occurred within a context of rapidly changing
economic and social conditions. In LAC during the 1990s, the macroeconomic adjustment
policies adopted at the beginning of the decade generally have led to economic growth
7
Wilkinson RG. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996.
24
Health Disparities in Latin America and the Caribbean
recovery, increased exports, substantially
higher levels of direct foreign investment, and
an increase in total public expenditure since
the crisis of the early 1980s.
Although social sector spending has now
exceeded the pre-crisis spending levels as a
percent of GDP, the Economic Commission for
Latin America and the Caribbean (ECLAC)
points out some sobering facts: spending levels vary significantly between countries, with
some countries spending at levels significantly
below pre-crisis levels; a “very large” percentage of the increase in social funding is spent
on social security (specifically on pension benefits, which is the least progressive item in
distributional terms); and spending on human
capital, such as education and health care, has
increased less than figures would indicate.8
Overall economic growth also has not led
to decreases in income disparities between
families:
• The Region of the Americas has been identified as having the most unequal distribution of income in the world; the Gini coefficient for Latin America is estimated at 0.49,
compared to 0.44 for Africa, 0.32 for East
Asia, and 0.31 for Southeast Asia, with Brazil, Guatemala, and Honduras leading the
way as the most skewed in terms of income
concentration among the better off.
• In some countries in LAC the wealthiest
10% of the population receives 84 times the
income received by the poorest 10%.9
• A World Bank study of 102 developing
countries in the world found that the poverty levels in 15 of the 17 LAC countries
studied were four times that of other countries with similar income levels.10
8
Ocampo JA. Income distribution, poverty and social expenditure in Latin America. Paper prepared for the first
Conference of the Americas convened by the Organization
of American States. Washington, DC: 6 March 1998. Found
at http://www.eclac.cl/english/Coverpage/oeaningles.htm.
9
Interamerican Development Bank. Economic and social
progress in Latin America, 1998–1999 report: Facing up to
inequality in Latin America. Washington, DC: IADB; 1999.
10
World Bank in Kliksberg B. Inequality in Latin America:
A key issue. Washington, DC: INDES IADB; 1998.
Further, the poor are falling further behind
regarding income distribution, as the wealthiest sector of the population captures most of
the benefits of economic growth:
• Between 1980 and 1989, the Gini coefficient
rose for almost every country in Latin
America, with Costa Rica as the only generally agreed-upon exception to growing income inequalities.11
• In 1995, the purchasing power parity of the
richest 1% (with $66,363 per capita per year)
and the poorest 1% (with $159 per capita
per year) of the Latin American population
reached 417, higher than at any time in recorded history, and likely has worsened
since then.12
• In Brazil, which has the highest income disparity in the world, the proportion of the
total national income of the poorest half of
the population decreased between 1960
and 1990 from 18% to 12%, while the income of the richest 20% of the population
increased from 54% to 65% of total national
income.13
While the proportion of income captured by
the wealthy grows, a large proportion of the
population continues to be trapped in poverty:
• Poverty rates in LAC are not improving: the
poverty rate in 1980 was 35%, topping 40%
for the 1990–1994 period, before falling to
35% in 1997.
• With the population’s demographic growth,
the number of people living in poverty in
LAC has increased over the last two decades, reaching roughly 200 million within
Latin America in 1997.14
11
Kliksberg B. Inequality in Latin America: A key issue.
Washington, DC: INDES IADB; 1998.
12
Londoño and Szkeley, in Kliksberg B. Inequality in
Latin America: A key issue. Washington, DC: INDES IADB;
1998.
13
Kliksberg B. Inequality in Latin America: A key issue.
Washington, DC: INDES IADB; 1998.
14
Economic Commission for Latin America and the Caribbean. Panorama social de America Latina. Santiago, Chile:
ECLAC; 1998.
Casas, Dachs, and Bambas
• The rate of extreme poverty was the same
in 1997 as in 1980, around 15%, which translates to more than 100 million people.15
• If income distribution in LAC had not worsened since 1980, the increase in poverty between 1983 and 1995 would have been half
of what it was.16
Although current poverty rates are comparable to those of twenty years ago, the geographic distribution of poverty has changed
considerably:
• Rapid urbanization of the population has
increased the proportion of urban dwellers
who are poor from 25% in 1980 to 34% in
1994; the urban poor now comprise the larger
portion of the desperately poor in the Region.
• More than half of the population in extreme
poverty now lives in cities, whereas only
one-third of the people living in extreme
poverty lived in urban areas in 1990.
• The percentage of the rural population living
in poverty has changed very little, hovering
between 53% and 56% from 1980 to 1994.17
• Some countries have suffered even more
severe poverty increases. For instance, the
poverty rate in Trinidad and Tobago increased from 3.5% of the households in 1980
to almost 15% in 1990, and it is estimated
that the poverty rate has exceeded 20% in
the mid-1990s.
The urbanization of poverty in LAC is
strongly linked to persistent structural unemployment and the marginal nature of most
new economic activities:
• Even in a country such as Chile, with a relatively modern economic structure, more
15
Inter-American Development Bank. Economic and social progress in Latin America, 1998–1999 report: Facing up
to inequality in Latin America. Washington, DC: IADB; 1999.
16
Birdsall N, Londoño L. Asset inequality matters: An
assessment of the World Bank’s approach to poverty reduction. American Economist Review 1997; 5.
17
Economic Commission for Latin America and the Caribbean. Panorama social de America Latina. Santiago, Chile:
ECLAC; 1998.
25
than half of new employment in the decade
has taken place in the informal sector of the
economy, which has a negative impact on
social protection, stability, and long-term
development.18
• The ILO estimated that, during the 1990s,
eight of every ten new jobs in LAC have
been in poor-quality occupations within the
informal sector.19
SOURCES OF DATA/ LITERATURE FOR
THE ANALYSIS OF DETERMINANTS
OF DISPARITIES IN HEALTH
IN THE REGION
Research conducted in the United States,
Canada, and Western Europe over the past
two decades has given increasing importance
to the study and understanding of the relations between living conditions and health, focusing on disparities. A bibliographic database
on this topic, prepared by PAHO’s Division
of Health and Human Development,20 includes more than four thousand entries, with
most of the empirical information based on
situations in developed countries. The concern
with this area has now reached what could be
called the mainstream public health literature
in the United States and Europe, and public
health oriented institutions are calling to
broaden the parameters of the health policy
debate to include economic and social issues.
The body of knowledge dealing with levels
of socioeconomic disparities and their effect
on health is significantly smaller for those areas of the world whose socioeconomic conditions are lower than those in the developed
18
World Bank. Labor and economic reforms in Latin
America and the Caribbean. Washington, DC: World Bank;
1995.
19
International Labour Organization. Labour overview,
1997. Lima, Regional Office for Latin America and the Caribbean; 1997.
20
Wing SB, Richardson D. Material living conditions
and health in the United States, Canada and Western Europe: Review of recent literature and bibliography. Washington, DC: Pan American Health Organization; 1999. (Research in public health technical papers #9).
26
Health Disparities in Latin America and the Caribbean
countries, particularly LAC. PAHO also has
completed a similar bibliographical review to
document the body of literature on socioeconomic disparities in health that has been produced within LAC, and found only 304 documents, many of which are unpublished.21
In addition to the paucity of information,
the literature was found to have other limitations, such as:
• Much of the literature addresses philosophical and theoretical considerations rather
than empirical information that can provide
evidence for action;
• Studies address narrow age groups, and
there is an absence of studies relating to
adult health in particular;
• Results are often unreliable due to flaws in
data quality, design, or analysis; and
• Very few studies have been conducted at the
local level with primary data collection.
Despite the limited number of studies focusing specifically on the Region, it is clear
that the disparities in health outcomes and
access to care between various socioeconomic
groups and geographic populations in LAC
have remained large in the past few decades,
even tending to increase in many cases. Disparities in health status and access/utilization
of health services between better- and worseoff groups according to socioeconomic criteria manifest themselves by almost any criterion of classification used.
There is most evidence for the socioeconomic category of income, and several studies have documented the differences between
the poor and non-poor in health outcomes and
access to health services.
Although these studies’ findings may appear intuitive, documenting these findings
through empirical observation not only
strengthens the case for socioeconomic dis21
Almeida Filho N. Inequalities in health based on living conditions: Analysis of scientific output in Latin
America and the Caribbean and annotated bibliography.
Washington, DC: Pan American Health Organization;
1999. (Research in public health #19).
parities in health, but also provides more
complete information for the analysis of these
health issues. One of the difficulties of interpreting these studies is that individuals in
vulnerable populations are often vulnerable
on several counts. The categorical associations presented below are not controlled for
other socioeconomic factors; they are simply
correlations, without explicit evidence for
causality.
The socioeconomic categories, as well as the
health indicators, were chosen as study topics primarily because sufficient empirical information exists for the described population
to establish the correlation. In addition to primary data collection, many studies use data
from Living Standards Measurement Surveys
(LSMS) and Demographic Health Surveys
(DHS), which have proven to be valuable, if
incomplete, information sources. An example
of this approach is the recently completed
IHEP-EquiLAC Initiative, carried out by
PAHO (Division of Health and Human Development) in collaboration with UNDP,
IADB and the World Bank, some of the findings of which are mentioned below,22 along
with other results from both published and
unpublished literature.
HEALTH INEQUALITIES
AMONG COUNTRIES
Although health indicators have generally
improved in every country, significant disparities persist between countries. Further, improvements in national health indicators have
occurred to different degrees among LAC
countries. Declining infant mortality rates are
one of the most heralded successes of health
improvements for the region over the last few
decades. But if we take a closer look at the distribution of benefits, we find a pattern of improvement that translates into increasing gaps
22
Economic Commission for Latin America and the Caribbean. Panorama Social de América Latina. Santiago, Chile:
ECLAC; 1998.
Casas, Dachs, and Bambas
between the countries with higher and lower
rates.
Specifically, infant mortality rates (IMR)
declined more in absolute terms in countries
with high initial rates, such as Bolivia and
Haiti. But relative to the lowest IMR for the
Region of the Americas, reductions were
greater in countries with lower initial rates.
There are only four countries in the Americas
where the IMR fell by a factor of four or more
between 1960–1964 and 1990–1994:
27
FIGURE 2. Ratio between the value of infant
mortality rate in each country and the minimum
achieved in the Americas, 1960–1994.
4
✖
✖
✖
2
✖
0
✖
8
✖
✖
6
• Chile fell from 109 to 14, almost an eightfold reduction;
• Cuba fell from 59 to 10, almost a sixfold
reduction;
• Costa Rica fell from 81 to 14, almost an eightfold reduction;
• Canada fell from 27 to 6, a 4.5-fold reduction.
Most of the countries with intermediate
rates in the 1960–1964 period had reductions
between 2.5 and 3.5 times in this 35-year period. During 1960–1964, ten countries had
IMRs above 100. By the 1990–1994 period,
three countries still claimed this dubious distinction, and the remaining six, excluding
Chile, had reduced their rates only by factors
of 2.5 or less. Although their initially high rate
presented the potential for dramatic improvements similar to those seen in Canada, Chile,
Cuba, and Costa Rica, these countries were not
able to capitalize on this opportunity. The behavior of ratios between the infant mortality
rates in each country and the minimum in the
Americas during these periods is shown in
Figure 2.
During 1960–1964, the IMR for the country
with the highest rate was seven times higher
than that for the country with the lowest rate
in the Americas. But by 1990–1994, that ratio
had risen to 14. The median value of these
country ratios rose from 4 to 6 in the same
period. The lower quartile rose from 2.5 to 3.3
and the upper quartile, from 4.8 to 8.0, so that
the inter-quartile range increases from 2.3 to
4.7, more than doubling. The trend of the increasing inter-quartile range seems to have
4
2
0
✖
✖
✖
1960– 1965– 1970–
1964 1969 1974
✖
✖
1975– 1980–
1979 1984
✖
✖
1985– 1990–
1989 1994
slowed in the last two periods, and for some
countries the ratios are beginning to decrease.
But the median value continues to increase,
and it is too early to predict if the improvements among the inter-quartile countries will
continue, stabilize, or worsen.
The health disparities among countries in
LAC become even more pronounced when
comparing the ratio of national (estimated)
maternal mortality rates with the minimum
rate in the Region. While the IMR ratio between the countries with the highest and lowest rates is currently close to 14 in the Region,
the ratios for maternal mortality are over 100
in two countries and over 20 in more than half
of them. These enormous differences in maternal mortality possibly have much to do
with inaccessibility to health care of acceptable quality. It is important to stress that a large
proportion of infant deaths relates to environmentally related conditions—diarrheal disease, acute respiratory infections, malnutrition—whereas maternal mortality is almost
wholly attributable to a lack of—or poor quality—prenatal, delivery, and puerperal care (see
Figure 3).
28
Health Disparities in Latin America and the Caribbean
FIGURE 3. Ratio of the maternal mortality rate and the minimum achieved
in the Region, compared with the ratio of the infant mortality rates and the
minimum in the Region, selected countries in the Americas, circa 1994.
Haiti
Bolivia
El Salvador
Peru
Honduras
Brazil
Guatemala
Paraguay
Nicaragua
Ecuador
Venezuela
Dominican Republic
Mexico
Colombia
Argentina
Cuba
Trinidad and Tobago
Uruguay
Chile
Costa Rica
Panama
Barbados
0
50
100
150
Maternal mortality rates/Regional minimum
Infant mortality rates/Regional minimum
HEALTH INEQUALITIES
WITHIN COUNTRIES
A general pattern of socioeconomic disparities in health among countries can be seen
clearly within countries. The few studies of
the relationships between socioeconomic conditions and health in LAC consistently find
large health differentials between the upper
and lower levels of well-being, be it measured
by income, education level, spatial distributions, ethnicity, gender, access to health services, or national origin.
Income, Household Expenditure, or
Other Material Living Conditions
Income is a useful socioeconomic category
in the sense that it tends to be associated with
a variety of other determinants, either for sociocultural reasons or for simple economics,
depending on the particular population and
social context studied. A few studies at the
country level, within regions of countries, and
at the local level have addressed disparities
in health outcomes and access to care among
populations with varied incomes. The health
measures used range from the extreme of infant and childhood (ages 1–4 years) mortality,
to low birthweight, stunting, and general
childhood diseases.
Between 1982 and 1987, mortality between
ages one and four was measured in southern
Brazil for children in three economic categories: family incomes under US$ 50 per month
(very low income), family incomes between
US$ 50 and US$ 149 per month (low income),
and family incomes above US$ 150 per month
(see Figure 4). For very low income families
the mortality rate for low birthweight children
is almost six times higher than for children
who were born weighing 3,000 g or more, but
is practically the same when the family income
is US$ 150 or more. And among all children
born with normal birthweight (over 2,500 g),
the mortality rate is five times higher in very
Casas, Dachs, and Bambas
FIGURE 4. Cumulative mortality in children
1–4 years of age, by income level and
birthweight, Pelotas, Brazil, 1982–1987.
Cumulative mortality (per 1,000)
35
30
25
20
15
10
5
0
< 50
50 to 149
150 and more
Monthly family income in US$
< 2,500
2,500 to 2,999
3,000 and more
Birthweight
low income families when compared to families with incomes of US$ 150 and more.23
In a 1992 study in Barquisimeto, a mediumsized city in Venezuela, each of the 900 barrios
(communities) was classified in terms of living conditions according to the accessibility
of sanitation, adult literacy rate, and general
condition of the dwellings. When comparing
the 10% of the barrios with the worst living
conditions with the 10% with the best living
conditions, the incidence of low birthweight
was almost twice as high for those with worse
living conditions (almost 14% compared to
7%). The incidence of very low birthweight
(under 1,500 g) was three times as high for
those living in the worst conditions.24
Country studies of time trends indicate that
relative levels of health disparities between
socioeconomic groups are not changing. In a
southern city in Brazil, children of two cohorts—born in 1982 and in 1993—presented
23
Victora C, Barros F, Hutley S, Teixeira AM, Vaughn
JP. Early childhood mortality in a Brazilian cohort: The
roles of bithweight and socioeconomic status. Intern J
Epidemiol 1992; 21: 423–432.
24
Montilva C. Universidad Central Occidental de Venezuela. (Personal communication).
29
similar levels of disparities, in relative terms,
between the lowest and highest income
groups for almost all health indicators. Between 1982 and 1993, infant mortality for children of families with monthly incomes of one
minimum wage or less decreased from 80 to
33 per 1,000 live births, while the rate in the
highest income group of ten minimum wages
or more dropped from 13 to 5 per 1,000 live
births. Notwithstanding the overall improvement in IMR for all socioeconomic groups, the
rate ratio between the low and high income
brackets actually remained at the same level
of 2.6 in that period of time.25
The prevalence of stunting in children
younger than age 5 in Brazil in 1989 was
roughly 30 times higher in families with per
capita monthly incomes under US$ 20, when
compared to families with per capita monthly
incomes of US$ 160 or more, ranging from
28.9% to 0.9%. Another study in 1996 showed
that households with no durable goods had a
prevalence rate of 22.6%, compared to 4.4%
for households with five or more durable
goods. Similar results were also found in a
cohort in southern Brazil, where the prevalence rate of stunting in households with only
one durable good was 26%, compared to 7%
for those with four or more such goods.26
The IMR in Peru for the poorest quintile is
close to five times higher than that for the upper quintile. This ratio is close to seven for the
mortality rate from 1 to 4 years of age. The
prevalence of childhood diseases in Peru in
1996 according to the bottom and top quintiles
of household assets varied between 25% and
15% for acute respiratory infections and between 22% and 13% for diarrhea (see Figure 5).27
25
Victora C. Reducing health inequalities: Can health
interventions make an impact? Paper presented at the
Ninth Annual Public Health Forum. London: London
School of Hygiene and Tropical Medicine; 1999.
26
Olinto MTA, Victora CG, Barros FC and Tomasi E.
Determinantes da desnutrição infantil em uma população
de Baixa Renda: Um modelo de análise hierarquizado.
Cad Saúde Pública 1993; 9 (Supl. 1): 14–27.
27
World Bank. Fact sheets on health, nutrition, population
and poverty in Peru: Poverty thematic group. Washington,
DC: World Bank; 1999.
30
Health Disparities in Latin America and the Caribbean
FIGURE 5. Prevalence of acute respiratory infections and
diarrhea in children under 5 years of age, and treatment
in public health institutions, Peru, 1996.
(a) Respiratory infections
(b) Diarrhea
30
50
25
40
20
30
% 15
%
20
10
10
5
0
0
Lowest
Highest
Quintiles of household assets
Prevalence
Lowest
Highest
Quintiles of household assets
Care in public institutions
Prevalence
Care in public institutions
Source: Demographic and Health Survey, Peru, 1996.
In addition to a greater burden of disease,
the poor also have less access to health services when they need care. Among those who
were sick in the above study in Peru, proportionately more from the better-off quintiles
sought care in public care facilities. Further,
percentages of pregnant women who received
prenatal care from trained personnel differed
between the first and fifth quintiles of household assets, rising from 40% to 95%, while the
figures for deliveries attended by trained personnel rose even more dramatically, from 15%
to 96% (see Figure 6).28
Similar results were seen in Mexico in 1990–
1996. The percentage of deliveries in hospitals increased from 8% in the municipalities
in the lowest decile of average household income to 93% in the municipalities in the high-
FIGURE 6. Percentage of pregnant women
who received prenatal care and delivery
by trained personnel, Peru, 1996.
100
80
60
%
40
20
Prenatal care
Delivery care
0
Lowest
28
World Bank. Fact sheets on health, nutrition, population
and poverty in Peru: Poverty thematic group. Washington,
DC: World Bank; 1999.
Highest
Quintiles of household assets
Source: Demographic and Health Survey, Peru, 1996.
Casas, Dachs, and Bambas
31
FIGURE 7. Distribution of health resources according to per
capita income in municipalities, Mexico, 1990–1996.
20
100
80
% hospital deliveries
60
10
40
Number per 10,000 population
15
5
20
0
1
2
3
4
Hospital deliveries (Y1)
5
6
7
8
9
10
0
Beds/10,000 population (Y2)
Physicians/10,000 population (Y2)
Source: Lozano R, Zurita B, Franco F, Ramírez T, Torres JL, Hernández P. Health inequality in
Mexico: Study by socioeconomic strata at the country and household level. Preprint. Chapter of a
book on the Global Health Equity Initiative to be published by the Rockefeller Foundation in 2000.
est decile of incomes. The number of hospital
beds per 10,000 population varied from
around 2 in the municipalities in the lowest
decile of per capita income to 15 in the highest decile, and the percentage of deliveries in
hospitals goes from less than 10% to over 90%
in those same groups (see Figure 7). 29
A recent study of the city of Rosario, Argentina indicated that poor women in greater
need of services are not necessarily the ones
who receive benefits, even when interventions
are inexpensive and cost-effective. Women at29
Lozano R, Zurita B, Franco F, Ramírez T, Tores JL,
Hernández P. Health inequality in Mexico: Study by socioeconomic strata at the country and household level.
Preprint. Chapter of a book on the Global Health Equity
Initiative to be published by the Rockefeller Foundation
in 2000.
tended in public hospitals delivered babies
with a mean neonatal weight of almost 200 g
less than those delivering in the private clinics (3,168 grams and 3,350 g, respectively), and
the still birth rate was 11.1 per 1,000 live births
compared to 3.8 per 1,000. Yet, women delivering in public hospitals, most of whom had
lower income levels, received iron and folic
acid supplementation during the pregnancy
in only 5.6% of cases, compared to 44.0% of
cases for those delivering in private clinics.
The percentages for other vitamin and mineral supplements were 0.3% and 24.8%, respectively, and for antibiotics, 4.8% and 15.7%,
respectively.30
30
Belizán JM, Farnot U, Carroll G, Al-Mazrou Y. Antenatal care in developing countries. Paediatric and Perinatal Epidemiology 1998; 12 (Suppl. 2) 1–3.
32
Health Disparities in Latin America and the Caribbean
FIGURE 8. Median of the percentage of persons who sought health care among
those who reported having some disease in the four weeks preceding the survey,
by sex and by quintiles of per capita household consumption, according to the
use of public and private services, selected countries in Latin America.
60
50
40
Male Public
% 30
Female Public
Male Private
20
Female Private
Male Public and
Private
Female Public and
Private
10
0
2nd
3rd
1st
4th
5th
Quintile Quintile Quintile Quintile Quintile
Source: Living Standards Measurement Surveys for Bolivia, Colombia, Ecuador, Nicaragua, and
Venezuela, 1994–1996.
Little has been documented in terms of disparities in expenditure on health care in Latin
American and Caribbean countries. An analysis of five countries, based on results of the
LSMS surveys, indicates a gradient in the utilization of health care for persons with a selfperceived need for care, with higher utilization
rates as family consumption increases. Although all groups present a similar rate of utilization of public services (around 20%), the
lower income groups, as would be expected,
have lower rates of utilization of private services (close to 10% in the lowest quintile) when
compared to the higher groups (over 35% in
the highest quintile) (see Figure 8).31
For those households where a health problem was declared to exist in the period previous to the survey, the average household
health care expenditure in Nicaragua in 1993
represented almost 40% of total income for the
31
Living Standards Measurement Studies for Bolivia,
Ecuador, Colombia, Nicaragua, Venezuela, 1994–1996. See:
http://www.worldbank.org/html/prdph/lsml/lsmshome.html
lowest quintile of income but less than 1% in
the highest income quintile.32 In the Dominican Republic, the poorest quintile paid 20%
of their average household income on health
care in 1996 while the highest quintile of income paid less than 10%.33
Level of Formal Education
In the area of formal education, there have
been improvements in population coverage
since 1985, but these advances have been
smaller than in other regions of the world: by
1995, only two-thirds of the school-age population of Latin America and the Caribbean had
completed the fourth year of basic education.
32
Herrera J, Rivas W, Gadea A, Romero N, Bolaños L,
Cáceres M, Campos F, Zamora JR. Cuentas nacionales en
salud: Estudio de fuentes de financiamiento y gastos en
salud 1995–1996. OPS/OMS, USAID, 1999.
33
Rathe M. Cuentas nacionales de salud: Un análisis
del financiamiento del sistema de salud de la República
Dominicana. Santo Domingo, República Dominicana;
1998.
Casas, Dachs, and Bambas
33
Southeast Asia, which had similar formal educational levels in 1985, has now surpassed
LAC in the proportion of its population enrolled in primary and secondary education.34
This finding may bode ill for improving
health, given the proven correlation between
family health and the formal education level
of men and women. In response to the low
development of formal education and its effect
on opportunities and well being, the recent
“Social Development Report” by the InterAmerican Development Bank stressed the
importance of increasing the access of poor
children to formal education as the main intervention for poverty reduction and reducing inequalities in the Region.35
Specific studies have borne out these concerns. A national study in Brazil in 1996
showed that rates of stunting in children under 5 years old correspond strongly to the
family’s level of formal education. Rates range
from 19.3% when the head of household has
no formal education to only 3.4% when the
family head has 11 or more years, an almost
sixfold increase. Intermediate measures of formal education follow a corresponding pattern,
with a 13.7% rate of stunting for 1 to 3 years
of formal education, 8.0% for 4 to 7 years, and
6.3% for 8 to 10 years, indicating that any continuation of formal education may have a
health impact. When the mother’s formal educational level is analyzed, similar patterns
emerge for both stunting—ranging from
19.9% for 0 to 3 years of formal education to
3.3% for 11 or more years—and for wasting—
ranging from 24% for mothers with zero to
three years of schooling to 7% when the
mother has 6 or more years.36
Studies in Chile found relationships between women’s formal education and their
babies’ health. Neonatal mortality rates stratified by maternal formal education level in
Chile for the 1990–1995 period range from 13.5
per 1,000 live births for those with no formal
education to 6 per 1,000 for those with 13 or
more years. Post-neonatal mortality rates decline from 24.5 per 1,000 live births to 2.6 for
the same categories, indicating a tenfold difference when the mother is illiterate as compared to mothers with 13 or more years of
schooling (see Figure 9).37
A dramatic example that demonstrates the
need to determine how benefits are being captured by socioeconomic groups is illustrated
by the rise in life expectancy among Chilean
women between the mid 1980s and the mid
1990s. Women in Chile gained almost two
years in their life expectancy at age 20, but
women with 13 years of formal education or
more enjoyed almost all the benefits, gaining
almost ten years in a ten-year period, while
gains in the groups with lesser formal education levels were negligible (see Figure 10).38
34
World Bank. World Development Report 1998. Washington, DC: World Bank; 1998.
35
Inter-American Development Bank. Economic and social progress in Latin America, 1998–1999 report: Facing up
to inequality in Latin America. Washington, DC: IADB; 1999.
36
Epidemiological Studies in Health and Nutrition,
Univerity of São Paulo. Melhoria em indicadores de saúde
associados à pobreza no Brasil do sanos 90. University of
São Paulo: School of Public Health. (Internal report).
37
Hollstein RD, Vega JM, Carvajal YB. Socioeconomic
level and infant mortality in Chile in the period 1985–
1995. Rev Med Chile 1998; 126:333–340.
38
Vega J, Holstein RD, Delgado I, Marshall G, Yach D.
Social inequalities and health in an intermediate-development nation: Education and adult mortality in Chile,
1980–1996. Preprint. Chapter of a book on the Global
Health Equity Initiative to be published by the Rockefeller
Foundation in 2000.
Spatial Distributions
Studies show that health varies according
to spatial distributions within countries, which
have been measured between geographic regions, between urban and rural populations,
and between wealthier and poorer communities. Data from the Demographic and Health
Surveys (DHS) show, for example, how different the rates of stunting for children below
5 years of age are between urban and rural
areas of various countries. In some cases, the
percentage of children under the standard in
rural areas is two-and-a-half times higher than
in urban areas (Table 1).
In Peru and Guatemala, the prevalence of
stunting in rural areas exceeds 50% of all chil-
34
Health Disparities in Latin America and the Caribbean
FIGURE 10. Life expectancy at age 20
according to years of schooling, females,
Chile, 1985–1987 to 1994–1996.
FIGURE 9. Neonatal and post-neonatal
mortality, Chile, 1990–1995.
25
Years of
schooling
75
20
13 & more
Life expectancy at age 20
Mortality rate
70
15
10
5
65
9 to 12
60
1 to 8
55
None
0
50
None
1 to 3
4 to 6
7 to 9 10 to 12 13 & more
Years of schooling of the mother
Post-neonatal
Neonatal
dren below age 5.39 In the city of Buenos Aires,
Argentina, the IMR in 1995 was close to 13 per
1,000 live births, but some of the country’s
provinces have rates that exceed 30 per 1,000
live births.40 In Chile, the years of potential life
lost below age 65 in the comunas (counties)
with better living conditions is close to 72
years per 1,000 population, but reaches almost
157 per 1,000 population in those with the
worst living conditions.41 In Mexico, the years
of potential life lost below age 70 ranges from
10 to 181 per 1,000 population in municipalities with the lowest and highest values according to a deprivation index.42
39
Macro International. Demographic and Health Surveys. Calverton, Maryland; 1996.
40
Pan American Health Organization. Health in the
Americas, 1998 edition.Washington, DC; PAHO; 1998.
41
Concha M, Aguilera X, Guerrero A, Salas J, Child V.
Metodologías de apoyo a la priorización local de problemas de
salud. Santiago, Chile: Ministerio de Salud; 1997.
42
Lozano R, Zurita B, Franco F, Ramírez T, Torres JL,
Hernández P. Health inequality in Mexico: Study by socioeconomic strata at the country and household level.
Preprint. Chapter of a book on the Global Health Equity
Initiative to be published by the Rockefeller Foundation
in 2000.
85–87
90–92
94–96
Source: Vega J, Hollstein RD, Delgado I, Marshall G, Yach D.
Social inequities and health in an intermediate-development
nation: Education and adult mortality in Chile, 1980–1996.
Preprint. Chapter of a book on the Global Health Equity Initiative
to be published by the Rockefeller Foundation in 2000.
Infant mortality in Brazil fell 40% between
1977–1985 and 1987–1995, but the gaps between the worse-off areas, with high rates, and
the ones with lowest rates have increased.
Table 2 presents the rates estimated from data
of Demographic and Health Surveys of 1986
and 1996 by the five great geographical regions for rural and urban areas of Brazil. The
mortality rates fell in all areas, but the rate ratios of the worst part (north-east-rural) and
the whole country increased from 1.7 to 2.0.
Stunting below age five fell in Northeastern
TABLE 1. Percentage of stunting in children under
5 years of age, by urban or rural area, selected
countries in Latin America and the Caribbean,
early to mid 1990s.
Country and year
Dominican Republic, 1996
Brazil, 1996
Colombia, 1995
Paraguay, 1990
Haiti, 1995
Bolivia, 1994
Peru, 1992
Guatemala, 1995
Urban
(%)
Rural
(%)
7.3
7.8
12.5
11.7
20.4
20.9
25.9
35.3
15.2
19.0
19.1
26.9
35.1
36.6
53.4
56.6
Casas, Dachs, and Bambas
35
TABLE 2. Trends in infant mortality rates, by geographical region and urban/
rural strata, Brazil, 1977–1985 and 1987–1995.
Stratum/region
1977–1985
1987–1995
Annual change (%)
Urban
North
Northeast
South-Central
Rural a
Northeast
South-Central
Brazil b
68.8
(51.1)
120.4
47.0
100.9
135.2
(61.2)
79.6
41.2
(42.1)
62.8
33.0
60.8
84.4
28.8
46.1
– 4.0
– 1.7
– 4.8
– 3.0
– 4.0
– 3.7
– 5.3
– 4.2
Source: Pan American Health Organization, Division of Health and Human Development (DHS),
1986, 1996.
a
Rates based on less than 1,000.
b
Does not include the rural areas of the Northern region.
Brazil from 47.8% in 1975, to 27.3% in 1989,
and to 17.9% in 1996. In the South-Central region the prevalence declined from 23.9% to
8.6% to 5.6% in the same years. In 21 years,
the prevalence fell almost fourfold in the
better-off regions but only 2.7-fold in the worst
one. The rate ratios were 2.0 in 1975, and over
5 in 1996.43
Ethnicity
Two ethnic groups in LAC are generally recognized as particularly vulnerable populations—the indigenous population and the
population of African descent. Studies by the
Inter-American Development Bank point out
that there are approximately 150 million persons of African descent in Latin America. Of
all the poor in Latin America, 40% are of African descent.44 Preliminary health data from
Colombia’s Pacific coast and evidence elsewhere suggest that Black communities suffer
poor health disproportionately.45 Racial categories for populations in the Americas correlate
with other socioeconomic indicators, such as
income, education, and geography.
43
Epidemiological Studies in Health and Nutrition, University of São Paulo. Melhoria em indicadores de saúde
associados à pobreza no Brasil dos anos 90. University of
São Paulo: School of Public Health. (Internal report).
44
These data do not include the Dominican Republic
and Cuba.
45
Cowater International Inc., Inter-American Development Bank. Poverty alleviation for communities of African ancestry. Washington, DC; 1996.
Since the 1990s, some countries in the Region
have made significant efforts to collect and analyze statistics based on race and ethnicity.
Belize, Bolivia, Brazil, Ecuador, Chile, Guatemala, El Salvador, Mexico, Nicaragua, Paraguay, and Peru already include the variable of
ethnicity in their national statistics. In other
cases, the stratification of data by geographic
location (urban vs. rural vs. hinterland or by
ethnically homogeneous small areas) is a proxy
method for identifying significant disparities
in the health situation between ethnic groups.
It also is necessary to recognize the differences in concepts and application of race and
ethnicity in North America, Latin America,
and the Caribbean and to see them as the social constructs that they are. Historical and
cultural factors account for the fact that race
underscores a phenotype that differentiates
human beings by skin color, whereas ethnic
groups display cultural characteristics beyond
skin color. In any case, the countries’ historical and cultural development, as well as the
level of relative empowerment of different ethnic groups, will determine the categories of
analysis which need to be studied and monitored in every particular case.
The results of the relatively few studies of
socioeconomic conditions of Latin America’s
indigenous populations are instructive.46 They
46
World Bank, Technical Division, Latin American and
Caribbean Division. Indigenous people and poverty in Latin
America: An empirical analysis. Washington, DC: World
Bank; 1993.
36
Health Disparities in Latin America and the Caribbean
confirm that the level of poverty among indigenous people in LAC is very high.
• In Bolivia over two-thirds of the bilingual indigenous population and almost three-fourths
of the non-bilingual population are poor.
• In Guatemala, the majority of the indigenous population does not have access to
such public services as water, sanitation,
and electricity, and approximately half of
the indigenous households have no access
to safe water and basic sanitary services
compared with 5% of the non-indigenous
population.
• In Bolivia formal education levels of the indigenous population are three years less, on
average, than the non-indigenous population.
• In Mexico poverty is highly correlated to
municipalities with indigenous populations.
• Recent poverty studies in LAC communities with African ancestry identified similar trends. Poverty in these communities
ranges from as low as 2% in the populations
of Bolivia and Costa Rica to as high as 40%
to 50% in Brazil and Colombia.47
As expected, patterns of health outcomes
according to race or ethnicity follow these patterns of socioeconomic conditions. The few
studies on the topic that have been published
confirm large disparities between the health
of indigenous groups and national statistics:
• For indigenous groups in the Region, infant
mortality is 3.5 times higher in Panama, life
expectancy is 29 years lower for men and
27 years lower for women in Honduras,
child mortality is more than 2.5 times higher
in Mexico, and maternal mortality is 83%
higher in Guatemala.48
• A 1993/1994 survey in Colombia of 11,522
Native Americans living in indigenous com47
Cowate A International Inc., Inter-American Development Bank. Poverty alleviation for communities of
African ancestry. Washington, DC; 1996.
48
Amaris A, Flores C, Mojica J. Mortalidad infantil en
Panamá: Un análisis de sus tendencias derivadas del
censo 1990. Panamá; 1992. Rivas R. Pueblos indígenas y
munities located in three geographically
and culturally distinct communities—the
Caribbean, the Amazon Basin, and the
Andes—found that health indicators among
those populations were significantly worse
than for most Colombians. Life expectancy
at birth for indigenous populations in 1993
was 57.8 years for women and 55.4 years
for men, compared to national averages of
67 and 65 years. The infant mortality rate
for these populations in 1990 was 63.3 per
1,000 live births, compared to the national
average of 32.49
• Again, these populations tend to have disproportionately low levels of access to care.
In Bolivia, indigenous people report more
than twice the number of illnesses and injuries and are off from work twice the number
of days. However, they receive less medical
help or care and have access to less preventive care such as vaccination for yellow fever than the Mestizo population, which composes the majority of the national population.
• Government efforts in Guatemala have expanded the coverage of immunization programs in rural areas, but the data shows that
percentage of children without access to any
form of immunization, or restricted access to
health services, information, and health promotion is still higher among indigenous and
rural communities (see Figures 11, 12, and 13).50
• A 1990 study in Brazil addresses infant
mortality in relation to both race and maternal formal education, and shows that for
illiterate mothers IMRs were close to 120 per
Garifunas. Honduras: Guaymuras; 1993. Instituto Nacional Indigenista. La salud de los pueblos indígenas en
México. México, DF: Secretaría de Salud; 1993. Health of
indigenous peoples. Rev Panam Salud Publica.
49
Piñeros-Petersen M, Ruiz-Salguero M. Aspectos
demográficos en comunidades indígenas de tres regiones
de Colombia. Salud Publica Mex 1998: Jul–Aug; 40(4):324–
329. United Nations. World population prospects, 1998 revision. New York, NY: UN; 1998. Pan American Health Organization. Health statistics from the Americas, 1998 edition.
Washington, DC: PAHO; 1998.
50
Pan American Health Organization, Health and Human Development, Public Policy and Health Program.
Health systems inequalities and poverty in Latin America
and the Caribbean: Trends and policy implications. Washington, DC: PAHO. (EquiLac/IHEP draft document); 1999.
Casas, Dachs, and Bambas
FIGURE 13. Percentage of women of childbearing age who knew about AIDS and
percentage of those who knew about
protection methods, Guatemala, 1995.
FIGURE 11. Gaps in delivery care: place
of birthing by ethnic group and area
of residence, Guatemala, 1995.
100
90
100
80
90
80
70
70
60
60
% 50
%
40
30
20
20
10
10
Urban
Non-indigenous
Rural
Indigenous
Home
Ministry of
Health
Social Security
Institute
Private
Source: INE (1996a).
FIGURE 12. Gaps in immunization: percentage
of children with complete immunization and
with no immunization, by area of residence
and ethnicity, Guatemala, 1995.
50
45
40
35
30
% 25
20
15
10
5
Urban
Non-indigenous
Complete vaccinations
Source: INE (1996a).
0
Urban
Non-indigenous
Rural
Indigenous
% of women who knew about AIDS
% of women who knew how to protect themselves against
AIDS (among those who knew about AIDS)
Source: INE (1996a).
1,000 for blacks, 110 for mulattos and darkskinned, and 95 for whites. For mothers
with eight or more years of formal education, the rates were much lower, respectively
82, 70, and 57 per 1,000 live births, but these
rates presented even greater relative disparities according to race than they did to
formal education (see Figure 14). Black
women needed between four and seven
years of formal education before they could
achieve the IMRs of illiterate white women,
0
50
40
30
0
37
Rural
Indigenous
No vaccinations
demonstrating the strength of the effect of
ethnically based discrimination in health.51
Gender
In addition to the differences in health needs
that are biologically derived and specific to
each sex, there are gender inequalities in
health outcomes, access to care, utilization and
financing of services that are socially produced. These gender inequalities constitute a
reflection of the differences in women’s and
men’s social roles, and of their relative positioning in terms of access to resources and
power over health determinants.
An illustrative example of the interaction of
gender and socioeconomic inequities is contained in Table 3 and in Figures 15 and 16,
which show the probability of dying between
15 to 59 years of age for poor and non-poor
males and females in 13 countries of the Region.52 The generally recognized fact that
51
Pinto da Cunha E. Raça: Aspecto esquecido da ineqüidade em saúde no Brasil. In Barata R et al.: Eqüidade
e saúde: Contribuições da epidemiologia. Rio de Janeiro, Brazil: Abrasco/Fio Cruz; 1997.
52
World Health Organization. The World Health Report,
1999. Geneva: WHO; 2000.
38
Health Disparities in Latin America and the Caribbean
Hostile conditions in the social environment
and lack of appropriate health services seem
to disproportionately affect women’s opportunities for health and health care, curtailing—
or in some rare instances, eliminating—the
long-standing biological advantage of female
survival.
The fact that women live longer does not
mean that they need less health care. On the
contrary, women’s need for health services is
greater than that of men, due primarily to the
female reproductive function. Women also
tend to exhibit higher rates of morbidity
throughout their lives and because of their
greater longevity they additionally bear a
heavier burden of chronic disease. In fact, in
every country and at every socioeconomic
level, women consistently report a higher incidence of health problems. Even though
women tend to utilize health services more
often than men, if utilization is measured in
relation to expressed need for care, women
actually are less likely to utilize health services
than men, particularly among the poor (see
Figure 8).
LSMS data from Peru corroborates the overall higher frequency with which women report health problems (disease and accidents)
and utilize health services (see Table 4 and
Figure 17). Indeed, women report 15% more
health problems than men. However, when it
comes to receiving health care, their use of
FIGURE 14. Infant mortality by mother's
education and race, Brazil, 1990.
120
100
Infant mortality
80
60
40
20
0
none
1 to 3
4 to 7
8 & more
Years of schooling of the mother
Black
Mulato
Dark
White
mortality rates are higher among males at any
age is clearly depicted by the higher male/
female risk ratio of premature death—which
varies from 1.6 to 4.0 among the non-poor.
Among the poor, however, this ratio is considerably reduced and even reversed in some
countries. In other words, poverty does not
appear to be an equal opportunity dispenser
of premature death among men and women.
TABLE 3. Probability of dying (per 100) between 15 to 59 years of age, by income and sex, 13 Latin
American and Caribbean countries.
Country
Male
poor
Female
poor
Male
non-poor
Female
non-poor
Poor
male/female ratio
Non-poor
male/female ratio
Brazil
Chile
Colombia
Costa Rica
Dominican Republic
Ecuador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Peru
Venezuela
55.2
44.4
52.5
38.5
40.8
48.6
43.7
30
46.4
33.6
33.3
27.2
48
47.4
36.9
52
31.8
48.5
48.4
31.4
28
43
33.6
30.8
21.6
45.6
23
12
25
7
12
18
23
15
16
16
9
16
16
6
3
10
3
5
11
9
7
5
6
4
6
6
1.2
1.2
1.0
1.2
0.8
1.0
1.4
1.1
1.1
1
1.1
1.3
1.1
3.8
4.0
2.5
2.3
2.4
1.6
2.6
2.1
3.2
2.7
2.3
2.7
2.7
Source: World Health Organization. The World Health Report, 1999. Geneva: WHO; 2000.
Casas, Dachs, and Bambas
39
FIGURE 15. Probability of premature mortality (per 100),
15–59 years of age, by sex and level of poverty,
13 Latin American and Caribbean countries, 1994.
Chile
Nicaragua
60
Male non-poor
Male poor
40
Venezuela
Female non-poor
Honduras
50
Guatemala
Female poor
30
20
10
Mexico
Dominican Republic
0
Panama
Peru
Colombia
Ecuador
Costa Rica
Brazil
health services is only 2% higher than that of
men. Furthermore, the tendency toward
higher utilization of female services completely vanishes in the lowest income quintile
where, paradoxically, the gender gap in
health-need is widest. Thus, despite the oftFIGURE 16. Poor/ non-poor ratio in the
probability of dying (per 100) between 15
and 59 years of age, by sex, 13 Latin
American and Caribbean countries.
Chile
Venezuela
Mexico
Panama
Colombia
Costa Rica
Brazil
Ecuador
Peru
Dominican Republic
Guatemala
Honduras
Nicaragua
noted higher utilization of services by women,
this pattern is still far from approaching the
equity principle of securing access to services
according to need.
Finally, because of their greater need for
health care and the features of current financial systems, women have higher out-ofpocket expenses, both in absolute terms as
well as in relation to their income or their to-
TABLE 4. Percent difference between females and
males in perception of health problems and
utilization of health services, by income quintiles,
Peru, 1997.
Income
quintiles
0
2
4
Male Poor:Non-Poor
6
8
10
12
14
Ratio
Female Poor:Non-Poor
Perception of
Utilization
health problems
of services
(females/males × 100) (females/males ×100)
Total
14.7
2.2
I (Low)
II
III
IV
V (High)
16.5
12.4
14.8
15.8
13.4
–0.5
2
2.2
4.5
5.3
Source: Living Standards Measurement Study (LSMS) survey, Peru,
1997.
40
Health Disparities in Latin America and the Caribbean
FIGURE 17. Peru: percent difference between
females and males in perception of health
problems and utilization of health services,
by income quintiles, 1997.
18
16
14
12
10
in the labor market. This disadvantage derives
from the social centrality of reproduction in
women’s lives which keeps more than 50% of
females outside the paid labor market, concentrates those who are employed in occupations that are poorly remunerated or fall outside the coverage of social benefits—such as
part-time or informal-sector jobs—and introduces discontinuity in their work histories.
Physical and Financial Access
to Health Services
8
6
4
2
0
–2
I
II
III
IV
Income quintiles
V
Perception of health problems (females/males × 100)
Utilization of services (females/males × 100)
Source: Living Standards Measurement Study, Peru 1997.
tal household expenditures. This higher expenditure has implications not only for
women’s health but also for their financial
well-being. Survey data recently reviewed in
PAHO’s Division of Health and Human Development for four countries show that
women’s out-of-pocket expenditures for
health care ranged between 15% to over 40%
higher than men’s (see Table 5). This disparity in expenditure is compounded by the fact
that throughout the Region women’s income
remains below that of men. For example, in
16 countries of the Americas, women’s earnings in urban areas continue to range from
under 60% to less than 80% of men’s average
income.53 Furthermore, to the extent that
health care and social security financing are
dependent on employment status, gender disparities in access to services will continue to
exist due to women’s disadvantaged position
53
Economic Commission for Latin America and the Caribbean. Panorama social de America Latina. Santiago, Chile:
ECLAC; 1998.
A series of case studies on health system
inequalities was undertaken within the framework of a joint PAHO/UNDP/World Bank
Project on Investment in Health, Equity, and
Poverty in Latin America and the Caribbean
(EquiLac/IHEP). The countries under investigation—Brazil, Ecuador, Guatemala, Jamaica, Mexico, and Peru—account for more
than two-thirds of the population, Gross Domestic Product (GDP), and overall national
health expenditure of the 45 countries and territories in Latin America and the Caribbean.
Among the fundamental issues addressed
were (a) the extent to which differences in organization, delivery, and financing of national
health care systems are relevant in explaining
health systems inequalities, and (b) the response of different national systems to the
needs of the poor.54
The population of the countries ranges from
3 million in the case of Jamaica to 94 million
in Mexico and 163 million in Brazil. Differences in per capita income in these countries,
expressed in US$ adjusted for purchasing
power parity (PPP), range from close to
US$ 4,000 in Guatemala to around US$ 6,300
in Brazil and US$ 7,600 in Mexico. Brazil and
Guatemala are the countries with the greatest
degree of income inequality; the Gini coefficient for these two countries is around 0.60,
54
Pan American Health Organization, Health and Human Development, Public Policy and Health Program.
Health systems inequalities and poverty in Latin America
and the Caribbean: Trends and policy implications. Washington, DC: PAHO. (EquiLac/IHEP draft document); 1999.
Casas, Dachs, and Bambas
41
TABLE 5. Out-of-pocket expenditures for health, by gender, selected Latin
American and Caribbean countries.
Health spending
(current US$)
Country
Percent
difference
Data
Brazil
Females
Males
Paraguay
Females
Males
Peru
Females
Males
Dominican Republic
Females
Males
Health expenditures as a percent
of total household spending
Percent
difference
Data
$239.51
$171.08
40.0
2.1
1.5
40.0
$381.95
$299.77
27.4
4.5
3.5
28.6
$100.31
$70.91
41.5
2.0
1.4
42.9
$162.52
$141.48
14.9
8.5
7.4
14.9
Source: Living Standards Measurement Study surveys for Brazil, Paraguay, and Peru; Demographic
and Health Surveys for the Dominican Republic.
while the ratio of the share of income going to
the top and bottom quintiles of the income
distribution is 47 in Brazil and 32 in Guatemala. Jamaica has the lowest level of income
inequality, with a Gini coefficient of 41 and an
income share ratio of top to bottom quintiles
of 8. The population living below a consumption-based poverty line—defined as those
whose income is below the cost of a market
basket of commodities providing a minimum
intake or consumption of calories and proteins—ranges from more than 50% in Ecuador, Peru, and Guatemala to 34% in Jamaica,
17% in Brazil, and 10% in Mexico. In Jamaica,
34% of the population has an income below
the poverty line (see Table 6).
The national health systems of these countries range from predominantly public, as is
the case of Jamaica and Mexico, to a wide
variety of mixed systems, as are the cases of
Brazil, Ecuador, and Peru. In all countries, private expenditures, including direct out-ofpocket expenditures and voluntary contributions to privately managed prepaid health
plans and health insurance schemes, are the
largest component of national health care expenditures, ranging from 66% in Brazil to
around 50% in Ecuador, Jamaica, and Peru. For
developed countries excluding the US, the
public-private mix is around 70/30. There are
even wider variations in out-of-pocket expenditure. It is 40% in Brazil, while in Ecuador
and Peru, where only 20% of the population
is covered by national health insurance, direct
out-of-pocket sources is the main component
of financing national health expenditure, a
TABLE 6. Selected indicators for countries participating in the EquiLAC and
IHEP projects.
Country
Brazil
Ecuador
Guatemalaa
Jamaica
Mexico
Peru
Population
(millions)
Per capita
income PPP
(US$)
Gini
coefficient
Ratio
20/20
Population
below PL-Ca
(%)
165.2
12.2
11.6
2.5
95.8
24.7
6,340
4,730
3,820
3,450
7,660
4,410
60
47
50
41
50
45
32
20
31
8
14
12
27.2
54.7
75.2
34.2
38.6
49.0
Source: World Bank, SID-CG, PAHO Health Status Indicators, 1999.
a
PL-C: Poverty line, consumption-based.
42
Health Disparities in Latin America and the Caribbean
TABLE 7. Distribution of Ministry of Health subsidy, by income quintiles, urban and rural areas, and type
of establishment, Peru, 1997.
Quintile
1 (Low)
2
3
4
5 (High)
Percentages
URBAN
RURAL
Health
Health
centers/
centers/
Hospitals posts MINSA Hospitals posts MINSA
18.1
20.5
19.7
21.1
20.5
24.3
22.5
21.5
21.0
10.7
6.0
10.4
19.2
31.9
32.4
17.8
16.6
25.1
17.5
23.1
situation which is evidently discriminatory
and greatly affects the ability of the poor and
disadvantaged in the Region to obtain needed
health care.
One example of the disparities that exist in
the use of public resources is contained in
Table 7, which presents the distribution of the
subsidies provided by the Ministry of Health
of Peru, according to income quintiles, for urban and rural areas and by type of establishment. The results show that with the exception of Health Centers and Posts, for which
the subsidies are more concentrated in the
lower quintiles (poorest households), the distribution is uniform at best (i.e., approximately
the same for all income groups) as in the case
of urban hospitals, or very skewed in favor of
the rich as in the case of rural hospitals. Within
rural hospitals, almost two-thirds of the resources are used by households in the two
upper income quintiles.
The same data from Peru are also presented
in several concentration curves (see Figure 18).
For the curves corresponding to urban hospitals and to rural health centers/posts, the distribution is almost equal. The urban health
centers/posts present a progressive distribution. Rural hospitals, on the other hand, evince
an extremely regressive distribution, favoring
the rich.
Using a methodology for measuring inequalities in health status and in the delivery
of health care that was originally developed
Cumulative percentages
URBAN
RURAL
Health
Health
centers/
centers/
Hospitals posts MINSA
Hospitals posts MINSA
18.1
38.6
58.3
79.5
100.0
24.3
46.8
68.4
89.3
100.0
6.0
16.5
35.7
67.6
100.0
17.8
34.4
59.5
76.9
100.0
for a project in ten European Union countries,55
the study concluded that, despite the diversity of socioeconomic conditions and a variety of organizational, financing, and delivery
systems, some common patterns emerged:
• Whereas the differences in perceived health
status as measured by self-reported symptoms of illness or accident and self-assessed
health between the various income groups
are relatively small, differences in health
status as measured by the incidence and
prevalence of diseases and mortality are
quite large. The low income groups are
more exposed to environmental risks, are
more frequently sick, live shorter lives, and
report more days of lost work due to illness
and disability.
• The size of the gap between health needs
and utilization of health services is inversely
correlated to the level of income. The lower
the level of income, the larger the gap between health needs and utilization of health
services.
• Distribution of private consumption expenditures compounds the socioeconomic differences associated with income/expenditure distribution.
• The larger the share of government expenditure as a percentage of national health care
55
Van Doorslaer E, Wagstaff A, Rutter F (eds). Equity in
the finance and delivery of health care. New York, NY: Oxford University Press; 1993.
Casas, Dachs, and Bambas
FIGURE 18. Concentration curves for the
distribution of the Ministry of Health subsidies
by type of establishment (hospital or
health center, and urban or rural area)
and by income quintiles, Peru, 1997 (Living
Standards Measurement Study survey data).
0.1
0.05
0
–0.05
–0.1
–0.15
–0.2
–0.25
1
Low
2
3
4
Income quintiles
Hospital, urban
Health center, urban
5
High
Hospital, rural
Health center, rural
Source: EquiLAC project report, PAHO, Health in Human
Development, 1999.
expenditure, the lower the differences in
health care service utilization and the differences between overall consumption expenditures between high and low income
groups.
• The distributive impact of government expenditures in health care services is limited
by the relatively low utilization of health
care services by the poor.
Based on the results from the case studies,
the report made the following observations
and suggestions related to the development
of policy.
• The lack of significant differences in the
perception of symptoms of illness or accidents among income groups suggests that
the service availability may not be a major
constraint on access for the poor, but rather
that differing thresholds of self-perceived
health and disease and other cultural, economic, and social barriers may be of more
43
importance in explaining disparities in
health service utilization.
• Increasing availability of health care services may not result in an increase in the
utilization of these services even if the services are provided free of charge or for a
nominal fee. It is necessary to increase
awareness among the lower income groups
and the uneducated about their real need
for health care, and to encourage and assist
the poor to make fuller use of health care
facilities for preventive purposes.
• Greater emphasis should be placed on evaluating the determinants of health status of
different socioeconomic groups so as to provide a better understanding of the relevant
types of health policies and health care services required to break the cycle of poverty.
Improving equity in access to supply driven
interventions (mainly preventative and
health promotion activities, as well as health
information) may improve overall population health more than demand driven services, which are more aligned to providing
individual satisfaction of a perceived need.
• The development of more sensitive and specific measurements of health status, health
service access and utilization, and health
needs are required in order to better explore
the determinants and interactions between
health disparities and access to health services among the particular population subgroups. Also, there is a need to link traditional epidemiological methods and data
sources (vital registries, disease surveillance, health service production statistics)
with emerging sources of reliable useful
data on living conditions, health status, and
health service utilization, such as periodic
national household surveys for monitoring
of demographic, social, and economic
trends (LSMS, DHS, MECOVI56). PAHO,
56
MECOVI: “Mejoramiento de Encuestas de Condiciones de Vida” is a UNDP, IADB, WB, ECLAC, and
PAHO initiative to improve design and utilization of
household surveys for use by a broader range of economic
and social sector monitoring and planning purposes, including health.
44
Health Disparities in Latin America and the Caribbean
through the Division of Health and Human
Development’s Public Policy and Health
Program, is to become the fourth member
institution of the MECOVI Project, which is
working to improve the health component
of the instruments used in the surveys, and
the use of the data to study inequalities in
health status, access, utilization and financing of health care. As part of this effort, a
database of existing surveys is now available online with information on almost 100
surveys used in the past 15 years that have
a health module, including all countries in
Latin America and several in the Caribbean.
Health, National Origin, and Migration
The relationship between health and internal and international migration has been recognized for many years. The effects of migration can be observed both in the place of origin
as well as at the destination, and affect health
status, access to health care, and demand for
health services. In general, migrant populations have worse health status and less access
to health services than non-migrants. Taking
this into consideration, the World Health Organization (WHO) and the International Organization for Migration (IOM) signed a
Memorandum of Understanding in Geneva in
October of 1999 to strengthen collaboration
between the two organizations to “better meet
the health needs of migrants and other displaced persons.” Specific goals include to reduce the mortality, morbidity, and disability
among migrants; to provide them with better
health services; and to campaign for effective
international health policies and support infrastructure for migrants.
International migration has increased considerably, and it is expected that this trend will
continue. The most recent worldwide estimates of the number of international migrants
(UNFPA) indicated that there were 120 million international migrants in 1990, accounting for about 2% of the world’s population.
At that time, the Region’s countries that experienced significant effects from international
immigration were the United States, Canada,
Belize, Costa Rica, Argentina, Venezuela,
Antigua and Barbuda, Bahamas, Barbados,
and Saint Kitts and Nevis: the immigrants represent more than 5% of the total population in
those countries.
From the perspective of the receiving countries and the immigration policies, IOM has
defined six different types of international
migrants: “permanent settlers,” “documented
labor migrants” (including both “temporary
contract workers” and “temporary professional transients”), “undocumented migrants,” “asylum seekers,” “recognized refugees,” and “de facto refugees” or “externally
displaced persons.” The respective health
needs of these groups as well as the effect of
their health status on the health services of the
recipient countries is different for every type
of migrant. This issue is being addressed in a
study that Division of Health and Human
Development’s Public Policy and Health Program and PAHO’s Country Office in Costa
Rica are developing in that country at the request of the national authorities and USAID.57
COMMENTS AND DISCUSSION
Most countries in the Americas are currently
undergoing health sector reforms. Often, these
processes occur as part of broader State reforms intended to facilitate the integration of
regional economies into the global market.
Considering the enormous disparities in the
socioeconomic status of the populations in this
Region’s countries, if these reforms are to succeed, they must take these inequalities into
account. In terms of health, the reforms’ main
objective has to be coupled with general policies that diminish the gaps between the extremes of the socioeconomic spectrum and
promote greater access to basic health care.
57
Pan American Health Organization, Division of
Health and Human Development, Public Policy and
Health Program. Project document: Spatial mobility, processes of integration and health in Central America. Washington, DC: PAHO; 1999. (Mim. September 1999).
Casas, Dachs, and Bambas
The Pan American Health Organization is
promoting several studies and projects in this
area, including a multicenter study in five
countries, using data from LSMS and DHS surveys and from national censuses, to increase
available knowledge about the inequalities in
health and their relationships with many of
their determinants. These studies emphasize
the need for results that can be used to address policy issues and to design and evaluate interventions both within and outside of
the health sector and to address these disparities in a meaningful way. The specific areas of
actions required will vary from country to
country, but the multiple causes of ill-health
call for the following four levels of policy action: strengthening individuals, strengthening
communities, improving access to basic services and facilities, and encouraging macroeconomic and cultural changes. Acting on
these levels requires a strategic approach that
takes into account the interrelationships across
sectors and policy levels.58
Research provides crucial support to an equity-oriented policy agenda by providing data
and analyses that address gaps in knowledge.
In so doing, it helps to identify policy options
and strategies, including those that would
help redress power imbalances in the decision
making process. The empowerment of the
weak, the disadvantaged, and the marginalized requires increasing their access to information. In the words of Julio Frenk:
If the evidence is clear and recommendations are
vigorous, those who have the power to decide may
be stimulated into action. At the very least, sound
policy analysis places limits on the discretion of
decision makers, who have to consider the costs of
ignoring the available data.59
Given the strength of available evidence, it
can be safely concluded that in LAC, as has
been demonstrated in North America and Eu58
Gilson L. In defence and pursuit of equity. Soc Sci
Med 1998; 47: 1891–1896.
59
Frenk, J. in Gilson L. In defence and pursuit of equity. Soc Sci Med 1998; 47: 1891–1896.
45
rope, the main social determinants of health
are those related to differential power relations
and opportunities, mainly evidenced by differences due to race or ethnicity, gender, and
social class (as measured by income level,
material living conditions, educational attainment, or occupation). A growing body of research has begun to develop alternative approaches to studying the health effects of these
features, and these new inquiries are seeking
to address the many limitations of the predominant epidemiological methods.60 This
work can be characterized by three basic assumptions about the nature of health and disease in human societies:
• Societal divisions based on race, gender, and
class are the expression of social relations,
not intrinsic facts of biology. Consequently,
social factors, not genetics, primarily explain why people’s membership in the
groups defined by these social relations can
predict their overall health status.
• The fact that population patterns of health
and disease parallel societal divisions based
on race, gender, and class implies that these
relations somehow shape the health of
groups on both sides of these social relations; disparate social and economic situations somehow become “incorporated” into
biological pathways that affect health and
survival.
• The responsible mechanisms exist at both
the social and biological level, and both levels must be studied to understand what
creates population patterns of health and
disease.
Although the results of these studies point
to large, persistent, and often increasing disparities in the Region, much more methodological and empirical research must be done
to better study how and why socioeconomic
factors are related to health status, access to
60
Krieger N, Rowley DL, Herman AA, Avery B, Phillips
MT. Racism, sexism and social class: Implications for studies of health, disease and well-being. Amer J Prevent Med
1993; 5 (suppl.).
46
Health Disparities in Latin America and the Caribbean
FIGURE 19. Policy factors and mechanisms influencing personal and household health and welfare.
Political Systems and Processes
Affects acceptance of discrimination, definition of public needs,
determinants of public policy, level of civil society participation,
accountability/transparency of public administration
Macro-economic
Policy
Fiscal, monetary,
balance of payments,
trade policy
Patterns of
investments,
price levels
Policies affecting
key assets
Public provisioning
policy
Labor policy, land distribution,
housing policy
Education, social welfare, health
care, water and sanitation
Employment levels
and patterns,
demand for goods
and services
Migration patterns,
remittance of
income
Income/ wealth levels/ distribution, Food intake, Access to health promoting inputs
Access to cost-effective quality health care and social services
Overall spatial development
Personal & Household Health and Welfare
Quality of environment, disposable income, food production, health seeking behavior,
household health investment, domestic allocation of time and resources
Source: Rockefeller Foundation, Global Health Equity Initiative Report. New York.
care, and utilization of health care services. In
Figure 19, a conceptual framework for the
identification and analysis of the interrelations
between the macro-determinants of health
equity is presented. These include the political system and processes (governance as well
as level of social and political participation),
macroeconomic policy, labor, agrarian and
housing policies, as well as policies related to
public provisioning of social goods, all of
which must be considered to assess the effectiveness of potential interventions to improve
health and welfare levels of the population
subgroups presenting avoidable and unfair
health disparities.61
Many of the democratic governments that
are now the norm in LAC are confronting difficulties in satisfying accumulated and unmet
demands among their citizens, a situation that
in time could compromise governance and
stability in the region. Political crises as well
as the external economic uncertainty that characterizes the global economy may worsen lev61
Rockefeller Foundation. Global Health Equity Initiative Report. New York, NY: Rockefeller Foundation. In
press.
Casas, Dachs, and Bambas
els of social exclusion in Latin America and
the Caribbean. There is strong evidence that a
major portion of health problems in LAC will
not be resolved without transforming our
societies into more equitable ones in terms of
opportunities for human development of the
majority of the population. The prevailing
model of economic growth without distribution has led to the growing recognition that
the agenda of economic reform of the 1990s
must be complemented by a comprehensive
package of social and human development
initiatives, so that growing health disparities
in Latin America and the Caribbean can be
successfully addressed.
Based on the conclusions of a recent interagency and interregional consultation for the
development of future directions in research
and policy analysis on health equity,62 as well
as the contributions of Gilson63 and others, and
especially the work that PAHO has been carrying out in the region, the following strategic areas are worthy of consideration as the
basis for an agenda to achieve greater equity
and fairness in the health of the people of the
Americas. These points would also serve as
the main areas for the development of technical cooperation activities in health geared towards supporting regional and country level
initiatives.
1. Measurement: not only to continue the development of instruments and methods for
measuring inter-group differences, but also
to develop tools to help program managers
set targets for reaching the poor and disadvantaged and measure progress towards
those targets.
2. Modification of health services: it is not
sufficient to increase access to existing services; we must also modify services to make
them more relevant for the health problems
of the poor and marginalized.
62
Rockefeller Foundation, World Bank. Health equity
consultation summary: Current activities and future directions in health equity. Crystal City, Virginia; 1999.
63
Gilson L. In defence and pursuit of equity. Soc Sci
Med 1998; 47: 1891–1896.
47
3. Broader determinants of health change: it is
necessary to expand current concern with
equity in health care access to other social
determinants of health, such as maternal
education, water, sanitation, food security,
housing and employment, in order to identify effective approaches to improving health.
4. Advocacy for health equity: the application
of sophisticated statistical techniques for the
measurement of intra-country health disparities by socioeconomic class will not
have much impact if effective means are not
found to introduce this information into the
political process to produce programs and
policies more relevant for the health of the
poor. This includes widening the scope of
interaction to include civil society organizations that will assume equity monitoring
and “health-watch” roles to influence public policies.
5. Identification of effective approaches:
Many local policy makers concerned with
health equity have already developed effective approaches that need to be recognized
and disseminated by international cooperation agencies, a need that would be filled
by a systematic search for natural experiments worthy of assessment and suitable for
sharing and replicating.
Some of the main conclusions and consequent questions that PAHO’s future work
may have to address in order to fully develop
an effective equity focus for its technical cooperation are highlighted below.
Health care plays a limited role in achieving health
status gains and redressing health disparities.
• What are the health systems’ “manageable
interests” in reducing health disparities?
• Which health interventions have the highest impact on reducing disparities, and for
which groups?
• How can “cost-effectiveness” as a criterion
for selecting health interventions be complemented by “health equity-inducing potential”? (For example, the provision of water
48
Health Disparities in Latin America and the Caribbean
and sanitation is not highly cost-effective as
measured by DALYs per dollar, but it has a
large impact on reducing disparities in
health outcomes by greatly improving
health of the poor.)
• What health promotion and preventative
services (supply driven) are most beneficial
to which group?
• How much should be spent on health care,
given available resources in each country?
ties illustrate aggregate differences or differences across individuals? What are the
policy implications of each approach?64
• What different measurement tools and indicators for health disparities need to be
developed and utilized for local level program monitoring? For advocacy purposes?
For resource allocation decisions? For target setting and trend analysis? For health
impact assessment and evaluation?
Broader interventions are required to promote
health and reduce health disparities.
Information dissemination is a key input in the
work for equity in health, both for advocacy at the
top as well as for empowerment below.
• What are the health system’s “areas of influence” through which it can better exercise advocacy for equity-inducing policies?
• Which groups benefit or lose most, and from
which interventions (categorizing by income, ethnicity, sex, education, occupation,
place of residence, national origin)?
• How can the “health equity impact” of public policies and interventions be estimated
and assessed as part of the policy analysis
process?
• What economic policies best promote health
development and equity in health?
The analytical approaches used in policy development should reflect these values and better inform
policy making and resource allocation.
• How could social weights be incorporated
into DALY’s and other measurements of
burden of disease to reflect social equity
values?
• How can the “equity inducing potential” of
specific health and other interventions be
measured?
• How can existing sources of data, both
within and outside the health sector, be better utilized for determining unfair health
disparities?
• How can “multi-level” and “multi-source”
methods be developed for combining data
from different sources for identifying and
monitoring health inequities?
• Should the measurement of health dispari-
• What simple and direct methods and measures can be developed and utilized for
quantifying, reporting, and monitoring
trends in health disparities?
• How can equity-related information on access to health, both at the local, as well as at
the national and global levels, be increased
for civil society groups in general and for
poor and marginalized groups in particular?
• How can effective participation by civil society and stakeholders in monitoring and
advocating for health equity be stimulated?
• How can health equity become a primary
national health objective, with clear measurable health goals, both for health related
outcomes as well as for determinants?
Health system research must develop broad-based
evaluation strategies that allow for the analysis of
the equity impact of public policies, including
health sector reform.
• How can we develop more effective methods to assess and monitor the impact of financing methods, including user fees, cost
recovery and prepayment schemes, decentralization, internal markets, and other reform measures, on different populations?
64
For an alternative viewpoint on the issue of measurement of health disparities across aggregate groups or individuals, see Murray CJL, Gakidou EE, Frenk J. Health
inequalities and social group differences: What should
we measure? Bull WHO 1999; 77 (7): 537–543.
Casas, Dachs, and Bambas
• How can we better identify the impact of nonphysical and non-financial barriers on access
to health services, such as quality of care (ineffectual poor quality services), gender, cultural factors, national origin, and others?
• How can we better determine objective
need, in contrast to perceived need, in order to assess equity in terms of health service utilization?
• What are the health services that require an
active “supply” strategy vs. those that are
more likely to be spontaneously demanded?
How does this difference affect utilization
and health outcomes?
ADDITIONAL BIBLIOGRAPHY
Breilh J, Campaña A, Costales P, Granda E, Páez R, Yépez
J. Deterioro de la vida: Un instrumento para análisis
49
de prioridades regionales en lo social y la salud.
Quito: Corporación Editora Nacional; 1990.
Duncan B, Rummel D, Zelmanowicz A, Mengue S, Santos
S, Dalmáz A. Social inequality in mortality in São
Paulo State, Brazil. International Journal of Epidemiology 1995; 24 (2): 359–365.
Laurell AC. Impacto das políticas sociais e econômicas
nos perfis epidemiológicos. In Barata et al. Eqüidade e
saúde: contribuições da epidemiologia. Rio de Janeiro:
Abrasco/FioCruz; 1997.
Mardones-Restat F, Díaz M. Una propuesta de clasificación de las comunas del país: según criterios de
riesgo biomédico y socioeconómico para medir la
vulnerabilidad infantil. Santiago, Chile: UNICEF;
1990.
Paim J, Costa MC. Decline and Unevenness of Infant
Mortality in Salvador, Brazil, 1980–1988. Bulletin of
the Pan American Health Organization 1993; 27 (1): 1–
14.
Velásquez L. Mujer maya y salud. Guatemala: 1994.
Weaver J, Sprout R. In M. Rock (ed.) Twenty-five years of
economic development revisited. 1993; 21(11).
POVERTY, H UMAN D EVELOPMENT, AND PUBLIC
EXPENDITURE: D EVELOPING ACTIONS FOR
GOVERNMENT AND CIVIL SOCIETY
Eduardo Doryan1
One dictionary defines poverty as “the state
of one who lacks a usual or socially acceptable amount of money or material possessions.” Two things are reflected in this definition: first, the standard for what is “socially
acceptable” could vary from country to country or between regions of the world; second,
poverty is linked not only to money but also
to material possessions or assets, including
land or any means of production. In the World
Development Report of 1990, the definition was
much more linked to absolute poverty, a condition of life characterized by such malnutrition, illiteracy, and disease as to be beneath
any reasonable definition of human decency.
This definition brought human outcomes into
the definition of poverty. We also have the
United Nations Development Program
(UNDP) definition of human development.
And the Human Development Index (HDI),
in particular, looks beyond income and has a
more comprehensive definition. Finally,
Amartya Sen’s definition of poverty is more
linked to capabilities, where citizens are well
prepared to take advantage of economic
opportunities.
The World Bank has conducted a global
study, interviewing 60,000 people in 60 coun-
tries throughout the world and capturing the
voices of the poor, their definitions of poverty,
and how they would like their problems to be
resolved. Someone from Ghana said that poverty is “like heat, you cannot see it, you can
only feel it. So, to know poverty, you have to
go through it.” For a poor woman in Moldova,
“poverty is pain, it feels like a disease. It attacks a person, not only materially, but also
morally. It eats away one’s dignity and drives
one into total despair.”
Keeping in mind the academic definitions
of poverty, or at least some of them, and having heard some of the voices of the poor, the
international community has established very
clear international development goals—halving of the number of people living in poverty
by the year 2015; universal access to primary
school by the same year; elimination of gender disparities by the year 2005; a two-thirds
reduction in infant mortality and mortality in
children under 5; and so on. If we look at these
goals more closely, we find some direction for
action: halving poverty by 2015 is conditional
on achieving poverty reducing paths; universal attendance to primary schooling is very
much dependent on the quality of teaching in
primary schools; gender equality is very much
linked to political and economical empowerment of women; and infant mortality in cer-
1
Vice President, World Bank Human Development
Network.
50
Doryan
tain parts of the world, and probably in certain areas all over the world, is very much
conditional on issues such as tackling the
spread of HIV/AIDS.
Some of these goals are unlikely to be attained because growth is very volatile, as demonstrated in the Asian crisis and in some of
the recent economic crises in Latin America.
We also have seen it during natural phenomena such as Hurricane Mitch in Central America. Inequality can rise rapidly in unstable
economies, as has occurred in many of the
Latin American countries. The adoption and
the effective implementation of pro-poor policies and interventions are central, but sometimes are subsumed with the overall macroeconomic policies. Economic policies are a two
way street for poverty, however.
There is nothing more effective against poverty than good policies. In Latin America, general economic growth has not led to a decrease
in income disparities, and the Gini coefficient
for Latin America is much higher than for most
other regions of the world. The poor are falling behind in terms of distribution of income;
the proportion of income captured by the
wealthy grows; and current poverty rates are
very much the same as 20 years ago. These
results are a reminder of the centrality of human development for all countries.
Although we still have a long way to go,
we have learned a great deal about human
development and growth. Girls’ education is
a key factor in health. A study that relates to
mothers’ education shows that a lack of secondary or higher education has a huge impact
on mortality in children under 5 years old (see
Table 1). This study also shows that mothers’
education is much more important than fathers’ in decreasing child mortality. This study
points to several important approaches: analyzing policy outcomes, looking beyond
health, and finding the linkages and how to
make the best investments. Our investments
must be directed by an understanding of the
dynamics of poverty and human development. This means learning about outcomes for
the poorest groups, not just national averages.
51
A former President of Costa Rica used to
tell the following story. “You can have a person lying down with his head in an oven and
his legs in a freezer, and the temperature in
the belly button is going to be 98.6 degrees.
That person is supposed to be in very good
health, but probably, that person is very uncomfortable.” So, averages are not that useful. We have to think more clearly about the
actual meaning of poverty and look at the different income levels in each society.
It is useful, for example to look at the link
between education and growth. The average
number of years of education for 25-year-olds,
grouped by income levels, in Latin America
can be divided into ten segments of the population (see Table 2). In Chile, the top decile has
twice the years of education as does the lowest decile. In Venezuela the gap between highest and lowest is 2.5 times. The same pattern
occurs in countries in different parts of the
world. Looking beyond national averages is
much needed in development policy.
So, where do we assign more spending?
Where we put the resources that are usually
meager? Well, that’s not an easy question.
Health spending alone cannot explain all the
variations in health among countries. Nor can
income, education, or even disposable income
and schooling together. Figure 1 illustrates
these discrepancies: the vertical axis shows the
deviation from predicted life expectancy in a
country; the first upper half of the figure
shows deviations from the value predicted on
the basis of the country’s income and average
schooling. France, Singapore, Costa Rica, Honduras, and Sri Lanka, all in the top half of the
figures, achieve five years or more of life beyond what would be expected. But Egypt,
Ghana, Uganda, the United States, and Zambia, all in the bottom half of the figure, have a
life expectancy of about five years lower than
expected, given their levels of income and
education. The horizontal axis of the figure
shows the deviation from predicted percentage of GDP spent in health. Although one
might expect that at any level of income and
education, higher health spending would
52
Poverty, Human Development, and Public Expenditure
TABLE 1. Mortality in children under 5 years old, according to the mother’s
education.
No education
Secondary/higher
education
No education as
a multiple of
secondary/higher
education
(col.2/col.3)
111
91
128
152
109
51
22
65
42
30
2.2
4.1
2.0
3.6
3.6
(74)
91
150
25
31
45
3.0
2.9
3.3
212
198
166
100
223
255
97
334
211
177
171
204
164
87
80
69
54
114
127
76
106
113
94
52
135
71
2.4
2.5
1.7
1.9
2.0
2.0
1.3
3.2
1.9
1.9
3.3
1.5
2.3
Mother’s educational status
Region/country
Asia/Near East/North Africa
Indonesia
Morocco
Pakistan
Philippines
Turkey
Latin America/Caribbean
Colombia
Dominican Republic
Peru
Sub-Saharan Africa
Burkina Faso
Cameroon
Ghana
Kenya
Madagascar
Malawi
Namibia
Niger
Nigeria
Rwanda
Senegal
Zambia
Unweighted average
yield better health, all else being equal, there
is no evidence of such a relationship. Countries are scattered in all quadrants of the figure, which is partly due to the importance of
institutions and policies.
There is much to be done in relation to policies. Probably the best image is that we need
developmental cocktails, that is, putting different policy elements together in a way that
has a leapfrogging effect, which allows countries to pass through stages of development
much more quickly than would be expected
from isolated policies.
The World Development Report for the upcoming year gives us some premises for
policy-making. First, poverty reducing strategies must recognize that appropriately designed combinations of policies will interact
in a way that will produce an effect greater
than the sum of the individual parts. If we
have a robust process of linking different policies, we can actually achieve leapfrogging effects in development. Without such synergistic effects, the 21st century is going to be very
difficult for most of the population of Latin
America. Another premise for policy-making
TABLE 2. Average years of education for 25-year-olds, by income level, selected countries in Latin
America.
Decile
Chile
Brazil
Mexico
Peru
Venezuela
1
2
3
4
5
6
7
8
9
10
6.24
1.98
2.14
3.87
4.66
6.88
2.49
2.95
4.17
4.94
7.09
2.97
3.78
4.85
5.27
7.40
3.41
4.15
5.69
5.72
7.69
3.66
4.78
6.60
6.23
8.16
4.40
5.66
7.05
6.68
8.47
4.49
6.06
7.66
7.20
9.80
5.98
7.24
8.28
7.78
10.88
7.43
8.89
9.04
8.58
12.83
10.53
12.13
10.80
10.81
Doryan
53
FIGURE 1. Deviation from predicted life expectancy and deviation from
predicted percentage of GDP spent on health, selected countries.
Deviation from predicted life expectancy (years)
10
China
Better outcome,
lower expenditure
Better outcome,
higher expenditure
Costa Rica
Sri Lanka
5
Honduras
●
●
Greece
●
Paraguay
●
●
●
● ●
●
●
Morocco
●
●
●
● ●
● ● ●● ●
●
● ● ●
●
●
● ●
●
●●
●
●
●
●●●
●
Syria
●
●
●●
●●
●
●●
●●
●
India
●
0
Singapore
–5
Haiti
France
Mozambique
United States
Malawi
Egypt
Ghana
●
Uganda
Worse outcome,
lower expenditure
–10
–5
–4
–3
Worse outcome,
higher expenditure
Zambia
–2
–1
0
1
2
3
4
5
6
Deviation from predicted percentage of GDP spent on health
is that both growth and inequality are outcomes of economic policy as well as institutional capability, and are subject to external
shocks and trends. It is odd that, in the past,
analyses have typically looked for mechanical links when investigating growth and inequality jointly, largely ignoring the role of
policies. When the role of policies has been
investigated, studies have usually looked at
growth and inequality separately, yet, the key
piece of information, from the point of view
of policy makers, is how policies influence
both growth and inequality.
The third premise for policy-making is that
policies to help the poor should address increasing growth and improving equality at the
same time, or at least mitigating inequality by
generating growth with pro-poor measures.
Policy makers should take into account (1) the
effects that different health care system financing methods have on improving health status, (2) how to ensure equity, (3) the linking of
microeconomic and macroeconomic efficiency,
(4) the enhancement of clinical effectiveness,
(5) the improvement of care quality and consumer satisfaction, and (6) the assessment of
the system’s long-run financial stability, as
they have important consequences for equity
across income groups. They must consider the
amount of revenue that can be raised, and
losses in consumer welfare and production
generated by different revenue raising techniques. These considerations are at the core
of how to tackle the problems of poverty, inequity, and development in our countries.
The political economy of health policies and
human development policies are going to be
very important. In the first place, there is a
54
Poverty, Human Development, and Public Expenditure
need to spend more, but with the caveat that
spending is not enough if developmental cocktails and leapfrogging effects are not present
in policy prescriptions. Second, health service
outputs are needed. Finally, we need to move
from outputs to outcomes. This third category
relates to the effects that health expenditures
have on health outcomes, and is tied to
intersectoral factors such as education, water
and sanitation, and women’s status, because
health services are just one factor among many
that determines the population health status.
This presents difficulties from a political
point of view, because the international financial community, which lends money, as well
as many organizations, have very sectoral
approaches. Those who work in health deal
with the Minister of Health, others deal with
the Minister of Education, and others deal
with the Minister of Labor. Pulling together
intersectoral development packages is not
easy, and without an articulated approach, it
will be impossible to prepare those cocktails
and achieve the leapfrogging effects as we
would like.
The “Voices of the Poor” study showed that
there was a comprehensive view of development. From villagers in a republic in Central
Asia we heard, “our problems are lack of jobs
and money; high price of food, clothes, and
health care; and lack of shops. Besides, we
don’t have training manuals, there is no high
school, no public baths, and most important,
there is no drinking water. We have to buy it
and then keep it for a long time, so it goes bad,
but we still use it.”
Development is moving from ill being to
well being. The 60,000 people who were interviewed repeated that they have a sense of
powerlessness, weak social relations, material
lack and poverty, physical weakness, and insecurity—ill being. And what they wanted
was good social relations, security, physical
well being, enough for a good life, and freedom of choice and action. Well being embodies much more than how to overcome poverty; it is related to equity, but it is also holistic
in relation to the experience of life.
Next year’s World Development Report will
focus on three core issues. Empowerment is the
first, and includes addressing economic, social,
political, and institutional inequalities that prevent the poor and disadvantaged from having
access to and influence over policies and interventions that influence their lives. The second
important issue is security, livelihood, and risk
management policies, including those related
to natural disasters and economic shock, which
poor nations will increasingly face in the global economy and which has always trapped the
poor in poor countries in poverty. The third
major component is opportunity and putting
in place the conditions for investment and sustainable economic development. The poor must
participate fully in the creation of such policies,
and the policies must not degrade the environment or increase risk and vulnerability. These
issues are not hierarchical, but rather are interrelated components of our overall framework
for poverty reduction and equity. This framework clearly cuts across the more conventional
sectoral framework of interventions. For example, health affects all three dimensions, even
as each of the three dimensions affect each
other.
From a policy-making perspective, we have
seen that empowerment, opportunity, and risk
management are core elements of equitable
development. Whenever countries have used
the benefits of growth to finance basic health
care and access to education for all, and when
countries have put in place incentive structures and complementary investments to insure that better health and education lead to
higher incomes, the poor have doubly benefited. They are healthier and better educated,
and they have increased their consumption.
We must not only finance basic education and
access to health, but also have a system in
place that feeds back those investments into
more productivity and growth. Such an approach will create a virtuous circle and not
reproduce a vicious circle in which financing
is not increased nor linked to the economic nor
productive strategies. Those cycles of growth
are followed by economic shocks that create a
Doryan
vicious circle that degrades health and education indicators. A final corollary is that moving from income, which has been the traditional focus of equity, to multi-dimensional
views of poverty has policy consequences.
Even if incomes do not increase, policies that
improve the health of individuals and increase
their capacity to absorb and exchange information improve the quality of their lives.
Health must be put in the context of poverty
55
reduction and linked to education, social protection, and other aspects of human development. The effect of health must also be considered in the context of its influence on
empowerment, opportunity, and risk management, and we must find ways to pull together
such policies and finance them in a way that
really tackles the key aspects that affect and
improve the quality of life and the well being
of the poor.
POVERTY, EQUITY, AND H EALTH :
SOME RESEARCH FINDINGS
Adam Wagstaff 1
This chapter will deal with research that is
of general interest both to the industrialized
and countries that are not part of the Organization for Economic Cooperation and Development (OECD). It will cover poverty, equity,
and health, and how we can link research to
policy-making. Let’s start with the goals we
are trying to pursue in the health sector and
how these relate to the notions of poverty and
equity. I have listed here two broad goals,
goals that keep coming up time and time again
in health documents.
The first is, obviously, the improvement of
health; not just improving health, however,
but also improving it equitably. Now that
means different things to different people. It
would mean, for example, at least, making
sure that you promote the health of the poor
and, possibly, even more strongly making sure
that the health of the poor improves faster than
the health of the non-poor. This would probably entail two things: promoting access to
health care, especially among the worse-off,
and focusing on the nonmedical determinants
of health—those things that lie outside of what
we traditionally think of as the health care
sector.
A second strand of policy objectives in the
health field involves income protection; essentially, making sure the poor don’t suffer large
reductions in their living standards through
out-of-pocket payments and through loss of
earnings when they fall sick. The second element of this income protection goal is to build
risk-pooling mechanisms that result in protection payments being linked to ability to pay.
As we’ll see in a moment, there are different
ways of providing people with protection
against out-of-pocket payments, and each has
different distributional consequences.
Let me start with the income protection
goal. A poignant example of the need for income protection is described in “Voices of the
Poor,” in which a 26-year-old man from Vietnam moved from being the richest member
of his community to being the poorest member of his community, simply because he incurred very large health care expenses associated with his daughter’s illness. If you read
“Voices of the Poor,” this is an issue that comes
through very strongly. When people think
about designing health care systems, the poor
feel very strongly that one of the important
dimensions of that debate is how to protect
their income and livelihood.
Among OECD countries, with the exception of Portugal, very few countries raise more
than 20% of their revenues from out-of-pocket
payments. Among non-OECD countries, the
picture is quite different. In Bangladesh, for
example, more than 60% of health care revenues are paid from out-of-pocket.
One issue, then, is how regressive these
payments are. What ‘regressiveness’ means is
1
Professor of Economics, University of Sussex, U.K.
and Principal Economist, World Bank’s Development
Economics Research Group and Human Development
Network
56
Wagstaff
what proportion of a family’s income these
payments represent. If, as we move up
through the income distribution, the proportion of income spent on out-of-pocket payments declines, then you have a regressive
structure. If, on the other hand, it increases—
that is, the rich pay a larger share of their income in out-of-pocket payments than the
poor—that is a progressive structure. Most of
the evidence on this issue comes from OECD
countries, but we now are getting some numbers in from the non-OECD countries. What
is emerging is that there are two distinct
groups of countries. There are countries such
as China, Rumania, and Bulgaria, where
people are seeking care and obtaining care, but
paying for it in a very severe way. For example,
there is a very high degree of regressiveness
in the out-of-pocket payment structure in
China. At the other end of the spectrum, we
have countries where out-of-pocket payments
are actually slightly progressive, as they absorb a larger share of the income of wealthy
households than they do of poor household
incomes. There are two possibilities here, of
course. One is that people who cannot afford
care are simply not getting it; the other possibility is that they are getting it, but there are
systems or mechanisms in place to reduce the
impact of out-of-pocket payments.
Regressiveness is only one part of the story.
Another part of the story is whether households are plunged into poverty through outof-pocket payments. According to our estimates, many households fall into poverty
through out-of-pocket payments, and the tendency for this is greater among those who
don’t have insurance. So, it is not just a question of regresiveness; it is a question of households being put into poverty through out-ofpocket payments.
How can we provide households with protection against out-of-pocket payments? Different countries raise their health care revenues
in different ways. We have some countries, specifically the United States and Switzerland,
which have a very strong emphasis on private
insurance, while the Netherlands has some
57
emphasis on private insurance. Social insurance, which is, of course, very common in Latin
America, represents a big portion of expenditures in Latin American countries, but also in
countries like France, Germany, and the Netherlands. The rest of the expenditures are generated through tax revenues.
These different ways of providing households with protection have different distributional consequences in relation to the income
that households have to spend on things other
than health care and also on private health
care. If we’re interested both in the consumption possibilities for private health care as well
as the extent to which households can purchase things other than health care—if we’re
concerned, for example, about poverty—then
these distributional consequences are important to take into account.
In the United Kingdom, direct taxes contribute progressively towards the total financing
burden. As a matter of fact, this also is the case
in Ireland, Egypt, and Bulgaria. If we also consider indirect taxes—as we know from our
studies of OECD countries—countries such as
the UK and Spain, which greatly emphasize
indirect taxes, these structures become regressive, which tends to reduce or offset the
progressivity of direct taxes. Interestingly,
what emerges for some of the non-OECD
countries is that indirect taxes actually end up
being progressive. This is not true in Mexico,
where the scheme is marginally regressive, but
it is true of those other countries. What is occurring there is that those countries are relying on a graded structure where luxury items
are taxed at a higher rate. In the case of social
insurance, the level of progressivity and
regressivity pretty much depends on what the
scheme is. In the Netherlands, Germany, and
Mexico, for example, social insurance programs are regressive. In countries like China,
they are actually progressive.
If we substitute private insurance as the financing mechanism, we see that in the two
big countries where this is an important source
of finance, the system is very regressive. In
other countries it is regressive, too, but either
58
Poverty, Equity, and Health: Some Research Findings
because it is less important, or because it is
not as regressive, it doesn’t feature so prominently in this chart. In almost all the OECD
countries, out-of-pocket payments are regressive, and in the non-OECD countries it varies
a little bit. In countries like Egypt, out-ofpocket payments are progressive, but in countries like China, where they’re very important,
they are very regressive.
EQUITABLE HEALTH PROMOTION
Poorer people are more often sick, sick for longer
periods of time than the less poor, so, they just sleep
and groan.
—Malawan woman, quoted in
“Voices of the Poor”
Is the burden of illness unequally distributed in these countries? In almost all these
countries inequalities and mortality in children under 5 years old are concentrated
among the poor to a statistically significant
degree. There are differences across countries:
the degree to which mortality in children under 5 is concentrated among the poor is not
fixed; it varies across countries. Brazil, for example, comes out with an especially high degree of inequality.
In the case of stunting, countries like Peru,
Brazil, and Nicaragua, which we know have
very unequal income distributions, also have
a very unequal distribution of childhood
stunting. The poor in these countries are much,
much more likely to be stunted than the nonpoor. What can we do to remove these inequalities, or at least promote the health of the
poor?
Another quote from “Voices of the Poor”
points out the importance of access to health
care. “It is precisely those who are most exposed to health risks, whose work entails the
greatest risks of accidents or debilitation, and
who are most dependent on the strength of
their bodies—in short, those who need health
care most—who are the least able to afford and
obtain it.”
Is health care distributed unequally? In most
of the OECD countries, it is actually the poor
who get more health care than the non-poor.
One might claim, in response, that this is not
taking into account the fact that the poor need
more health care. If we standardize the distributions, the pro-poorness is reduced substantially, but not eliminated, except in the United
States and Switzerland. In other words, we
don’t have to throw up our hands in despair
and say it’s never going to be possible to get
health care to the poor. There are countries in
the world that manage to do it.
In China, the picture is quite different from
the picture for the OECD countries. Inpatient
care in particular is highly skewed, not towards the poor, but towards the better-off. It
is a less pronounced disparity in the case of
outpatient visits, but overall what we see is a
picture where the Chinese are failing to get
health care to the poor.
One might say, well, that’s sometimes because the rich choose to purchase more, but
let’s look at what happens to the public subsidy, which surely ought to be going to the
poor. There are some data from a variety of
different countries that show how the poor
compare to the non-poor, showing the concentration index for public subsidies. There are
many countries where the subsidies are actually going to the better-off, including Brazil
and Peru. Some Latin American countries
seem, on this criterion, to be doing quite well,
but what I suspect we’re picking up right here
are only the ministry of health’s subsidy, not
the subsidies going through the social security systems. Data from Peru and from Honduras are much more comprehensive, and I
think you’d get a much better picture from
those data.
Why do the poor get less, then? Well, if we
look at econometric work, and this is backed
up by consultation studies with the poor,
what’s going on seems to be lack of income,
low education, poor understanding of what
there is to be gained from the system, money
prices, and insurance status, all of which are
clearly important. But things we tend to for-
Wagstaff
get include distance to travel, ease of transportation, waiting time, and opening hours.
Very often the poor will say, “I don’t go to the
clinic, because when I get there it’s never
open.” Quality of care is fundamentally important and comes through very strongly in
some recent econometric work. Often the poor
don’t go to clinics because when they get there,
even if the place is open, the clinic has no
drugs. They prefer to pay out-of-pocket and
go somewhere that is closer and well stocked.
Staff attitudes also are important. The poor
complain about things like being slapped by
staff or, if not being physically abused, of being verbally abused.
The fundamental point, though, is that health
care is never going to be enough. Another person cited in “Voices of the Poor” says, “the poor
frequently are disadvantaged by where they
live due to geographical isolation; marginal
land; . . . lack of transport, sanitation, water,
and other services; isolation from information;
environmental hazards; inadequate shelter; insecure rights to land; physical insecurity and
crime. . . .” These are all important for health
itself, not just in their own right.
Some figures from Cebu, the Philippines,
show us the degree to which different determinants of health are concentrated among the
poor or the non-poor. It’s much more likely,
for example, that poor households are those
that will have no water supply. Mothers who
only have elementary education are much
more likely to be among the poor; households
that don’t have a toilet are much more likely
to be amongst the poor; the poor take longer
to travel to a health center; and poor women
are more likely to have more pregnancies. In
the case of Cebu, it seems that the local facilities in poor areas are actually more likely to
offer immunization than those in the non-poor
areas. Corn and rice seem to have slightly
higher prices in poor areas. Among richer
households, there tends to be access to a
greater number of nurses in local facilities,
mothers are more likely to have a high school
education, and the better-off are more likely
to have some form of health insurance.
59
We can estimate the impact of these factors
on childhood survival using a survival model.
Being a boy in Cebu is not that good in terms
of childhood survival prospects, nor is having an old mother when you’re born or having a mother who has had a lot of children by
the time you are born. If you have a mother
who’s well educated, that’s good for survival.
Living in a low-income household is bad for
survival, and not having a toilet is bad for survival. Having health insurance is good, and
having a local facility that offers an immunization program also is good for your survival
chances.
Now, none of these things come through as
particularly surprising. You’d say, “but I knew
all that, anyway, and I also knew that the poor
didn’t have toilets and that they had to travel
further, and so on.” But what we can do with
these two sets of numbers is put them together
and try and get a handle on this question of
how important health care is. We say health
care is just one of the factors, and we feel we
ought to say that, but how important is it—
50%, 60%? More precisely, if we were to reduce the inequalities that we saw a moment
ago in each of these various determinants of
health, what impact could we have on inequalities in health outcomes?
We saw, for example, that the poor tend to
have to travel further, and it takes them longer
to reach a health facility. What would happen
if we had the poor and all the bottom four
quintiles traveling the same amount of time
as the top quintile? Not a lot. This shows that
we get a slight reduction in the overall average rate and a slight improvement in the inequality, but it’s not exactly something to write
home about.
What if we improve the quality of medical
facilities? In this case, because it’s actually the
poor areas that have better immunization
facilities, the exercise brings everybody else
down to the level of the top quintile. Not
surprisingly, we actually worsen the outcome.
What if we could give everybody the same
insurance coverage as the top quintile has? We
60
Poverty, Equity, and Health: Some Research Findings
actually get a little bit further in the right direction. But if we could give the poor and the
bottom four quintiles generally the same sanitation conditions as the rich top quintile, we
would actually achieve quite a big jump.
If we could equalize mothers’ schooling,
and stop poor women from having children
late in life and from having so many of them,
we also would achieve a big impact.
The final exercise is to look at the effect of
equalizing income distribution. Holding everything else constant, we would achieve a
very large reduction in the average rates and
a very big reduction in the inequalities. This
gives us a sense of humility, if you like, by
demonstrating how and how much we need
to cooperate with people in other sectors, because it’s not just simply that there are other
things that matter. It’s more important than
that; it’s that these other things matter tremendously when we are thinking about improving outcomes of the poor.
We’ve learned quite a lot about income protection: out-of-pocket payments very often hit
the poor hardest and very often cause poverty. We can have different ways of linking
protection to ability to pay and they have different income distribution consequences. We
need to think those through. In the area of
improving the health of the population we see
dramatic differences between poor and nonpoor. We see a difference between the OECD
countries and the non-OECD countries in
terms of who gets health care and who gets
the subsidies to the health system. And when
it comes to looking at the nonmedical determinants of health, the results we saw for Cebu
suggest we need to think very carefully about
the relative importance of different types of
inequality for reducing health inequality. Increasing access to health services, promoting
health insurance coverage, and so on, are definitely important, but there are other big things
we need to really worry about, too.
EQUIDAD , M INORÍAS ÉTNICAS Y D ERECHOS
H UMANOS FUNDAMENTALES
Pilar Córdova1
Mientras escuchaba las presentaciones anteriores sentía una gran preocupación, porque
yo no soy una técnica experta en salud. Podría decirse que soy una aficionada, una persona que lucha por la construcción de equidad para los hombres y mujeres de mi país y
de la Región. ¿Por qué estoy aquí entonces?
Hace unos tres años vine al Banco Interamericano de Desarrollo con el afán de contribuir a
la discusión acerca de la problemática de las
minorías étnicas no solo de Colombia, sino de
América Latina en general. Logré interesar al
Doctor Iglesias, Presidente del Banco Interamericano Desarrollo, sobre la necesidad de
asignar recursos y realizar estudios diferenciales de estas poblaciones en la Región, no
solo de los grupos indígenas sino también de
los afro-colombianos. En esa ocasión, visité la
OPS y conocí a Cristina Torres, a quien también le planteé el tema —que me parece muy
importante desde la perspectiva de la salud—
de las diferencias que deberían existir en relación con las minorías, en este caso negras o
afro-colombianas, o afro-americanas, dado
que en la Región ya existía un interés o una
intención diferente con respecto a las comunidades indígenas. Hoy estoy aquí para compartir con ustedes una serie de inquietudes,
proponer alternativas y, sobre todo, aportar
elementos para la discusión y la preparación
de agendas públicas.
1
Creo que al hablar de factores de inequidad
se hace referencia al tema de los derechos humanos, de los derechos fundamentales que no
solo se asocian a los derechos civiles y políticos, sino a los que han sido denominados derechos de segunda generación o derechos
blandos, es decir, los derechos sociales, económicos y culturales. Esto me lleva al tema
de la justicia social moderna, una de las cuestiones importantes de este fin de siglo, y a indagar sobre la forma más efectiva de eliminar
las inequidades y construir sistemas de salud
igualitarios, universales, accesibles, eficaces y
eficientes. El concepto actual de justicia social
se basa en dos elementos fundamentales: en
primer lugar, la distribución o desconcentración de la riqueza, y en segundo término, una
cuestión novedosa e interesante: el reconocimiento de la diferencia y de la participación.
Juntos, estos elementos constituyen un sistema integral.
Esta idea de la justicia social nos conduce a
la conceptualización del estado social y democrático de derecho. Así, a finales del siglo XX,
al concepto de estado liberal y utilitarista se
le contrapone el de estado social y democrático de derecho, con sus tres elementos fundamentales: el objetivo social, la concepción democrática del poder, y la sujeción a la ley. Esta
es la concepción moderna del estado social de
derecho, y ella nos lleva necesariamente al
tema de los derechos humanos, de los derechos fundamentales que forman parte esen-
Senadora, Colombia.
61
62
Equidad, Minorías Étnicas y Derechos Humanos Fundamentales
cial del nuevo estado social, democrático y de
derecho.
Estos derechos fundamentales humanos,
sociales, económicos y culturales surgen como
respuesta a las inequidades que imperaron en
el siglo pasado y que todavía están presentes
en este siglo: la pobreza, la exclusión, la
marginalidad, la falta de participación y, sobre todo, la violencia. Hace unos dos o tres
años, en Costa Rica, participé en la presentación del informe sobre el desarrollo humano.
En esa ocasión expresé la necesidad de incorporar el fenómeno de la violencia, porque, a
mi juicio, no se puede hablar en términos generales de desarrollo humano sin incluir una
problemática que está desgarrando a muchos
de nuestros países. No tener en cuenta la violencia impide medir en forma apropiada el
índice de desarrollo humano. La propuesta
no recibió buena acogida en ese momento;
sin embargo, vemos que el último informe
de desarrollo humano ha incorporado el elemento de la violencia, que es un factor de
inequidad, como una de las mediciones reales del índice de desarrollo humano.
Los factores de inequidad que acabo de
mencionar no representan más que la incapacidad de lograr la igualdad. Cuando hablamos
de lograr la equidad, no tenemos que ir muy
lejos, porque la pobreza, la exclusión, la violencia, la marginalidad y la discriminación son
los fenómenos subyacentes de las causas estructurales que generan inequidad. Estas causas tienen mucho que ver con la mala distribución del ingreso y la imposibilidad de
participación, y todo ello se relaciona con la
construcción del poder político y con lo que
alguien ha denominado el buen gobierno. Los
factores de inequidad mencionados se vinculan estrechamente con la corrupción, fenómeno que no puede considerarse de manera superficial porque expresa las falencias de una
sociedad que elimina la disponibilidad de recursos que posibilitarían la construcción de
equidad e igualdad.
Creo que una de las metas del fin de siglo y
una de las discusiones importantes del próximo milenio es el reconocimiento de esos de-
rechos sociales, económicos y culturales como
derechos fundamentales. No es lo mismo hablar de estos derechos fundamentales como
derechos humanos, pues son diferentes en la
medida en que los estados no les conceden a
los derechos fundamentales —el derecho a la
participación política, al reconocimiento de los
derechos civiles, el derecho de reunión, de
opinión— igual importancia que a los derechos sociales, económicos y culturales que se
relacionan precisamente con la salud, la educación, la vivienda y el derecho a la diferencia
cultural y a la recreación.
Por eso decía —y me parece importante hacer esta digresión aquí— que los estados tienen la obligación de observar esos derechos
fundamentales, no únicamente la obligación
de acatarlos, sino de no omitirlos, incluso bajo
sanciones no solo nacionales sino internacionales. Los países deben establecer progresivamente los derechos sociales, económicos y
culturales, y deben arbitrar los recursos necesarios para que la población cuente con sistemas de salud universales, eficientes y eficaces. Si bien es importante hablar de los factores
sociales de inequidad, es necesario ubicarlos
en el contexto de una concepción filosófica del
estado social democrático de derecho, que tiene un objetivo social, está sujeto a la ley y, además, posee una concepción democrática del
poder. Todo ello en el marco de los derechos
sociales, económicos y culturales que han sido
los elementos contrapuestos para eliminar los
factores de inequidad que aún se observan en
la sociedad de fin de siglo.
Es importante hacer estas observaciones
iniciales, porque los derechos sociales, económicos y culturales se materializan en sistemas
de salud, de educación, de vivienda, de recreación, y estos sistemas deben estar respaldados jurídicamente por un marco constitucional, por leyes y disposiciones legales, y por
planes y programas de desarrollo. Los sistemas y el marco constitucional y legal poseen
un objetivo último que es el ser humano, es
decir, deben posibilitar condiciones de vida
dignas, igualdad de oportunidades y reconocimiento —del que forman parte la diferencia
Córdova
y la participación— y, sobre todo, el acceso
sostenido a los sistemas de salud, educación,
vivienda y recreación.
En relación con los derechos sociales, económicos y culturales y, en este caso específico, con el tema de la salud, debe hacerse una
consideración muy de fondo. Cuando se habla de la universalidad de los derechos, se hace
referencia a la generalidad de los derechos sin
hacer abstracciones de tipo regional, local, étnico o de género. Hay que recalcar que la idea
de universalidad no supone dejar de reconocer lo étnico, lo cultural, lo genérico, lo regional o lo local. Sin desconocer la importancia
de la universalidad y de la igualdad de oportunidades, creo que no reconocer esos factores implica quitar visibilidad a grandes sectores poblacionales, o a la mitad de la población
que somos las mujeres, generando inequidades en la pobreza, en la exclusión, en la violencia o en la marginalidad.
En Colombia, desde hace seis o siete años,
algunos sectores —mujeres o minorías étnicas,
como en mi caso— comenzamos a reflexionar
sobre la necesidad de que se materialice una
discusión muy importante sobre el derecho a
la diferencia por parte de grupos como los
afro-colombianos y las poblaciones indígenas
del país. Esto coincide con la discusión sobre
la Constituyente, que dio como resultado la
formulación de una nueva Constitución en la
que se dice que Colombia “es un país multiétnico y pluricultural”. Se trata de una discusión interesante en la medida en que comprende no solo las obligaciones del Estado hacia
estos grupos, que no habían sido hasta ahora
reconocidos en la Constitución, sino también
los derechos adquiridos por ellos frente a las
exigencias del estado. Esto supuso discusiones arduas e interesantes y, al mismo tiempo,
avances significativos, ya que condujeron a la
aprobación de artículos específicos sobre la
población afro-colombiana y la población indígena desde el punto de vista étnico.
En cuanto a la elaboración de planes de desarrollo, tanto en lo que respecta al país en
general como a las poblaciones afro-colombianas en particular, la problemática ha sido en-
63
riquecida de manera importante. No sé qué
grado de conocimiento tengan muchos de ustedes acerca de esta discusión de lo étnico, que
va mucho más allá de la polémica de los años
sesenta y setenta sobre los derechos civiles y
políticos de los grupos afro-americanos en los
Estados Unidos. En Colombia y en otras regiones de América Latina ya no se trata solamente del reconocimiento de poder elegir y
ser elegido, sino del derecho a un desarrollo
diferenciado. Todo esto ha conducido a la sanción de la Ley 70, o Ley de Negritudes, y a la
puesta en marcha de un programa de cooperación internacional llamado Plan PacíficoBID, que posibilitó la asignación de recursos
muy importantes en materia de salud en las
zonas de la Región donde los grupos afro-colombianos tienen ascendencia y presencia. No
obstante, aun cuando los resultados no fueron los esperados, porque esto sucedió en la
época del cólera, lo importante de la experiencia es que desde una perspectiva de política
pública, con una visión de nación y a partir
de la discusión sobre la plurietnia o la multiculturalidad, se elaboró un plan cabal de desarrollo que fue sometido a la cooperación
internacional y discutido con las comunidades, y se pudieron arbitrar los recursos.
En efecto, en esos momentos una epidemia
gravísima de cólera azotaba toda una región
de población negra que antes no había tenido
visibilidad para las políticas públicas, y desde la perspectiva del gobierno, del Ejecutivo
e incluso el Legislativo, tampoco existían las
condiciones necesarias para arbitrar este tipo
de recursos. Hoy, por ejemplo, de esa Ley 70
de Negritudes se han desprendido otras disposiciones. Así, en el Plan Nacional de Desarrollo se establece la obligación de que las
comunidades afro-colombianas también analicen y aprueben un Plan de Desarrollo precisamente para esta población. El Plan de Desarrollo Nacional no se puede aprobar si antes
el Plan de Desarrollo de las Comunidades
Afro-colombianas no ha sido discutido, aprobado e incorporado en el marco del primero.
Esto es muy interesante como discusión teórica sobre el estado y la construcción de la
64
Equidad, Minorías Étnicas y Derechos Humanos Fundamentales
nacionalidad, y sobre todo es interesante en
el sentido de que este tipo de perspectivas de
políticas públicas diferenciadas por regiones,
por etnias o por género, puede evitar conflictos en la sociedad, porque en la medida en que
estos grupos (o la mitad de la humanidad que
somos las mujeres) no sean visibles en las políticas públicas, no se posibilita la convivencia, y, sobre todo, el goce de los derechos sociales, económicos y culturales que eviten esos
bolsones de inequidad.
Aun cuando Colombia tiene uno de los
marcos legislativos más interesantes de la Región en lo que se refiere a lo étnico (no solo lo
indígena), todavía falta mucho por avanzar.
Con respecto a la cuestión de la africanidad,
en muchos países de América Latina ni siquiera se reconoce la existencia de poblaciones
negras, como ocurre en el Uruguay, o en el
Paraguay. Incluso en el Brasil, que tiene 80
millones de negros, las políticas públicas son
generales y no atienden a las diferencias culturales. Es más, aunque no soy médica, me
atrevería a decir que las enfermedades que
afectan a una persona mestiza o blanca no son
las mismas que las que afectan a una persona
negra o indígena. Igualmente, aplicar las políticas de manera general sin “tranversalizarlas”, sin focalizarlas (aunque no me gusta
este término) y sin diferenciar, termina por
quitar visibilidad a las personas, generar más
pobreza e impedir el acceso a la salud y a los
sistemas de salud, porque sus enfermedades
ni siquiera son reconocidas en las políticas
públicas como afecciones propias de una etnia, una raza o una condición de la Región.
Para finalizar, considero que no solo es importante hablar de las políticas públicas, los
planes de desarrollo o el buen gobierno, es
decir, de sistemas eficaces y sin corrupción,
sino también discutir algo que mencionó hace
muy poco Kofi Annan cuando hablaba de la
paz, el desarrollo y la desigualdad horizontal. La desigualdad horizontal se da cuando
en un país los mismos recursos se concentran
en unas pocas personas o regiones, desconociéndose o ignorando a otras minorías que
existen en el país, o desconociendo a más de
la mitad de la población que somos las mujeres. La desigualdad horizontal genera muchos
conflictos y más desigualdad, y es un elemento que debe agregarse a los factores sociales
de inequidad. Los recursos en el país no se
aplican en forma adecuada debido a ese desconocimiento y falta de visibilidad de sectores marginales de la población, o marginados
del desarrollo. Por eso es importante hablar
sobre el buen gobierno, en el sentido de lo que
son los desarrollos legislativos, los marcos
constitucionales, el reconocimiento de los derechos sociales, económicos y culturales, la
visibilidad pública y política de los pobres, la
marginalidad, la exclusión, todos ellos factores subyacentes a la construcción de igualdad.
Es muy importante, y no solo necesario, que
esto se conozca, que se coloque en la agenda
pública y que se discuta, a fin de asignar mejor los recursos una vez identificadas las necesidades fundamentales. Dos de las cosas
más importantes que he escuchado aquí en la
mañana de hoy, se refieren a los derechos sociales fundamentales que no se pueden convertir en derechos de mercancías: el derecho
a la educación y el derecho a la salud. Creo
que hay que avanzar del parroquialismo y de
las barreras mentales que tenemos entre países, o las barreras no tanto ideológicas sino
territoriales, para decir que es importantísimo
que esos recursos se arbitren en forma apropiada. Que el presupuesto, cuando se discuta, tenga la importancia y la implicancia necesaria para saber si es más importante el
desarrollo y la paz que la guerra y la dedicación de recursos a otros destinos que no son
los fundamentales para los países.
En cuanto a la cooperación internacional,
creo que tiene muchas tareas por delante. En
primer lugar, la tarea de informar a las regiones, a los países, a las comunidades. En segundo lugar, en el caso de las minorías étnicas, capacitar. Nuestra gente tiene la posibilidad de
participar en la discusión del plan de desarrollo, de elaborar su propio plan, pero no sabe
cómo hacerlo porque carece de los instrumentos necesarios; en lo que se refiere a la salud,
no cuenta con la información pertinente. Las
Córdova
comunidades no poseen los conocimientos que
les permiten discutir el plan de desarrollo y
demandar la asignación de recursos para que
la fiebre amarilla, por ejemplo, se pueda tratar
y erradicar, haciendo hincapié en las diferencias étnicas y regionales. En tercer lugar, creo
que hay un tema que debe figurar en todas las
agendas de cooperación internacional, trátese
de mujeres, de minorías étnicas o de países
pobres, y es el seguimiento de los recursos y la
determinación de su implicancia en relación
con los objetivos que se persiguen.
Si se está tratando de acabar con la pobreza, entonces cómo es que esa pobreza se va a
acabar con esos recursos de la cooperación. Si
se habla de que las minorías étnicas, que son
65
las más pobres, las que viven en las zonas de
mayor descuido estatal, las más enfermas,
cómo es que esos recursos de salud se están
removiendo de esas causas que los vuelve más
enfermos y más pobres, es decir, cuáles son
los resultados finales que arrojó esa asignación de recursos y si los objetivos realmente
se están cumpliendo. Y cuáles son las sanciones que habrán de aplicarse en un momento
determinado. Esa es una discusión que quisiera dejar abierta, porque no sé en realidad a
quién se sanciona, si a la pobre gente, que es
la que no está recibiendo los recursos, o al estado, que no es capaz de utilizarlos para eliminar las causas de inequidad y lograr la construcción de igualdad. Muchísimas gracias.
LA M EDICIÓN DE LAS D ESIGUALDADES EN SALUD :
ALGUNOS EJEMPLOS DE LA REGIÓN DE LAS AMÉRICAS
George A. O. Alleyne,1 Carlos Castillo-Salgado,2 Cristina Schneider,2
Oscar J. Mujica,2 Enrique Loyola2 y Manuel Vidaurre2
La obtención de evidencia objetiva sobre las
diferencias en las condiciones de salud y de
vida representa el primer paso para distinguir
las inequidades en salud (6). Desigualdad e
inequidad no son sinónimos: la inequidad es
una desigualdad injusta y evitable, y por ello
es un concepto crucial para la definición de
políticas públicas de salud. El análisis de las
inequidades requiere un conocimiento de sus
causas determinantes y un juicio acerca de la
evitabilidad y la probable injusticia de dichas
causas.
Este capítulo tiene el propósito de mostrar
algunas evidencias objetivas de las desigualdades en materia de salud entre los países de
la Región, y su asociación con indicadores
socioeconómicos. También se propone ilustrar
el empleo de algunos instrumentos clásicos
para la medición de las desigualdades, por
medio de la presentación y análisis de algunos ejemplos escogidos.
INTRODUCCIÓN
Durante el último decenio, varios de los
principales indicadores de salud de las Américas han mostrado una considerable mejoría,
resultante de factores sociales, culturales y tecnológicos favorables, así como de una mayor
disponibilidad y acceso a los servicios y programas de salud. Sin embargo, la mejoría no
ha sido igual para todos los países, ni para
todos los grupos humanos de un país cualquiera. Diversas publicaciones de la Organización Panamericana de la Salud (OPS) documentan estas desigualdades (1–4).
El logro de la equidad en salud es fundamental en la Región de las Américas, en particular en América Latina y el Caribe, cuya distribución del ingreso es la más inequitativa del
mundo (5) (Figura 1). La disminución de las
desigualdades y el logro de la meta de salud
para todos a mediano plazo constituyen un
desafío y un compromiso para los gobiernos,
la Organización Mundial de la Salud (OMS),
la OPS, y otros organismos e instituciones que
actúan en este campo.
LAS DESIGUALDADES DE
LA SITUACIÓN DE SALUD
EN LAS AMÉRICAS
Director, Organización Panamericana de la Salud.
Programa Especial de Análisis de Salud, Organización
Panamericana de la Salud.
1
Los instrumentos que se emplean en este
artículo para medir las desigualdades en sa-
2
69
70
La Medición de las Desigualdades en Salud
FIGURA 1. Distribución del ingreso por quintiles,
varias regiones del Mundo, 1990.
100
90
lud como resultado de posibles intervenciones; por tal motivo, estas medidas son especialmente importantes en relación con la toma
de decisiones y el diseño de políticas públicas
encaminadas al logro de la equidad.3
80
Ingreso (%)
70
EFECTO DE LAS DESIGUALDADES
60
50
40
30
20
10
0
América Norte de Asia
Latina África y MeriOriente dional
Medio
Quintil 1
Quintil 2
(más pobre)
Asia
Europa OECD y
Suddel Este países
oriental
altamente
industrializados
Quintil 3 y 4
Quintil 5
(más rico)
Fuente: Banco Mundial; Sistema de Información Técnica, Programa Especial de Análisis de Salud, Organización Panamericana
de la Salud.
lud se basan en datos de morbilidad, mortalidad y factores asociados al estado de salud
contenidos en el Sistema de Información Técnica de la OPS. Hay varias revisiones metodológicas importantes en este campo, de las
cuales las más conocidas son los trabajos de
Mackenbach y Kunst (7, 8), y de Wagstaff, Paci
y van Doorslaer (9).
La comparación de la situación de salud
entre grupos socioeconómicos puede expresarse tanto en términos absolutos (en unidades de desigualdad) como relativos (en relación con un valor de referencia). Otra opción
metodológica consiste en el empleo de medidas para evaluar el efecto de la situación
socioeconómica sobre las condiciones de salud, o su impacto. La diferencia esencial entre
ambas opciones es que las medidas de impacto toman en cuenta el estado real de la situación socioeconómica y ponderan los cambios
que pueden esperarse en la condición de sa-
Los indicadores de efecto se utilizan con frecuencia para documentar las inequidades en
salud. El informe Black (10), un innovador trabajo de los años ochenta, describió la existencia de desigualdades en la mortalidad por clase social en Inglaterra utilizando indicadores
de efecto.
Estos indicadores pueden expresar tanto la
desigualdad absoluta como la relativa. El primer ejemplo de este artículo (no tabulado)
incluye la cuantificación de las magnitudes
relativa y absoluta del efecto de las desigualdades en la mortalidad materna en el Cono
Sur, durante el período comprendido entre
1992 y 1997. Para ello, se calcularon: (a) la razón de tasas de mortalidad entre el país con
mayor producto nacional bruto per cápita
(PNB) ajustado por el poder adquisitivo de la
moneda (PAM), y el país con menor PNB ajustado por PAM, y (b) la diferencia de tasas entre esos mismos países. Los resultados fueron,
respectivamente, 4,9 (123/25) y 98 por 100.000
nacidos vivos (123–25). Esto indica que, en el
país con peor situación económica, el riesgo
de las gestantes de morir durante el parto o
puerperio es casi 5 veces mayor que en el país
con mejor situación, y que el valor absoluto
de esta desigualdad representa 98 muertes
maternas más por cada 100.000 nacidos vivos.
El segundo ejemplo (Figura 2) se refiere al
efecto absoluto de las desigualdades en la distribución del ingreso sobre la esperanza de
vida al nacer en 1998. Para medir este efecto,
se ordenaron los países con más de 500.000
habitantes, de acuerdo con el valor del PNB
3
La relación entre los conceptos de efecto e impacto
puede homologarse con la que existe entre las nociones
de “riesgo relativo” y “riesgo atribuible” tan bien
conocidas en el contexto de la epidemiología.
Alleyne, et al.
71
FIGURA 2. Esperanza de vida al nacer en la Región de las Américas,
quintil inferior y superior de producto nacional bruto (PNB)
ajustado por poder adquisitivo de la moneda (PAM), 1997.
Quintil superior
79,0
72,9
Años
Quintil inferior
66,8
60,6
54,5
Fuente: Programa Especial de Análisis de Salud (SHA), Organización Panamericana de la Salud
(OPS).
Nota: En 1997, la diferencia en la mediana de esperanza de vida al nacer entre los quintiles
superior e inferior de ingreso económico en las Américas fue de 9,5 años. En la Región, los más
pobres viven cerca de 10 años menos que los más ricos.
corregido, y se calculó la mediana de la esperanza de vida en los quintiles superior e inferior, que fue de 76 años y 66,5 años, respectivamente. En el grupo de países de ingreso
más bajo, la esperanza de vida es 9,5 años
menor. Esta es, por supuesto, una medida promedio que ilustra el efecto del ingreso sobre
la esperanza de vida, pero que puede enmascarar desigualdades, aun de mayor magnitud,
que se producen en los países en función
del ingreso o de cualquier otro indicador
socioeconómico.
La principal objeción a las medidas de efecto presentadas en los ejemplos anteriores, es
que solo toman en cuenta los grupos extremos
e ignoran los grupos no incluidos en la comparación (7–9). Esta limitación puede superarse mediante el ajuste de modelos de regresión
en los cuales uno de los parámetros, o varios,
constituyen medidas de efecto que hacen uso
de toda la información y no solo de la conte-
nida en grupos escogidos. Esta opción se aplicó en el tercer ejemplo de este estudio (Figura
3), que relaciona la tasa de mortalidad infantil con el acceso a agua potable en varios países de Centroamérica en 1997. La pendiente
del modelo de regresión lineal (β = –0,48) sugiere que por cada 10% de incremento en el
acceso a agua potable, la tasa de mortalidad
infantil disminuye en 4,8 muertes por cada
1.000 nacidos vivos. Al aplicar estos modelos,
es importante prestar atención a la pertinencia del modelo elegido y a la existencia de casos atípicos que pueden distorsionar los
parámetros y, por tanto, la estimación de las
medidas de desigualdad. En la aplicación de
los modelos al estudio de las inequidades con
datos agregados, suele ser preferible utilizar
el método de estimación de los parámetros
basado en mínimos cuadrados ponderados
(MCP) en lugar de los mínimos cuadrados
ordinarios, debido a las diferencias en los ta-
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La Medición de las Desigualdades en Salud
FIGURA 3. Mortalidad infantil y acceso
a agua potable, América Central, 1997.
Tasa de mortalidad (por 1.000 nacidos vivos)
Línea de regresión
Pendiente = –0,48
60,0
50,0
40,0
30,0
20,0
10,0
0,0
0,0
20,0
40,0
60,0
Acceso a agua potable (%)
80,0
100,0
Fuente: Programa Especial de Análisis de Salud (SHA), Organización Panamericana de la Salud (OPS).
Nota: En América Central, por cada 10% de aumento en el
acceso al agua potable, la mortalidad infantil disminuye en 5
muertes por cada 1.000 nacidos vivos en un año.
maños de las unidades; sin embargo, la elección no es automática y debe basarse en los
errores estándares de las estimaciones.
IMPACTO DE LAS DESIGUALDADES
Uno de los indicadores de impacto total más
conocidos en el campo de la salud es el riesgo
atribuible poblacional (RAP), relativo y absoluto. El RAP permite estimar la proporción reducible en la tasa general de morbilidad o mortalidad que se conseguiría si todos los países
tuviesen la tasa del grupo de naciones con el
nivel socioeconómico más alto. Cuanto más se
desvía de cero, mayor es la desigualdad, y
mayor su margen de reducción potencial.
En otro de los ejemplos de este estudio (tampoco aparece tabulado) se calculó el RAP asociado a la mortalidad por infección respiratoria aguda (IRA) en niños menores de 5 años.
Para ello, se utilizó como referencia la subregión
de América del Norte, donde la tasa de mortalidad por IRA de ese grupo de edad era de 0,16
por 1.000 nacidos vivos en 1993, mientras que
la tasa total de la Región era de 2,18 por 1.000.
El RAP calculado (expresado porcentualmente)
fue 92,7%, es decir que si la Región presentase
las tasas de América del Norte habría alrededor de 93% menos de defunciones por esta causa para el grupo de edad en cuestión.
Mediante análisis de regresión se calcularon
también el índice de desigualdad de la pendiente (IDP) y el índice relativo de desigualdad
(IRD) (7–9). Para ello, los países del Caribe con
población superior a 150.000 habitantes se ordenaron de acuerdo a su PNB corregido por
PAM. El modelo toma como variable dependiente la tasa de mortalidad en niños menores
de 5 años, y como variable independiente la
proporción relativa acumulada de nacidos vivos. La pendiente (b) del modelo de regresión,
ajustado por el método de los MCP, corresponde al IDP y expresa el cambio en la tasa de
mortalidad por cada unidad de cambio en la
posición relativa en la jerarquía socioeconómica. La tasa de mortalidad en menores
de 5 años en 1997 (Figura 4) para el país con
PNB corregido más alto fue de 15,3 por 1.000
nacidos vivos, y para el país con PNB más bajo,
de 131 por 1.000. La pendiente del modelo fue
–142,5 por 1.000, lo que indica que el cambio a
un decil superior en la jerarquía socioeconómica en 1997 se acompaña en promedio
de una reducción de 14,3 muertes por cada
1.000 niños menores de 5 años. El IRD se obtuvo como el cociente entre el valor de la pendiente β de la regresión y el valor que el modelo predice para la situación económica más alta.
El valor así obtenido (10,7) indica que en el país
con ingresos más bajos mueren casi 10,7 veces
más niños menores de 5 años que en el país
con ingresos más altos.
MEDICIÓN DE LAS DESIGUALDADES
POR MEDIO DEL COEFICIENTE DE
GINI Y DEL ÍNDICE DE
CONCENTRACIÓN
El coeficiente de Gini es una medida de desigualdad basada en la curva de Lorenz, con-
Alleyne, et al.
73
FIGURA 5. Distribución del ingreso
en las Américas, 1996.
FIGURA 4. Mortalidad en menores
de 5 años en países del Caribe, 1997.
Curva de Lorenz
Línea de regresión
1
Pendiente = –142,5
Coeficiente de Gini = .03698
140
0,9
0,8
100
0,7
80
Ingreso acumulado
Tasa de mortalidad
(por 1.000 nacidos vivos)
120
60
40
20
0,6
0,5
0,4
0,3
0
0,0
0,2
0,4
0,6
0,8
1,0
Posición relativa acumulada de población de nacidos vivos
ordenada por producto nacional bruto (PNB) per cápita
ajustado por el poder adquisitivo de la moneda (PAM).
0,2
0,1
0
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
Fuente: Programa Especial de Análisis de Salud (SHA), Organización Panamericana de la Salud (OPS).
Nota: En l os países del Cari be que ti enen l a si tuaci ón soci oeconómi ca más desfavorabl e, mueren 143 ni ños menores de 5
años por cada 1.000 más que en los de situación más favorable.
Con un índice relativo de desigualdad (IRD) de 10,7, en los países
de peor situación mueren casi 11 veces más menores de 5 años
que en los de mejor situación.
Fuente: Programa Especial de Análisis de Salud (SHA), Organización Panamericana de la Salud (OPS).
Nota: El 30% más rico de la población de las Américas concentra alrededor del 60% del ingreso total.
sistente en una representación gráfica de frecuencias acumuladas que permite comparar
la distribución observada de una variable con
la distribución uniforme. Esta última está representada por la diagonal con pendiente 1
que pasa por el origen de coordenadas en un
sistema de ejes cartesianos. Cuanto mayor es
la distancia entre la curva de Lorenz y esta
diagonal, mayor es la desigualdad, de modo
que la curva proporciona un recurso visual de
cuantificación de las desigualdades. El coeficiente de Gini se define como el doble del área
comprendida entre la curva de Lorenz y la
diagonal de la distribución uniforme.
Un ejemplo clásico es la distribución del
ingreso, que en una situación de completa
igualdad arroja un valor nulo del coeficiente
de Gini, y que en el caso concreto de la Región de las Américas tomó un valor de 0,37
(Figura 5).
La aplicación directa de la curva de Lorenz
y el coeficiente de Gini en el contexto de las
desigualdades en salud tiene el inconveniente de que no toma en cuenta la dimensión
socioeconómica, pues la población se ordena
en función de la variable de salud elegida. Sin
embargo, si la población se ordena de menor
a mayor ingreso económico, se supera esta
desventaja y se obtiene la llamada curva de
concentración y su índice de concentración correspondiente.
El índice de concentración de la mortalidad
infantil en 1997 en las Américas fue de –0,32,
y el de la mortalidad materna en el período
de 1992 a 1997 fue de –0,48. En ambos casos,
la mortalidad se concentra en los grupos socioeconómicos más pobres. Casi 35% de las defunciones de menores de un año se producen
en el quintil más pobre, es decir en el 20% más
pobre de la población de nacidos vivos. En el
otro extremo, el quintil más rico aporta solo
2% de las muertes maternas.
El índice de concentración se aplicó también
al estudio de la distribución del analfabetismo
Población acumulada ordenada por
producto nacional bruto (PNB) per cápita
ajustado por el poder adquisitivo de la moneda (PAM)
74
La Medición de las Desigualdades en Salud
en población femenina en las Américas, en 1995
(Figura 6). Los países de la Región se agruparon y ordenaron de acuerdo con el valor de su
PNB per cápita (grupo V: menor ingreso; grupo I: mayor ingreso). La Figura 6 presenta la
curva de concentración del analfabetismo en
relación con el PNB, y muestra que el 70% del
analfabetismo femenino se concentra en el 40%
de la población más pobre de las Américas. El
índice de concentración es de –0,42.
LA MEDICIÓN DE LAS
DESIGUALDADES EN SALUD COMO
BASE PARA LA DEFINICIÓN DE
POLÍTICASY PROGRAMAS
Mediante el uso de indicadores clásicos y
de algunas variables de salud elegidas, el pre-
FIGURA 6. Distribución del analfabetismo
femenino en lasAméricas por grupos
de país según ingreso, 1995
Curva de Concentración
Población acumulada femenina analfabeta (%)
Indice de Concentración = –0.4204
1,0
0,9
0,8
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
Población acumulada población ordenada por
producto nacional bruto (PNB) per cápita
(US$ constantes 1995)
Fuente: Programa Especial de Análisis de Salud (SHA), Organización Panamericana de la Salud (OPS).
Nota: En 1995, alrededor del 70% del analfabetismo femenino
en la Región se concentró en el 40% de la población de ingreso
económico más bajo.
sente artículo pone de relieve la existencia de
grandes desigualdades en la Región. Este ejercicio descriptivo puede considerarse como un
primer paso para la identificación de las
inequidades en salud. Hay una gran cantidad
de datos agregados disponibles, en especial
de mortalidad, morbilidad y otros factores
relacionados con la salud, que pueden usarse
regularmente en los distintos niveles geopolíticos como base para el análisis de las desigualdades en salud.
La OPS sostiene que la evidencia de una situación de inequidad debe conducir a la ejecución de acciones por parte de los niveles de
decisión política, orientadas a disminuirla y,
eventualmente, eliminarla. La documentación
de las desigualdades en salud es fundamental para definir esas acciones, y, en tal sentido,
el fortalecimiento de la capacidad de análisis
de los datos que permiten fundamentar la existencia de dichas desigualdades es una condición indispensable. Una vez que se ha
instrumentado una intervención específica, los
mismos métodos y técnicas de medición y
análisis pueden servir para el monitoreo y
evaluación de su impacto.
Hay una relación estrecha entre la naturaleza de las intervenciones y las técnicas que se
emplean para medir las desigualdades. La
metodología y el análisis deben subordinarse
a la existencia de un repertorio de acciones factibles y previsibles. Si las acciones previstas
suponen el diseño de políticas intersectoriales
de alcance poblacional para aumentar al máximo la efectividad, la desigualdad debe documentarse por medio de medidas de impacto;
si, por el contrario, las acciones posibles o previstas tienen un carácter intrasectorial y selectivo, las desigualdades deben expresarse por
medio de medidas de efecto.
Para la OPS, la búsqueda de equidad en
salud no solamente es una cuestión teórica
sino un marco concreto para la cooperación
técnica con los países, pues la equidad en salud constituye un imperativo para el desarrollo económico regional.
Alleyne, et al.
REFERENCIAS
1. Organización Panamericana de la Salud. Las condiciones de salud en las Américas, Edición 1994, vol. 1.
Washington, DC: PAHO; 1994. (Publicación Científica No. 549).
2. Organización Panamericana de la Salud. Informe
Anual del Director 1995. En busca de la equidad. Washington DC: OPS; 1996. (Documento Oficial No. 277).
3. Organización Panamericana de la Salud. Informe
Anual del Director 1996: Gente sana en entornos saludables. Washington DC: OPS; 1997. (Documento Oficial
No. 283).
4. Organización Panamericana de la Salud. La salud en
las Américas, edición de 1998, vol. I. Washington DC:
OPS; 1998. (Publicación Científica No. 569).
5. Deininger K, Squire L. A new data set measuring income
inequality. The World Bank Economic Review 1996; 10(3).
75
6. Alleyne GAO. La salud en el marco de reducción de
la pobreza. 5ta. Reunión del Foro Permanente para
la Aplicación de la Estrategia de Cooperación al Desarrollo. Lima: Organización Panamericana de la Salud; 1998. (OPS/PER/99.03).
7. Mackenback JP, Kunst AE. Measuring the magnitude
of socio-economic inequalities in health: an overview
of available measures illustrades with examples from
Europe. Soc Sci Med 1997; 44(6).
8. Kunst AE, Mackenbach JP. Measuring socioeconomic
inequalities in health. Copenhagen. WHO Regional
Office for Europe; 1994. (EUR/ICP/RPD 416).
9. Wagstaff A, Paci P, van Doorslaer E. On the
measurement of inequality in health. Soc Sci Med 1991;
33(5).
10. Townsend P, Davidson N. The Black Report. En:
Townsend P, Davidson N, Whitehead M (eds).
Inequalities in Health. London: Penguin Books; 1988.
N ONCOMMUNICABLE D ISEASES AND
RISK FACTOR SURVEILLANCE
Sylvia Robles,1 Jeanette Vega,1 and Stephen Corber1
the data and technical cooperation that already
exists with regard to equity for that program.
INTRODUCTION
The reduction of inequities should be a component of every PAHO technical cooperation
program. To be effective in the area of disease
control and prevention, the following steps
should be undertaken:
MAGNITUDE OF THE PROBLEMS
AND TRENDS
Outside of information from the United
States and Canada, data from the Region on
the relationship between health and the absolute or relative socioeconomic position are
scarce, with the possible exception of infant
mortality studies (Hollstein et al., 1998; Casas
and Dachs, 1998; Paim and Costa, 1993;
Victora et al., 1992). Few studies on socioeconomic health inequality, and even fewer that
assess time trends or analyze information by
causes of adult mortality, have been published. In most Latin American and Caribbean
countries, social and economic transformations of the last decades have led to changes
in the mortality and morbidity patterns, with
an overall decrease in mortality rates and an
increase in life expectancy. Noncommunicable
diseases (NCDs) now predominate (Murray
and Chen, 1993); they account for two-thirds
of the mortality in the Region and their proportion is increasing. Fifty percent of these
deaths are premature deaths in persons under 65 years of age, which means that they
could be prevented or postponed.
1. Identifying and selecting equity-oriented
indicators to measure the burden of morbidity and mortality in the Region.
2. Analyzing existing data to identify and
quantify the main social inequalities in
health (including self-perceived health,
morbidity, and mortality) and access to
health care, both within and between countries in the Region.
3. Putting information systems in place to
monitor health equity as well as trends
within and between countries.
4. Developing equity-oriented technical cooperation programs.
5. Conducting periodic evaluations in member countries to assess progress in reducing
health inequities as demonstrated by socioeconomic position.
The particular activity that should be undertaken in a given program will depend on
1
Division of Disease Prevention and Control, Pan
American Health Organization.
76
Robles, Vega, and Corber
Several behavioral and biological factors
have been identified in the scientific literature
as risk factors for NCDs, of which the most
important are cigarette smoking, a sedentary
lifestyle, a high fat diet, obesity, hypercholesterolemia, and hypertension (DHHS, 1991;
Stamler, 1987; WHO, 1990). Excessive alcohol
consumption is associated with chronic liver
disease and is also a major risk factor for disability and death associated with motor vehicle related injuries (DHHS, 1991). Psychosocial factors, including social support,
characteristics of the work environment, and
depression, have been shown to be related to
cardiovascular disease (Marmot, 1982;
Berkman, 1982; Rosenman, 1982; Theorell,
1992). Although they are not risk factors in the
traditional sense, selected preventive services
have proven effective in reducing mortality
from cancer of the breast and cervix. There is
general agreement that screening by mammography and clinical examination in women
50–69 years of age or older reduces breast cancer mortality (The Canadian Task Force, 1994;
US Preventive Services Task Force, 1996), and
early detection through PAP smears and other
screening methods can decrease mortality
from cervical cancer (The Canadian Task
Force, 1994; US Preventive Services Task Force,
1996). Similarly, the use of seat belts and helmets has been found to be effective in reducing deaths and disabilities resulting from
motor vehicle related injuries (The Canadian
Task Force, 1994; US Preventive Services Task
Force, 1996). In industrialized countries, improvements in these behavioral risk factors
have been associated with marked reductions
in the incidence and mortality of the respective NCDs.
Several surveys of NCD risk factors have
been conducted in Latin American and the
Caribbean, although only Barbados, Colombia, Cuba, and Saint Kitts have conducted
these surveys country-wide (Lessa et al., 1996;
Martins et al., 1993; Piccini and Victora, 1994;
de Lolio et al., 1993a, 1993b; Rego et al., 1990;
Llanos and Libman, 1995; Duncan et al., 1993;
Litvak et al., 1987; Ordúñez, 1998; Jadue et al.,
77
1999; PAHO, 1997; Ministry of Health of Barbados, 1992). Most studies have been crosssectional surveys and have not been repeated
over time. The exception are the recent efforts
in surveillance of tobacco conducted by a few
countries, in which increased prevalence of
smoking has been described among females
and adolescents. Existing evidence suggests
that many of these factors are highly prevalent or are becoming highly prevalent in Latin
American and Caribbean countries. The prevalence of smoking in adults in those countries
has been estimated to range from 30% to 50%
in men and from 10% to 30% in women
(PAHO, 1992; Lessa et al., 1996; Duncan et al.,
1993; de Lolio et al., 1993; Ordúñez et al., 1998;
Jadue et al., 1999). Paradoxically, infant malnutrition may coexist with a high prevalence
of obesity in some adult populations, reaching as high as 30%–55% in some groups
(PAHO, 1998; Foster et al., 1993). The prevalence of hypertension has been estimated to
range between 8% and 30% (Lessa et al., 1996;
Duncan et al., 1993; Rego et al., 1990; Piccini
and Vitora, 1994; de Lolio et al., 1993b; Berrios
et al., 1990; Alvarez Perez et al., 1992). Even
higher prevalence of hypertension (more than
40%) has been documented in some Caribbean
countries (Foster et al., 1993; Ordúñez et al.,
1998). High prevalence of hypercholesterolemia (as high as 30%–40%) also has been
documented in some areas (Lessa, 1996). The
few studies that have quantified physical activity also have documented high prevalence
rates of sedentary lifestyle (as high as 50%–
90%) (Duncan et al. 1993; Rego et al., 1990;
Berrios et al., 1990; Ordúñez et al., 1998; Jadue
et al., 1999). Even diabetes, which used to be
relatively uncommon in many developing
countries, appears to be growing in importance (Vaughan et al., 1989; Phillips and
Salmeron, 1992; PAHO, 1998; Llanos and
Libman, 1995), with prevalence estimates for
Latin American countries generally ranging
between 5% and 10% (Llanos and Libman,
1995). Much higher prevalence—as high as
18%—has been documented in some Caribbean countries (Foster et al., 1993). No system-
78
Noncommunicable Diseases and Risk Factor Surveillance
atic information on the prevalence of psychosocial factors potentially related to NCDs and
injuries exists for the Region.
As with mortality, data related to trends in
prevalence and incidence of risk factors according to socioeconomic variables are scarce
in the Region, with the exception of some studies conducted in the United States and
Canada. In the U.S., studies have shown that
most of these risk factors, including perception of health, smoking, physical inactivity,
obesity, hypertension, and poor diet, are clustered among individuals in the lower socioeconomic groups. These risks are higher in the
most disadvantaged communities, even after
adjusting for the individual risk factors, indicating that both individual and contextual
characteristics contribute to a person’s risk. All
of these factors are correlated with an increased risk of mortality over the years (Yen
and Kaplan, 1999).
Although some health outcomes are consistently more prevalent in the lower social
strata—including, for example, tuberculosis
mortality and alcoholism—some of the diseases and associated risk factors evolve over
time through social epidemiological transitions. In the first phase of this transition, risk
factors are positively associated with socioeconomic position; that is, risk factors are more
prevalent in higher socioeconomic groups,
although overall incidence of disease may still
be low. In the second phase, risk factors become less prevalent in upper social strata, but
the incidence of disease increases, while the
prevalence of risk factors within the lower
social strata remains stable or begins to increase. During this phase, an inverse u-shaped
mortality curve might be seen. In the third
phase, after the transition is completed, the
typical inverse relation between socioeconomic position and risk factor prevalence is
observed. Later, due to the time lag between
risk exposure and the development of the disease, incidence and premature mortality from
NCDs become higher in low socioeconomic
groups. For example, the tobacco consumption epidemic may begin in the upper socio-
economic groups, who have the economic resources to purchase cigarettes, and eventually
reveal a positive correlation between lung cancer and socioeconomic level. However, over
time, persons in lower socioeconomic strata
smoke more, while persons in upper socioeconomic groups begin to lower their smoking
rates and resort to better technology in the
treatment of the disease. Consequently, socioeconomic strata and morbidity/mortality become inversely related.
LIMITATIONS OF THE
MEASUREMENTS
In order to measure the strength of the relationship between socioeconomic strata and
disease—and thus measure socioeconomic
health inequalities—we need to identify and
use appropriate indicators, and we must
gather sufficient and high-quality data on specific subpopulations.
The Limitations of Measures
Several methods are available for measuring socioeconomic inequalities in health outcomes associated with NCDs. A major methodological issue is the quality of the indicators
being used to classify individuals in terms of
social position. Another methodological issue
concerns the methods used to quantify health
inequalities. There is some agreement that in
examining social inequalities in health the
joint distribution of both health and socioeconomic status should be considered, as should
average and dispersion measures. Some of the
range measures for mortality and morbidity
data for NCDs include comparisons of health
between groups at the extremes of the socioeconomic spectrum using rate ratios (RR) or
rate differences (RD). The limitation of these
measures is that they overlook the intermediate group. Inequalities in health outcomes
between the upper and lower socioeconomic
groups might, for example, remain unchanged, while inequalities between the in-
Robles, Vega, and Corber
termediate groups and the upper or lower
groups might be diminishing or increasing
(Wagstaff, 1991).
Several measures of economic inequalities
have been developed based on the Lorenz
curve, including the Gini coefficient and concentration index. All have the drawback that
they measure inequality in relative terms.
Other measures have been developed to summarize differences among several groups, taking into account the average level, the differences between groups, and the relative sizes
of the groups. One of the most commonly used
is the slope index of inequality (SII), which
compares the distribution of health outcomes
across subgroups; these subgroups are ordered by socioeconomic position by calculating the slope of the (weighted least square)
linear regression as a summary measure of
health inequality. The result can be interpreted
as the rate difference between those at the
bottom of the hierarchy and those at the top.
Another issue, especially relevant to NCDs,
is that when considering the underlying reasons for the observed differentials in health
outcomes in a population, there is a growing
consensus that systematic differentials play a
prominent role in exposure to health hazards and
risk conditions. However, depending on the
etiologic period, the time interval between
exposure and health outcomes can vary, as
occurs with changes in mortality associated
with changes in prevalence of risk factors for
diseases such as cancer, cardiovascular diseases, diabetes, and others. NCDs are characterized by long latency periods between some
risk factor exposures and health outcomes,
such as with smoking and lung cancer.
Finally, indicators of morbidity may show
very different patterns from those in mortality rates, and, therefore, the ranking of countries or communities according to prevalence
of diseases will not necessarily match rankings
for mortality for those same diseases. Morbidity from NCDs commonly shows much
steeper social gradients than mortality, and sex
differences are almost always reversed when
morbidity is compared to mortality.
79
Availability and Quality of Data
A serious limitation of all routinely used
measurements is that they are based on averages and do not take into account differences
among groups—the essence of inequity. Properly designed behavioral risk factor surveys
can address this important limitation by collecting and analyzing the information according to different categories of potential inequities (income, education, occupation, gender,
race/ethnicity, geography, etc.).
Another limitation of routinely collected
data is the fact that information about socioeconomic position for the numerator and
denominator of specific rates usually comes
from different sources, for example calculating death rates for manual laborers by
using death certificates (for the numerator)
and census data (for the denominator). This
difference can lead to numerator-denominator biases, in which the classification by socioeconomic position indicators varies systematically according to the source. This
numerator-denominator problem has been
widely discussed in the literature and usually leads to an underestimation of the relationship between socioeconomic position
and health risk. The probability of bias can
be minimized using aggregated categories
(Schkolnikov, 1998) and eliminated using
linked registries.
Mortality statistics for NCDs are, on average, fairly reliable over the Americas. However, there are still some countries where coverage and quality of registries need to be
improved (PAHO, 1998). A few countries have
specific registries for selected problems, for
example, cancer registries to provide information about the incidence of malignant neoplasms. One serious limitation of the existing
data, however, is that most come from vital
statistics registries, which do not always contain information about socioeconomic position, such as income, occupation, and education. When the information is collected, it is
usually of poor quality, for example, data on
occupational status of the deceased.
80
Noncommunicable Diseases and Risk Factor Surveillance
The best data for program planning and that
can function as an early predictor of the potential benefits of equity-oriented interventions would come from risk factor surveillance
through health surveys repeated over time.
Experience in some industrialized countries
shows that these surveys can give accurate
information about the prevalence of risk factors for NCDs, including the differential risks
by socioeconomic groups, as well as trends.
In these countries, the survey questions have
been validated and changes are being monitored over time. A standardized methodology
is currently being developed to produce valid
and reliable estimates of the prevalence of risk
factors in the Region of the Americas. In carrying out behavioral risk factor surveys, questions must be validated to ensure that they are
well-understood and will be answered honestly by the respondent in a given environment. Additionally, sampling must be representative, surveyors must be well-trained, and
standardized quality control and quality assurance mechanisms at the data collection and
data entry levels should be in place. Currently,
the lack of standardization of methodologies
used across surveys and differences in the information collected makes it difficult to ensure
the validity of the results and the comparability among countries and within countries.
influence, for example, age, gender, marital
status, and race/ethnicity. In the framework
being presented here, it is assumed that
“health inequities” refers to differences in
health status related to differences in socioeconomic position (income, education, occupation, race/ethnicity, and gender). Krieger
(1997) notes that most measures of socioeconomic position reflect both availability of
material and social resources, as well as social status or an individual’s rank in a social
hierarchy. From this point of view it is important to study and intervene to address the socioeconomic inequities, including gender and
race/ethnicity in different geographic settings.
The study of gender inequities in NCDs is
particularly important, because it is known
that some associations between risk factors
and disease are not the same in men as in
women (Barrett Connor, 1997). Mortality rates
associated with NCDs are almost always
lower among women than men, and have a
lower socioeconomic gradient, but these gender differences are reversed for morbidity and
self-perception of disease (women show more
morbidity than men, and often show steeper
social gradients).
INEQUALITIESTHAT MAY
CONSTITUTE INEQUITIES
Both the socioeconomic context and health
outcomes associated with NCDs can be measured with reference to magnitude and time.
It is important to try to clarify the links between health and socioeconomic position, because they are powerful clues about a given
society’s forms of discrimination which may
generate health inequities. Also, in measuring
inequities, individual and aggregate-level
variables can be used. Aggregate measures for
NCDs should mainly be used to compare
countries. Mortality comparisons within country, however, should be based on small-area
analyses (such as counties) or subpopulations,
and survey data is more appropriately analyzed at the individual level.
Kunst and Mackenbach (1994) argue that an
inequality can be measured, while an inequity
cannot. However, it does appear possible to
measure and study the perception of such an
inequity in a population or in subgroups of
that population.
Evans (1994) uses the term “heterogeneity”
and MacIntyre (1997) uses “social patterning”
as synonyms for “inequality.” These authors
clarify that inequalities/heterogeneities/social patterns can refer to differences between
groups that are not necessarily socioeconomically determined, but that do have a social
THE INFLUENCE OF
DIFFERENT DETERMINANTS
Robles, Vega, and Corber
There is currently little data in the Region
about the influence of one determinant on others and about the direct and joint effects of
individual and contextual variables. Again,
risk factor surveillance can be a key instrument
for identifying such influences. The scarce data
available have shown some interesting findings. In Valparaiso, Chile, for example, the
combined effect of low socioeconomic status
and female gender results in higher rates of
many risk factors for NCDs.
Additionally, it is important to examine the
social context in which a particular risk factor
or group of risk factors occurs. Most measurements and interventions currently used for
NCD risk factors tend to focus on bringing
about behavioral changes in a person, but it is
important not to ignore the individual’s social environment. The compelling evidence
that the lower socioeconomic groups tend to
have poorer nutrition, be less physically active in leisure, have greater prevalence of
smoking, and have more damaging patterns
of alcohol use is only half of the story. It is of
critical importance to understand why this is
so. The growing literature from qualitative
studies on the daily circumstances of people
experiencing disadvantages, highlights the
greater restrictions on the choice of a healthier lifestyle, due to practical constraints of
time, space, and money, as well as psychosocial mechanisms (WHO, 1998). From a methodological perspective, this represents a challenge, since epidemiological studies and
surveillance have focused mainly on the individual, and, therefore, assume that personal
choice determines behavior. Nonetheless, recent discussions and conceptual approaches
have led to new proposals that include both
individual and contextual effects—that is, collective characteristics on individual-level outcome measurement and interventions (DiezRoux, 1998; Van Korff et al., 1992; Hox, 1994).
From a public health perspective, this implies
that control of risk factors is much harder
among the most disadvantaged groups and
therefore the interventions should be deliberately tailored towards the worst-off.
81
HOW TO REDUCETHE GAPS
1. Identifying inequities between and within
the Region’s countries by implementing
monitoring systems.
In the case of routinely collected information, it is crucial to recognize the growing need
to supplement vital statistics (such as mortality and birth) and other health data (such as
hospital discharge and notification data) with
appropriate socioeconomic data that can serve
as a foundation for contemporary public
health knowledge about patterns and trends
of social inequalities in health. This information also can be used to help allocate resources
and plan public health interventions at the
regional, country, and local levels. Routinely
collected mortality data should then be analyzed (at least) by socioeconomic position between countries and ideally for different
smaller geographical units within countries.
Socioeconomic measures should be included
in all health surveys routinely carried out, including risk factor surveys, DHS (Demographic and Health Surveys), and LSMS (Living Standards Measurement Surveys). PAHO
could support a line of action that would include validation, standardization, and quality control of risk factor surveys in member
countries to facilitate the identification of inequities and create the basis for an ongoing
surveillance system for NCDs.
2. Developing a framework to continuously
monitor and evaluate progress in countries
in achieving health equity for NCDs by taking into account not only the average level
of health indicators but also the distribution
of health among socioeconomic groups.
3. Collaborating with countries to set health
objectives and priorities for NCDs that consider the distribution of health across the
population; in other words, set equity targets for the NCD prevention and control
health agenda.
4. Working with countries to implement health
interventions that address health inequities.
82
Noncommunicable Diseases and Risk Factor Surveillance
The NCD intervention programs to be developed may not be equally effective in all
socioeconomic groups, but efforts should be
made to ensure they reach the most disadvantaged. Monitoring of progress should
include the extent to which these interventions have been successful in addressing
needs and in decreasing health inequities.
5. Reorganizing technical cooperation programs based on an equity-oriented approach.
AN EXAMPLE OF THE USE OF RISK
FACTOR SURVEYSTO MONITOR
HEALTH INEQUALITIES IN NCDS
The behavioral risk factor survey carried out
in Valparaiso, Chile, in 1996 showed several
areas of inequalities (Table 1). Surveillance of
behavioral risk factors should provide guidance for program planning and maintenance,
leading to the reduction of inequities where
they exist.
Smoking was highest among males of low
socioeconomic status, and overall prevalence
was higher among males than females.
Among males, no significant differences were
observed in the prevalence of obesity, as mea-
sured by body mass index, whereas females
exhibit higher rates than males. Further, females in the low socioeconomic group exhibit
rates significantly higher than females in the
middle/high socioeconomic group. Lack of
physical activity and the prevalence of hypertension were higher among females than
males, and in both groups there was a socioeconomic gradient, with those in the lower
end having higher risk. On the other hand, the
ratio of total cholesterol to high-density lipoprotein, which indicates the risk of a lipid profile, was higher among the middle/high socioeconomic group among males and females
than among the low socioeconomic group.
However, when the use of preventive services
was analyzed, a higher proportion of males
and females in the middle/high socioeconomic group had been tested for cholesterol
and glycemia. Further, in spite of the high proportion of women who had had Pap smears,
the rate was still lower among those in the low
socioeconomic group than in the middle/high
group. Further investigation may explain why
these differences exist and point to technical
cooperation initiatives to address them. Repeated measurement of these risk factors will
provide information on trends and on how
these differences persist or change.
TABLE 1. Prevalence of risk factors and use of preventive services, by gender
and socioeconomic status, Valparaiso, Chile, 1997.
Gender and socioeconomic status
Male
Female
Low (%) Middle/high (%) Low (%) Middle/high (%)
Risk factors
Regular smoker
Body mass index (>25)
No physical activity
Hypertension
Ratio of total cholesterol/
HDL (>4.5)
Use of preventive services
Ever tested for cholesterol
Ever tested for glycemia
Ever had a Pap smear
50.2
62.0
76.5
13.9
47.6
45.5
59.5
68.1
10.0
50.0
36.4
67.9
97.0
15.7
35.8
34.6
60.7
92.1
10.2
39.0
10.9
20.4
–
27.7
37.1
–
18.3
43.1
74.6
30.5
53.6
81.4
Robles, Vega, and Corber
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H EALTH EQUITY AND M ATERNAL M ORTALITY
Ernesto Pate,1 Carol Collado,1 and Jose Antonio Solís1
Ultimately, maternal death is a tragedy for
individual women, families, and their communities. The impact of maternal death is felt
by the whole family and rebounds across the
generations. The complications that cause the
death and disability of mothers also damage
the infants they carry. The poor health and lack
of care that contribute to the death of women
in pregnancy and childbirth also compromise
the health and survival of the infants and children they leave behind. It affects the family’s
well-being and that group’s potential to contribute to the development of the community.
It is estimated that nearly two-thirds of the
eight million infant deaths that occur each year
result largely from poor maternal health and
hygiene, inadequate care, inefficient delivery
management, and lack of essential care of the
newborn. The social costs to the immediate
family group are compounded with economic
costs to the health care system and missed
development opportunities.
INTRODUCTION
Each year, 600,000 women between the ages
of 15 and 45 die in the world from complications arising from pregnancy and childbirth.
And for every woman who dies, many more
suffer morbidity that can affect them for the
rest of their lives. The tragedy is that these
women die not from disease, but during the
normal life-enhancing process of procreation.
What is worse is the fact that most of these
deaths could be avoided if preventive measures were taken and adequate care were
available.
Maternal mortality is not merely a “health
disadvantage,” it is a “social disadvantage.”
Health, social, and economic interventions are
most effective when they are implemented simultaneously. Since the 1940s, maternal
deaths in the developed world have become
increasingly rare. Not so in developing areas,
where persistently high maternal mortality
levels are symptomatic of a pervasive neglect
of women’s most fundamental human rights,
a neglect that is most acutely suffered by the
poor, the disadvantaged, and the powerless.
The level of maternal mortality reflects
women’s place in society, as well as their access to social health and nutrition services and
economic opportunities.
MATERNAL MORTALITY IN THE
REGION OF THE AMERICAS
What Is a Maternal Death?
A maternal death, according to the International Statistical Classification of Diseases and
Related Health Problems, Tenth Revision (ICD10), is the death of a woman who was preg-
1
Division of Health Promotion and Protection, Pan
American Health Organization.
85
86
Health Equity and Maternal Mortality
nant at the time of death or had recently been
so, and whose death was related directly or
indirectly to the pregnancy. Direct maternal
deaths are those resulting from complications
of pregnancy occurring in the prenatal period,
during labor and childbirth, or within 42 days
following termination of the pregnancy. Recently, the following has been added: “. . . irrespective of the duration and site of the pregnancy, from any cause related or aggravated
by the pregnancy or its management but not
from accidental or incidental causes.” Further,
maternal deaths are to be reported in two
groups: (a) direct obstetric deaths and (b) indirect obstetric deaths. ICD-10 also recognizes
late maternal deaths as those deaths occurring
up to one year after the termination of the
pregnancy. However, the applications of these
changes in definition are not uniform among
countries, even in those with good registration systems.
Why Do Women Die?
Globally, approximately 80% of all maternal deaths are the direct result of complications arising during pregnancy, delivery, or the
puerperium. It should be noted, however, that
there is under-reporting of deaths and their
causes, and the available databases are weak.
The most commonly registered clinical causes
of death in Latin America and the Caribbean
are characterized below:
• Hemorrhage, especially postpartum, which results in 20% of maternal deaths, is unpredictable, sudden in onset and swift to kill.
It can lead to death very rapidly in the absence of appropriate and prompt lifesaving
care.
• Hypertensive disorders of pregnancy, particularly eclampsia (convulsions), result in some
20% of all maternal deaths.
• Abortion complications cause 16% of maternal deaths. Laws should ensure the availability of services for the management of
abortion complications and post-abortion
care. Where abortion is legal, safe pregnancy
termination should be made available. National policy can discourage the use of unsafe abortion by providing protection
against unwanted pregnancy and establishing national health campaigns to raise
awareness of the risks of unsafe abortion
and to show how to recognize and seek
treatment for abortion complications.
• Complications of pregnancy, responsible for
14% of maternal deaths, include puerperal
infections, often the consequence of poor
hygiene during delivery or untreated STIs,
and prolonged or obstructed labor, caused
by cephalopelvic disproportion or by an abnormal positioning of the fetus.
Many of the above medical problems are
aggravated by chronic or residual conditions.
Of these indirect contributors to death, one of
the most significant is anemia, which also is
thought to underlie a substantial proportion
of direct deaths (particularly those caused by
hemorrhage and sepsis), as well as contribute
to death by cardiovascular arrest.
The Health Disadvantage
Within the above-mentioned clinical causes,
there is a clear relationship between the population and the health care system. A good number of the deaths could have been prevented
through timely quality care. Examples of this
would be: careful monitoring during pregnancy and the post-partum period; treatment
with relatively simple measures and drugs;
access to specific services such as family planning; attendance at birth by trained personnel; and attention to cultural and ethnic practices that exacerbate or potentiate problems.
Approximately two-thirds of all pregnant
women in Latin America and the Caribbean
deliver with the help of skilled attendants.
Many women, however, are assisted only by
relatives or traditional birth attendants, and
many deliver alone. Providing birthing
women with a skilled attendant who is able
Pate, Collado, and Solís
to prevent, detect, and manage the major obstetric complications and who has the equipment, drugs, and supplies to treat them effectively is considered to be the single most
important factor in preventing maternal
deaths. Data from Peru shows that trained
personnel attend only 16% of deliveries by
women within the lowest quartile of household assets. In comparison, trained personnel
deliver 92% of women within the highest
quartile of household assets (see Figure 7 in
the chapter titled “Health Disparities in Latin
America and the Caribbean: The Role of Social and Economic Determinants,” which appears in Part 1 of this publication).
The lack of access to and utilization of quality obstetric services is a crucial factor leading
to high maternal mortality. Although an estimated 15% of pregnant women will experience life-threatening complications that require emergency care, there are virtually no
data on the proportion of women with access
to such care. As many as 40% of pregnancies
are likely to require some form of special care.
The Social Disadvantage
While the above sections speak to the clinical causes of maternal mortality, there also are
a number of social disadvantages leading
these women along a death march. These involve many contextual factors such as socioeconomic factors, cultural and ethnically
based belief systems and practices, and geographical barriers, to name a few.
Some women’s low social status limits their
access to economic resources, basic health resources, and educational resources, among
others. It also affects their ability to make decisions related to their health and nutritional
needs and to seek assistance.
Many other factors underlie the medical
causes of maternal mortality, such as poverty,
low income, poor nutrition, excessive physical work, lack of decision-making power, and
cultural beliefs. The common pathway for
most of these factors is poor access to care.
87
EVIDENCE IN MATERNAL
MORTALITY MEASUREMENT
Trends in Maternal Mortality in Latin
America and the Caribbean
Longitudinal data from PAHO from 1960 to
1980 shows that the maternal mortality ratios
in all countries have fallen, but the rate of decline has been slow in the less developed countries. There are still vast differences between
countries in the Region; more than 10 countries continue to suffer maternal mortality ratios greater than 100 per 100,000 live births (see
Figure 1).
Measures of Maternal Mortality
There are three main measures of maternal
mortality: the maternal mortality ratio, the
maternal mortality rate, and the lifetime risk
of maternal death.
• The maternal mortality ratio represents the
obstetric risk associated with each pregnancy, described as the number of maternal deaths per 100,000 live births during a
one year period. Although it has traditionally been called a rate, this is actually a
ratio and is now usually called such by
researchers.
• The maternal mortality rate measures both
the obstetric risk and the frequency with
which women are exposed to this risk, and
is calculated as the number of maternal
deaths per 100,000 women of reproductive
age (usually 15–49 years) during a given
period.
• The lifetime risk of maternal death takes into
account both the probability of becoming
pregnant and the probability of dying as a
result of that pregnancy, accumulated across
a woman’s reproductive years. The lifetime
risk is calculated using the maternal mortality ratio and the total fertility rate,
increased by 25% to allow for pregnancy
wastage.
88
Health Equity and Maternal Mortality
FIGURE 1. Maternal mortality per 100,000 live births, selected countries
in the Americas, 1960, 1970, 1980, and circa 1984.
350
Argentina
Canada
Colombia
Costa Rica
Cuba
Chile
Peru
Dominican Republic
Uruguay
Venezuela
300
250
200
150
100
50
0
1960
1970
1980
Because the term “ratio” and “rate” are often used interchangeably, for the sake of clarity it is essential to specify the denominator
used when referring to either of the first two
measures of maternal mortality.
The setting where the problem of maternal
mortality is most acute is precisely that in
which it is least likely to be accurately measured. Of the 600,000 maternal deaths that
occur yearly around the world, most occur in
developing countries. If we focus on the Region of the Americas, in Canada the maternal
mortality ratio averages about 4 maternal
deaths per 100,000 live births (1995); in contrast, in Latin America and the Caribbean the
ratio is nearly 20 times higher. Because the
maternal mortality ratio represents a measure
of the obstetric risk every time a woman becomes pregnant, the risk of maternal death is
magnified in areas where women have many
pregnancies in their lifetime.
In developing countries, 1 woman in 12 may
die of pregnancy-related causes, compared
with 1 in 4,000 in industrialized countries. The
discrepancy between these two figures not only
1984
1990
represents one of the starkest and most telling
differentials in development, but also reflects
the huge differences in national commitment
between different developing countries.
In the Region of the Americas, a woman’s
lifetime risk of dying during pregnancy and
childbirth ranges from 1:17 (Haiti), to 1:510
(Panama), to 1:3,700 (USA), and to 1:7,000
(Canada). These disparities can be largely explained by poor access to quality care.
Measurement Limitations
As experience with implementing “safe
motherhood” programs2 has grown, it has
become increasingly clear that the traditional
indicator of maternal health status—the ma2
The safe motherhood initiative was founded at an international conference in Nairobi in 1987 to address the
high maternal mortality seen in developing countries.
Over the past decade of advocacy and action for safe
motherhood, a broad range of needed interventions has
been mapped out by the many partners working in this
area, including governments, multilateral and bilateral
funding agencies, technical support agencies, NGO’s, and
other interested parties. However, the interventions iden-
Pate, Collado, and Solís
ternal mortality ratio—is not an appropriate
indicator for monitoring progress in the short
term. Maternal mortality ratios are inappropriate for short-term monitoring:
• The maternal mortality ratio is not sensitive
to changes in the delivery of care and, therefore, is not very useful as a monitoring tool.
• Few developing countries have the sophisticated and comprehensive systems of vital
registration needed to accurately monitor
levels of maternal mortality. In such circumstances, household surveys have to be used
to estimate maternal mortality.
• Maternal deaths are relatively rare events
even where maternal mortality is high.
Thus, all household survey techniques are
subject to wide margins of error and are
very expensive to implement.
• The simple measurement tools developed
in recent years, such as the sisterhood
method, are not appropriate for regular
monitoring purposes because they provide
data relating to a point some time in the
past.
Surveillance Issues
As a result of the measurement limitations
and for other technical reasons, most maternal mortality reduction programs now rely on
process indicators for regular program monitoring. Such process indicators can include the
number and distribution of essential obstetric-care services, the proportion of deliveries
attended by skilled health care providers or
occurring in institutional settings, or the rates
of operative delivery and institutional case
fatality rates.
tified have not always been implemented systematically
or comprehensively, and although there have been some
successful examples, global progress has been slow.
The inter-ministerial meeting held in Lima in 1998
looked at progress in this area since 1990 and stated that
the reduction in maternal mortality has reached a plateau. This has resulted in the formation of the inter agency
task force comprised of PAHO, UNFPA, UNICEF,
UNIFEM, USAID, The World Bank, and IADB to coordinate activities in this area.
89
Guidelines have been developed to assist
countries in gathering, analyzing, and interpreting such indicators. These process indicators describe the major pathway to reducing
maternal mortality in terms of access to essential obstetric care, appropriate utilization of
such services, and some aspects of quality
of care. An important advantage of these
measures is that they are not only relevant
for monitoring progress, but also permit
policy-makers and planners to better target
interventions to reduce maternal mortality
and morbidity. They often are derived from
routine data or as part of program implementation, thus limiting data collection costs.
While process indicators such as these are
useful for monitoring programs, more detailed
investigation is needed to diagnose the underlying causes of maternal mortality and to identify ways of dealing with them.
Maternal mortality is under-reported worldwide, and most of the figures reported for developing countries are estimates. Surveys done
in Latin America and the Caribbean show that
we should multiply our reported rates by a factor between 1.5 and 2.3.
In Argentina in 1995, Elida Marconi used a
systematic process to reduce misclassification
by matching death certificates to clinical records, and found that the extent of misclassification for the country as a whole was 53%.
Consequently, official estimates of maternal
mortality should be adjusted by a factor of 1.53
to correct for errors in classification.
To describe the Brazil experience, Ruy
Lurentis compared the official maternal mortality ratio of 44 per 100,000 live births to the
study’s finding, a ratio of 99.6 per 100,000 live
births. This meant that there was an underreporting of 65.9%, which requires an adjustment factor of 2.26 when all factors are
considered.
Recent research has highlighted the extent
of under-reporting and misclassification of
maternal deaths, even in countries with good
vital registration (Atrash et al., 1995). Research
in the USA, which used six different sources
in addition to published vital records to iden-
90
Health Equity and Maternal Mortality
tify deaths related to pregnancy, also detected
significant under-reporting. No single source
of information identified all maternal deaths.
In some countries, there is a tendency to
report higher levels of maternal mortality
where there is an expectation of receiving
funding for program activities, and to report
lower levels when it was necessary to demonstrate success. These tendencies aggravate
the inaccurate reporting.
DALYs (Disability Adjusted Life Years)
measures are a time-based indicator of health
outcome that forms a composite measure of
the overall burden of disease due to losses
from premature death and non-fatal disability. DALYs are the measurement unit for the
global burden of disease study (GBD); they
have been designed to assist with cost effectiveness analysis and are used as a tool for
priority setting. This single outcome measure
has limitations because only a restricted number of dimensions of health care can be taken
into account. Some experts have expressed
concerns that the methodology may reinforce
a medical model of health care and narrow
vertical approaches. DALYs should not be
used as the only tool for prioritization or resource allocation. Recommendations are currently being developed to enable DALYs to
better capture the burden of reproductive ill
health and will be used in the revision of the
GBD study planned for 2000.
A CLOSER LOOK AT INEQUITIES
Differences between Men and Women
Health expectancies make it possible to
specify inequities between social groups, regions in a country, and sexes. It is increasingly
clear that a very strong relationship exists between short life expectancy and amount of
morbidity (Robine et al., 1999). Although this
relationship has been demonstrated by data
in developed countries, no such calculations
have been made for Latin American and Caribbean countries. Data from Latin America
and the Caribbean, however, show a high
mortality and morbidity among females due
to reproductive health causes.
Most studies indicate that life expectancy
and positive health expectancy are higher for
females than for males, but the proportion of
morbidity-free years to total life expectancy
is slightly lower for females. The difference in
life expectancy between the sexes is reduced
when an estimate of health expectancy is produced. Results from studies using data from
repeated wave surveys have suggested that
the greater proportion of years lived with disability or handicap by women may be explained by the longer survival of women after the development of these problems.
Life expectancy in Latin America and the
Caribbean has been increasing in all countries
over the past decade, but this increase is lower
in countries with high maternal mortality, and
is also closely linked to education.
Socioeconomic Differences
Socioeconomic differences have been studied for nine countries. All but one of the studies has demonstrated that social inequalities
in health are much greater than has been
shown by differential mortality. Not only are
the poorest and the least educated people
shorter-lived, but they also experience a
greater part of their lives with disability or
handicap. This was first observed in Canada:
the difference in life expectancy between the
richest 20% and the poorest 20% in the community was 6.3 years, but increased to 14.3
years for disability-free life expectancy.
Finnish and Dutch studies have demonstrated socioeconomic inequalities by means
of calculations using several educational levels, and found that the higher the educational
level, the higher both life expectancy and positive health expectancy. Kennedy et al. (1996)
have shown that race along with other socioeconomic differences are good predictors of
excess mortality. Calculations comparing different ethnic groups in the USA show much
lower life expectancies and disability-free life
Pate, Collado, and Solís
expectancies for black people than for Asian
people as compared to whites.
Studies show that socioeconomic differences, including education and race, are
closely related to maternal mortality. Although
this data is not readily available for Latin
America and the Caribbean, infant mortality
parallels maternal mortality trends in the region, and some data exist in this area.
Data from Brazil shows a six-fold difference
in infant mortality between families in the
highest and the lowest income groups, and
this difference holds true even for data collected ten years apart (see Figure 4 in the chapter “Health Disparities in Latin America and
the Caribbean: The Role of Social and Economic Determinants,” which appears in Part
1 of this publication).
91
FIGURE 2. Socioeconomic stratification of
departments according to percentages of the
gross domestic product, indigenous population,
and rural inhabitants, Guatemala, 1998.
Geographical Comparisons
within Countries
Strata
1
2
3
4
Rural Versus Urban Disparities
Data from Guatemala shows that areas with
high percentages of indigenous people have
higher maternal mortality than other areas.
Associated with this increased mortality is
lower life expectancy among females, lower
availability of water, lower literacy, and lower
spending on health services. In general in
Latin America and the Caribbean, analyses
show that most maternal deaths occur in rural areas. In Guatemala, there are 0.3 hospital
beds per 10,000 people in the rural population, compared to 1.3 hospital beds per 10,000
people in the urban population. Such disparities in the distribution of resources can cause
inequities in health outcomes such as mortality. There is little direct data reporting on
rural/urban differences for most of the countries in LAC. This is in itself an inequity as it
prevents and delays action being taken to
reach the underserved populations (see Figures 2–6).
Factors resulting in an increased risk of
maternal morbidity and mortality also affect
the fetus and young child, and frequently re-
sult in low birthweight and, later, stunting in
children. Using low birthweight and stunting
in children as indirect measures of inequalities in maternal mortality risk factors, we can
further demonstrate rural/urban differences
in Latin American and Caribbean countries.
Data from these countries show an almost
two-fold increase in low birthweight and
stunting in children from rural areas. At the
same time, there has been a 68% decline in
infant mortality rates in low birthweight babies born to wealthy parents over a ten-year
period in Brazil, but only a 36% decline in infant mortality in low birthweight babies born
to poor parents (see Figures 7 and 8).
Maternal Mortality and
Educational Levels
Maternal mortality is greatest among
women with the lowest educational level,
30%–50% of whom never arrive at the health
facilities. This is especially true in rural areas.
Health Equity and Maternal Mortality
FIGURE 3. Female life expectancy, according to
socioeconomic group, Guatemala.
76
Life expectancy
74
72
70
68
66
64
62
2
1
N=
6
9
2
3
Socioeconomic group
G-1
72.4
DE
2.7
F 1,3 = 2.032
TL F = 5.61
G-2
69.1
2.3
x
5
4
G-3
G-4
68.9
67.7
1.6
3.2
p = 0.15
p = 0.03
FIGURE 4. Available water according to socioeconomic group, Guatemala.
100
90
Water availability
92
80
70
60
50
40
30
N=
2
1
6
9
2
3
Socioeconomic group
G-1
88.9
DE
2.8
F 1,3 = 3.41
TQ F = 5.49
x
G-2
68.6
8.1
G-3
G-4
58.6
67.2
11.4
18.8
p = 0.04
p = 0.03
5
4
Pate, Collado, and Solís
FIGURE 5. Female illiteracy according to socioeconomic group, Guatemala.
80
60
50
40
30
20
10
0
N=
2
1
6
9
2
3
Socioeconomic group
G-1
x
18.0
DE
6.3
F 1,3 = 13.3
FTL = 36.6
G-2
34.9
3.1
5
4
G-3
G-4
44.3
57.7
7.8
12.9
p = 0.000
p = 0.000
FIGURE 6. Distribution of hospital beds per 10,000 population
according to socioeconomic group, Guatemala.
Hospital beds (per 10,000 population)
Female illiteracy
70
1.4
1.2
12
1.0
.8
.6
.4
.2
0.0
N=
2
1
6
2
9
3
Socioeconomic group
G-1
x
1.25
F 1,3 = 7.8
TL F = 23.3
G-2
.62
G-3
G-4
.48
.30
p = 0.002
p = 0.000
5
4
93
94
Health Equity and Maternal Mortality
FIGURE 7. Percent reductions in infant mortality rates in Pelotas, Southern
Brazil, between 1982 and 1993, by income group and birthweight.
Wealthy, adequate birthweight
Wealthy, low birthweight
Poor, adequate birthweight
Poor, low birthweight
–70
–60
–50
–40
–30
–20
–10
0
Reduction 1982–1993 (%)
Source: Victora, C. 1999.
FIGURE 8. Percentage of stunting in children below 5 years of age,
according to urban or rural area, selected countries, Latin America
and the Caribbean, early to middle 1990s.
Guatemala 1995
Peru 1992
Bolivia 1994
Haiti 1995
Paraguay 1990
Colombia 1995
Brazil 1996
Domin. Rep. 1996
0
10
20
30
Rural
40
50
60
Urban
Source: Demographic and Health Surveys, DHS.
Data from Chile shows that life expectancy
is lowest for women with no education and
increases rapidly as the years of schooling increase. Further, this difference has widened
over the past ten years. In 1996 the life expectancy for a 20-year-old woman with no education was 53 years, compared to 72 years for a
woman with 13 or more years of schooling—
a striking difference of 19 years of life expectancy (see Figure 10 in the chapter titled
“Health Disparities in Latin America and the
Caribbean: The Role of Social and Economic
Determinants,” included elsewhere in this
publication).
Not only do race and education levels affect maternal mortality and life expectancy,
Pate, Collado, and Solís
but they also affect the mortality and morbidity of the children. A recent study from Brazil
by Pinto da Cunha (1997) on infant mortality
showed that infant mortality was highest for
infants of black mothers, decreased for infants
of mulatto and dark mothers, and was lowest
for infants of white mothers, among mothers
with no formal education. This trend persisted
consistently as years of schooling in the mothers increased (see Figure 14 in the chapter
titled “Health Disparities in Latin America and
the Caribbean: The Role of Social and Economic Determinants,” included elsewhere in
this publication).
Economic Inequities
As described elsewhere in this publication,
Latin America is the region with greatest social and economic disparities. In this Region,
60% of the national income is earned by the
richest 20% of the population (see Figure 9).
The introduction of extensive economic adjustment and reform programs in the Region,
with policies of free trade, currency liberalization, and reduction of government expenditures, has resulted in moderate economic
growth since 1990. These changes have not
had any significant impact on levels of poverty or on employment. Data show that in
Latin America and the Caribbean, the percentage of the population living in absolute poverty has increased, widening the gap between
the urban and rural populations. This Region
demonstrates a model of growth without distribution (see Figures 10 and 11).
Income Disparities
Reduction of mortality in infants under 1
year old is strongly associated with an increase
in total available resources in the society. The
general data for the Americas in 1996 demonstrates that lower national infant mortality
rates correlate with the increase in per capita
income adjusted for purchasing power parity.
However, in countries in which per capita
income adjusted for purchasing power parity
falls below $4,000, the disparities in the internal distribution of income seem to be poorly
associated with the level of mortality. In these
societies, it seems that the total amount of resources is more a determinant of the health
status of the population than the internal distribution of these resources. Although subnational groups with more or less per capita income may exist, the national health status is
more associated with the total amount of available resources.
In general, per capita income greatly influences the distribution and utilization of health
care resources in Latin America and the Caribbean (see Figure 12 for data for Bolivia and
Peru). This is clearly demonstrated by data
from Mexico showing that as per capita income increases the percentage of hospital deliveries, and number of physicians and beds
per inhabitant increases exponentially (Lozano et al., 1999) (see Figure 7 in the chapter
titled “Health Disparities in Latin America and
the Caribbean: The Role of Social and Economic Determinants,” included elsewhere in
this publication).
FIGURE 9. Percent of national income by income quartiles,
selected regions of the world.
Regions
Latin America
Africa
East Asia
Southeast Asia
0%
20%
1st quartile
4th quartile
95
40%
60%
2nd quartile
5th quartile
80%
3rd quartile
100%
96
Health Equity and Maternal Mortality
FIGURE 12. Inequity in delivery assistance
by income quartiles, Bolivia and Peru.
FIGURE 10. People living in extreme poverty
(in thousands), 19 countries.
100,000
92.4
100
(Thousands)
80
80,000
Total
Urban
Rural
60,000
40,000
20,000
1990
1994
20
FIGURE 11. Poverty rates in 19 countries
in Latin America.
60
55
50
Total
45
Urban
40
Rural
35
30
25
1980
1990
1994
15.1
13.3
20% poorest
Peru
Bolivia
2°
3°
Income quartiles
4°
20% richest
Source: World Bank, 1998 (unpublished).
In countries whose per capita income adjusted for purchasing power parity falls
above the $4,000 threshold, the absolute level
of wealth or available resources no longer explains differences in health status. In these
countries the infant mortality rate and maternal mortality ratio tend to be higher in the
countries with higher income disparities,
measured as the ratio of the income of the
highest 20% of the population and the income
of the lowest 20%. Countries with the highest income disparities have infant mortality
rates up to three times higher than those with
less disparity.
These examples demonstrate that a country’s
overall wealth is not, in itself, the most important determinant of maternal mortality. There
are examples of countries with modest levels
of GNP and with low income disparities that
are coupled with low maternal mortality.
Percentage
40
0
1980
81.6
60
Clearly, in situations where the level of
wealth available to the majority of the population is low and the income disparity is significant, access to quality care will be affected
and maternal mortality and morbidity will be
high.
Inequity among Countries in Latin
America and the Caribbean
As demonstrated by maternal mortality ratios, the disparities among countries in the
Americas are made even more manifest by
comparing the ratio of national maternal mortality rates with the regional minimum rate.
There is a 14-fold difference in infant mortality
rates between the Region’s countries with the
lowest infant mortality rates and those with the
highest rates. If a similar comparison is carried
out for maternal mortality we will see a greater
than 100-fold difference in two countries and a
20-fold difference in more than half of the countries in Latin America and the Caribbean. These
enormous differences in maternal mortality
have much to do with inaccessibility to quality
health care. It is important to stress that while
a large proportion of infant deaths are due to
environmentally related conditions—diarrheal
diseases, acute respiratory infections, and malnutrition—maternal mortality is almost wholly
attributable to a lack of or poor quality prenatal and perinatal care (see Figure 3 in the chapter titled “Health Disparities in Latin America
and the Caribbean: The Role of Social and Economic Determinants,” included elsewhere in
this volume).
Pate, Collado, and Solís
Actions to Reduce Maternal Mortality
The historical record demonstrates that
rapid reductions in levels of maternal mortality can be achieved when key interventions
are in place. Ten years of implementing safe
motherhood programs has shown that we can
advance safe motherhood through:
• improving human rights;
• empowering women and ensuring choice;
• acknowledging that safe motherhood is a
vital social and economic investment;
• delaying first birth;
• planning ahead to deal with pregnancy risks
since every pregnancy faces risks;
• ensuring skilled attendants at each delivery
(this requires national policies favoring professionals with midwifery skills for all
births, coupled with standards for quality
of care);
• improving access to maternal services by
establishing community-based maternal
health care systems comprising prenatal,
delivery, and postpartum care and a system
of referral to a higher level of care when obstetric complications arise; and
• preventing unwanted pregnancy and addressing unsafe abortions.
Countries vary enormously in terms of the
situations and challenges they face and in
terms of their capacity to address these challenges. However, experience has demonstrated that several features are common to
successful efforts to address maternal mortality, such as carrying out:
• coordinated efforts over the long term;
• actions within families and communities,
and in society at large;
• actions at the legal and policy level and in
health systems;
• interactions among the interventions in
these areas, which are critical for reducing
maternal mortality and for building and
supporting momentum for change; and
• political will to implement change.
97
There will be a need to support:
• a social, economic, and legislative environment that will enable women to obtain
health care and overcome the multiple barriers that reduce their access to this care;
• policies ensuring that all couples and individuals have access to good quality, clientoriented, and confidential family planning
information and services that offer a wide
choice of effective contraceptive methods—
policies should address the regulatory, social efforts to offset economic and cultural
factors that limit women’s control over
sexuality and reproduction;
• services that assign health workers trained
in midwifery to community-based health
facilities, thus reducing barriers to access
due to distance, lack of transport, and costs
of services;
• health care services developed with protocols and statutes for providing routine maternal care and managing obstetric complications at each level of the health system;
and
• decentralized services that are as close to
people’s homes as possible—particularly in
rural and remote areas, facilities must have
supplies, equipment, and trained staff.
CONCLUSIONS
Maternal Mortality is an Area of
Significant Inequity in Health in Latin
America and the Caribbean
If we are to help reduce inequity we must
clearly identify the unfair disparities in health
that occur in our countries and apply those
technologies that reduce those disparities. In
the case of maternal mortality, the disparities
are multi-faceted and complex. Many factors
are outside of the control of the health sector;
some are supply-driven while others are
demand-driven.
Data from the Region shows that we need
to increase access to quality care. Research has
98
Health Equity and Maternal Mortality
shown that accessibility does not necessarily
imply usage. The motivation of the socially
disadvantaged to make use of services that are
theoretically accessible may not be the same
as for the more fortunate groups, even apart
from the differences in transactional costs. We
initially thought that the socially disadvantaged were more resistant to changing risk
behaviors; we now know this is not the case.
Current research shows that issues of respect, confidentiality, auditory and visual privacy in the service areas, dialogue, and sharing of information are as important as the
medical therapy being provided in encouraging utilization of resources.
Improving Access and Quality of Care
are Indispensable Interventions for
Reducing Maternal Mortality
Many of our countries in the Region of the
Americas are going through an epidemiological transition, have different socioeconomic
gradients, and display varying degrees of inequity. Therefore, we need to develop interventions for specific countries by using different approaches.
In the past, data on life expectancy, maternal and infant mortality, and causes of death
were seen as sufficient for assessing population health status and determining public
health priorities. As mortality rates have declined and life expectancy has increased, questions have arisen about the quality of life. The
former indicators remain indispensable, as
there are still major inequalities in mortality
between countries and between groups within
countries. Nevertheless, for a few countries in
Latin America and the Caribbean, changes during the last 20 years have demonstrated the
need for new indicators, namely disability-free
life expectancy, healthy life expectancy, or active life expectancy. These indicators provide
information on the functional state and vitality of the population as well as people’s quality of life. These new indicators, which are
appropriate for the epidemiological conditions
of today, are not seen as a priority and are
monitored in only a few Latin American and
Caribbean countries, and this is another indication of the inequity among the countries of
the region.
REFERENCES AND BIBLIOGRAPHY
Atrash H, Alexander S, Berg C. Maternal mortality in
developed countries: Not just a concern of the past.
Obstetrics and Gynecology 1995; 86(4) (ii).
Graham W, Brass W, Snow RW. Estimating maternal mortality: the sisterhood method. Studies in Family Planning 1989; 20:125–135.
Kennedy BP, Kawachi I, Prothrow-Stith D. Income distribution and mortality: cross-sectional ecological study
of the Robin Hood index in the US. BMJ 1996;
312:1004–7.
Lozano R, Infante C, Schlaepfer L, Frenk J. Desigualdad,
pobreza y salud en Mexico. Mexico, DF: Editora el
Nacional; 1993.
Maine D, Rosenfield A. The safe motherhood initiative:
why has it stalled? American Journal of Public Health,
April 1999; 89(4).
Pinto da Cunha EMG. Raca; aspecto esquecido da
iniquidad em saude no Brazil. In Barata, R.B. et al.
(eds) Equidade e Saude. São Paulo, Brasil: Abrasco
Huticet; 1997.
Robine JM, Romieu I, Cambois E. Health expectancy indicators. Bulletin of the World Health Organization 1999;
77(2).
UNICEF, WHO, UNFPA. Guidelines for Monitoring the
Availability and Use of Obstetric Services; 1997.
Weaver J, Sprout R. Twenty-five years of economic development revisited. World Development 1993; 21(11).
WHO, UNICEF. The sisterhood method for estimating
maternal mortality: guidance notes for potential users; 1998. (WHO/RHT/98.27).
Wilkinson RG. Socioeconomic determinants of health:
health inequities: relative or absolute material standards? BMJ 1997; 314:591 (22 January).
World Health Organization. Maternal mortality ratios and
rates: A tabulation of available information; 1991.
(WHP/FHE/MSM/91.6)
H EALTH EQUITY IN RELATION TO
SAFE D RINKING W ATER SUPPLY
Horst Otterstetter,1, 2 Luiz A. C. Galvão,1 Vicente Witt, Peter Toft,1
Sergio Caporali,1 Paulo C. Pinto,1 Luiz C. R. Soares,1 and Carlos Cuneo1
be the keystone of our strategy if it is to be
ecologically viable. This, together with the
rational use of natural resources, must be the
central focus of our strategy. Every other concern must be subordinated to it.” The Agenda
also stresses that the achievement and maintenance of health for the Latin American and
Caribbean population “. . . demands the integration of health concerns with those of the
environment as part of the new model of sustainable development” (Latin American and
Caribbean Commission on Development and
Environment, 1990).
About 200 million poor live in Latin
America and the Caribbean—in 1994, 38% of
the total population was poor and 16% was
indigent. Poor people in urban and rural areas by and large do not have safe drinking
water supplies. Some carry water to their
homes from stand pipes and consequently
waste valuable work or study time and risk
their health by carrying heavy loads and consuming unsafe water. Others purchase water
from vendors at prices up to twenty times
higher than that paid by people with piped
water.
The implementation of Agenda 21 underscores the close and complex links between
the environment and human health, as well
INTRODUCTION
The United Nations Conference on Environment and Development, held in Rio de Janeiro,
Brazil, in June 1992, issued a Declaration of
Principles, asserting that “human beings are
at the center of concern for sustainable development. They are entitled to a healthy and
productive life in harmony with nature.” The
Conference’s plan of action—Agenda 21—
approaches environmental concerns and actions within a sustainable development process that focuses on the well-being of present
and future generations. Section I of the
Agenda, “Social and Economic Dimensions,”
emphasizes that the elimination of poverty
and the protection and promotion of health
are important elements of sustainable development (United Nations, 1992). Latin American and Caribbean countries took the position
that, “There will not be sustainable development as long as almost half of the population
continues to be in abject poverty.” They further stated that, “Human development must
1
Division of Environmental Protection and Development, Pan American Health Organization.
2
The authors would like to acknowledge the contributions to this article by Division of Environmental Protection and Development’s Country Advisors.
99
100
Health Equity in Relation to Safe Drinking Water Supply
as the need for decision-makers to have a
broad understanding of the relationship between environmental risk and health outcome
in order to control exposures and protect
health, and concomitantly to contribute to the
reduction of inequities. Unfortunately, even
though the matter is of critical importance, it
has been given limited attention so far, and
there are few studies available on socioeconomic inequalities in access to safe water
supply.
In addition to its marked interest in the issue of equity and health outcomes, the Pan
American Health Organization (PAHO) also
is concerned with equity in the various determinants of health, including the broad physical, social, and economic determinants of
health. In many cases, the determinants of
health are key to attaining equity in health.
Many determinants of health, as are determinants in other sectors, are linked directly
or indirectly to poverty. Because the relationship between poverty and health, which has
been known for centuries, is clearly evident
today, PAHO is striving to identify and define inequalities and inequities in health status within and among countries. Through its
various activities and programs, the Organization is trying to improve the knowledge
about and understanding of this issue as a
basis for diminishing health harms and risks,
particularly for the more disadvantaged
populations.
The relationship between health and the
environment touches on an extremely broad
range of issues. The ability to link health to
environmental data, and to better understand
how the physical, social, and economic environments affect health, continues to challenge
health professionals. Nevertheless, this step is
fundamental for controlling the adverse environmental effects on human health in general, and on the more disadvantaged groups,
especially the poor, in particular. In order to
establish these links, health and environment
data must be analyzed as a way to estimate
the health impact of environmental factors and
set priorities for action according to the
population’s basic physical, social, and economic requirements (Associação Brasileira
de Engenharia Sanitária e Ambiental, 1999;
Associação Brasileira de pós-graduação em
Saúde Pública, 1998; World Health Organization, 1996; World Health Organization, 1997).
The World Health Organization (WHO) has
developed a six level cause-and-effect framework as a basis for analyzing how environmental risks generate health outcomes (World
Health Organization, 1996). This framework,
although still being tested, has provided valuable results that may help decision-makers
and policy-makers understand these complex
relationships and focus their actions on the
health aspects of sustainable human development. This process should provide data to
identify and better define where inequalities
and inequities are concentrated and to determine which interventions are required to improve the situation.
In discussing the relationship among
health, the environment, and sustainable development this chapter establishes a context
for describing the basic situation that countries face in the new development processes.
It also emphasizes the importance of water
resources and the related inequalities that
may affect the provision of safe drinking
water supplies. This is a critical element
among environmental determinants of health
and an important expression of inequity, especially in relation to the health of the urban
and rural poor. Further, this discussion demonstrates how water supply and sanitation
measures affect populations, and how inequities in safe drinking water supplies can be
demonstrated, specifically in relation to cost,
coverage, and water quality. Finally, the chapter discusses the Environmental Health
Framework for Decision-making, including
the six lines of action designed to reduce inequities in relation to the provision of drinking water. It is expected that this methodology will be a useful mechanism for the
identification, definition, prioritization, and
implementation of actions to attain equity in
health through environmental interventions.
Otterstetter, et al.
HEALTH AND ENVIRONMENT IN
HUMAN DEVELOPMENT
Inequalities and inequities in the provision
of safe water have been expressed in many
different ways and are considered explicitly
in the broader global agenda on sustainable
development. The Declaration of Principles
issued in Rio de Janeiro, as expressed in
Agenda 21, implies that development should
meet the needs of people, their health, and
their well-being, as well as provide a healthy
environment in which people can attain their
development, including health.
The basic human needs for a healthy environment are safe water, adequate food, and
shelter, as well as the social and economic conditions whereby different people can live together with equity and peace—a desire of human beings over the ages. More recently, this
aspiration has evolved into the concept of “human development” in the broadest sense, and
is becoming a fundamental objective of more
general development. Consequently, increasing awareness of the complex links between
economic growth and environmental protection has become a major challenge in governments’ efforts to achieve human-oriented sustainable development (Carey, 1999; United
Nations, 1992; World Bank, 1999).
In the Region of the Americas, the subject
of health and the environment in development
has been discussed in several meetings of
heads of state and, in particular, at the 1996
Pan American Conference on Health and Environment in Sustainable Human Development. Presently, governments and peoples are
cognizant that they must reconfigure their
development policies and programs to equitably meet growing human needs and to correct existing inequities, while at the same time
maintaining an ecological balance and facing
the pressing demand for constructing healthy
social systems. It is important to keep in mind
that insufficient development, which is generally a consequence of poverty—and poverty
affects a very large portion of the population
in developing countries in the Americas—can
101
be a major contributor to environmental deterioration; this, in turn, can result in poor
health (Pan American Health Organization,
1998; Pfaff, 1999).
Currently in this Region there is an understanding of the fact that people’s health cannot be promoted and protected by the health
sector alone, or even primarily. As was shown
during the Pan American Conference on
Health and Environment in Sustainable Human Development in 1996, good health is the
result of a series of actions by the whole of
society, led by governments. Therefore, the
establishment of partnerships that mobilize
public and private sectors to act synergistically to address health goals is essential if significant progress is to be made. To fit within
the framework of sustainable development,
approaches to support health must shift from
the traditional sectoral approach to a new,
broader intersectoral effort. Intersectoral
action is especially important when dealing with health and environment, because of
the intrinsic links between the human and
the natural environments (Pan American
Health Organization, 1998; World Bank, 1999;
Alleyne, 1998).
WATER RESOURCES AND
QUALITY OF LIFE
Clean water is essential for life and for maintaining good health; it also is necessary for human activities, including those that enhance
the quality of life. Except for some Caribbean
islands, the Americas are endowed with a
plentiful supply of surface water resources.
About 13% of the world’s continental waters
are found in Latin America and the Caribbean.
On a per capita basis, this Region is very rich
in terms of water, compared with other continents, as shown in Figure 1, particularly since
estimates of the amount of water needed for
development indicate that countries with
1,000 m3 to 1,600 m3 per person per year may
experience shortages in drought years, and
that those with less than 1,000 m3 per person
102
Health Equity in Relation to Safe Drinking Water Supply
River flow per person in 1,000 m3
per year
FIGURE 1. Availability of water resources for
human use, by region, 1970
and projections for 2000.
60
1970
50
2000
40
30
20
10
0
North
South
America America
Africa
Europe
Asia
Source: Adapted from Reiff, 1989.
per year may see development curtailed
(World Resources Institute, 1998).
Groundwater is a valuable source of drinking water supply, and most countries of the
Region take care of the water supply needs of
large populations using this resource. Although freshwater supplies in Latin America
and the Caribbean vary significantly from
country to country, few countries currently
face problems nationwide. Nevertheless, several must deal with localized shortages of adequate drinking water sources, particularly in
large metropolitan areas and in some smaller
cities, where the poorer strata of the population are usually affected.
The need for water resources goes beyond
quantity and must also consider quality. The
capacity of these resources to provide water
for human well-being is shrinking as a result
of population growth, degradation from pollution and other environmental abuses, inefficiency, and waste. The poor can be further
disadvantaged, as the areas they live in often
receive effluents discharged by residents living upstream. Projections indicate that in the
year 2000, the demand for water due to the
increase of population alone will have
doubled since 1980. The rate of increase is
likely to grow further in future decades if appropriate policies are not implemented and
appropriate actions are not taken.
The production of goods and services is
necessary to meet the needs of ever-growing
urban populations and improve the quality of
life of the urban and rural poor. However,
most of the uses of water contribute to degrade
water quality, and this, in turn, affects human
beings and other species that depend on this
water for survival. In general, water quality
must satisfy the requirements of society’s
many uses, but it is essential that drinking
water meet public health requirements. Further, as pressure for different uses of water
increases, the potential for conflicts also increases, with the risk that water quality for
human consumption may fall by the wayside,
thereby exacerbating existing inequalities. To
avert severe conflicts relating to quantity and
quality of drinking water, strong advocacy for
new policies that give proper attention to water for human consumption is required. Presently, 2 billion people drink water that others
would not even use to wash their cars, while
another 1.2 billion people would dearly love
to have such water (Otterstetter, 1996).
The quantity of water required by different
users varies widely. On a global scale, needs
for irrigation account for about two-thirds of
all human water use: for example, it takes
about 1,000 tons of water to grow 1 ton of
grain, and some 2,000 tons to produce 1 ton
of rice. However, these processes have associated water losses that may range from 50% to
80% (World Resources Institute, 1987), which
means that there is room for improvement
here. Reuse of municipal wastewater is another potential area of recovery for irrigation.
In many cases, policies do not favor or give
attention to the equitable distribution of scarce
natural resources, such as the adequate assignment of water for drinking and other purposes. Frequently, the needs of the poor are
ignored and, because of this, poor people often miss opportunities such as developing
cottage industries or other activities that require water that could improve their economic
status (World Bank, 1999).
In the Region of the Americas, it was estimated that 12% of the water consumed in 1995
was used for domestic purposes, while 26%
was used for industrial purposes, with agri-
Otterstetter, et al.
culture as the largest consumer (World Resources Institute, 1998).
DRINKING WATER SUPPLY AND
HUMAN HEALTH
Water is an essential element in every aspect of human life: drinking, hygiene, cooking, and leisure. People are in contact with
water all their lives and are exposed to whatever it contains. Water is also essential for
other living organisms, including disease
vectors.
Among all the uses of water and the needs
of human beings, a safe drinking water supply is the most essential, although not sufficient in itself to attain and maintain good
health. The association between safe drinking
water and other sanitary measures to attain
good health has been recognized for a long
time. One example is the drop in diarrheagastroenteritis mortality rates in Costa Rica
with the implementation of such measures
(Figure 2). However, this knowledge is not
always readily incorporated into water supply projects or other health and development
projects. Figure 2 demonstrates the importance of water and sanitation to improve community health. Further, although the benefits
are in many cases reaped by the better-off, the
extension of coverage also usually benefits
marginal areas to some extent (Alleyne, 1998).
An estimate of the impact of the exposure
to poor water supply and poor sanitation on
the risk of disease can be estimated on the basis
of Disability Adjusted Life Years (DALYs).
DALYs are the expression of the number of
FIGURE2. Mortality ratesfrom diarrhea and gastroenteritisversustime and
percent of total population with improved water supply, Costa Rica.
120
Diarrhea-gastroenteritis
mortality rate
100
Percent of total population
with improved water
200
80
150
60
Water treatment
improvement
program
100
40
Housing & electrification
program
50
Municipal water
systems
installation
program
20
Rural water
facilities
program
0
1930
1940
Source: Adapted from Reiff, 1981.
1950
1960
1970
0
1980
% of total population with improved water supply
Mortality rate from diarrhea and gastroenteritis
(per 100,000 population)
300
250
103
Health Equity in Relation to Safe Drinking Water Supply
FIGURE 3. Decrease
in the prevalence of diarrhea
–
in children 0–5 years old due to improvements
in sanitation in Baixa do Camarajipe, Salvador,
Bahia, Brazil, 1993–1998.
Prevalence (%)
years of life lost (YLLs) added to a comparative adjusted measure of years living with disability (YLD). The YLD measurement adjustments are based on the severity and duration
of the disease and age and sex of the individual
(Murray, 1996).
For Latin America and the Caribbean, the
DALYs of water- and sanitation-related risk
factors is estimated at 5,183. This value means
that water and sanitation are the most important environmental determinants of health—
compared to determinants such as occupation
and air pollution—and are more significant for
this Region than malnutrition, which is the
highest risk factor globally according to DALY
calculation. Table 1 illustrates this data and
reveals other related details. Unfortunately,
there are no data available that specifically
address low-income or poor populations
(Murray, 1996).
Further illustrations of the association between the availability of water supply/sewerage/drainage and health indicators are
shown in Figures 3 and 4. These figures are
based on the results of a sanitary intervention
in Baixa do Camarajipe, Salvador, Brazil,
where a poor community received better sanitation from 1992–1998. As a result of these interventions, the level of diseases was reduced
significantly (Borja, 1999).
The installation of water supply systems not
only makes water available but also decreases
the unit cost of water. This is particularly beneficial for the poor, who are subjected to paying high prices for limited quantities of water
that is usually of questionable quality. Those
50
40
30
20
10
0
Aug/93 Aug/94 Feb/95 May/95 Jul/96
Jul/97
Jul/98
Source: Adapted from Borja, PC, Moraes, LRS, 1999.
who have no water or lack sufficient water are
mostly poor, and for them the cost of water is
higher than for the better-off, as shown in Figure 5. Consequently they use less water, and
have lower levels of hygiene and a higher
incidence and prevalence of several waterrelated diseases. There is no other way to break
this vicious cycle than by improving access to
adequate quantities of safe water through disinfected piped supply systems (Pan American
FIGURE 4. Decrease in the prevalence of
helminthes infestation in children 7–14 years old
due to improvements in sanitation in Baixa do
Camarajipe, Salvador, Bahia, Brazil, 1994–1997.
Prevalence ( % )
104
100
90.5
80
55
60
40
20
0
1994
Year
1997
TABLE 1. Burden of diseases attributable to selected risk factors, Latin America and Caribbean, 1990.
Risk factor
Deaths
(1,000)
% total
deaths
YLLsa
(1,000)
% total
YLLsa
YLDsb
(1,000)
% total
YLDsb
DALYc
(1,000)
% total
DALYc
Poor water supply, sanitation,
and personal and domestic
hygiene
Malnutrition
Occupation
Air pollution
135.3
135.0
97.7
33.6
4.5
4.5
3.2
1.1
4,254
4,540
1,973
377
7.6
8.1
3.5
0.7
929
520
1,708
98
2.2
1.2
4.1
0.2
5,183
5,059
3,681
476
5.3
5.1
3.7
0.5
Source: Adapted from Murray, 1996. p.: 312–315.
YLLs: Years of Life Lost; bYLDs: Years Lived with Disabilities; cDALYs: Disability-Adjusted Life Years.
a
Otterstetter, et al.
105
FIGURE 5. Comparison of the cost of water between areas with and
without water supply systems in selected countries of the Region.
5
4
3
2
Countries
costs in areas with systems
Health Organization, 1997). Evidence such as
that shown in Figure 5 provides a strong argument that less than full coverage produces
an unfair distribution of benefits and burdens;
that is, inequities.
Even with the evidence available, governments often give a lower priority to investment projects for water supply and sanitation
due to the cost. This may be due to a misconception of the role of water supply systems
and sanitation, which, in addition to providing water for human consumption, are also
an essential element of urban and industrial
development. In the Region of the Americas
only about 5% of the water supply produced
is consumed directly for health-related purposes. Therefore, only about 5% of the cost of
such investment should be considered a
health-related cost. Furthermore, water systems are built with a projected life of 50 or 60
years; amortization of the investment should,
therefore, be spread over this same period. By
taking into account these two issues, investment in water supply becomes extremely cost
beneficial in terms of improvements in health
(Briscoe, 1996).
MEASURING INEQUITIES IN SAFE
WATER SUPPLY
The main health inequities related to water supply deal with population coverage,
LAC
VEN
TRT
URU
SUR
PER
DOR
PAR
NIC
PAN
MEX
HAI
HON
ELS
GUT
ECU
COR
BRA
COL
BAR
ARG
0
BOL
1
BAH
Cost in US$ per m 3
6
costs in area without systems
quality, cost, and accessibility. Other factors,
such as the geographic location of freshwater sources and the distance individuals must
travel to gain access, accentuate existing
inequalities.
To facilitate the analysis of the relationship
between countries’ economic level and the
availability of water, information on countries
in the Americas can be grouped on the basis
of per capita GNP, according to the division
adopted by PAHO. Group I includes the countries with the highest per capita GNP and
Group V, the countries with the lowest per
capita GNP (Table 2) (Pan American Health
Organization, 1996; Pan American Health Organization, 1997; Pan American Health Organization, 1998).
In the Region of the Americas, 18% of the
population has no access to water systems. In
Group V, 43.8% of the population has no access and in Group I, 4.6% has no access. The
ratio between the lowest and the highest GNP
group of countries is 9.6, which means that
the countries in Group V have 10 times more
people without access to water than the countries in Group I (Figure 6) (Pan American
Health Organization, 1997; Organización
Panamericana de la Salud, 1998).
Inequalities also occur between rural and
urban populations. In urban areas, 13.28%
does not have access to water, while in rural
areas, 40.58% has no access, indicating that the
proportion of population without access to
106
Health Equity in Relation to Safe Drinking Water Supply
TABLE 2. Country groups according to per capita GNP in 1996, population and population without
access to water in 1998, and rate of population without water, Region of the Americas.
Groups
Per capita
GNP, 1996
Population, 1998
Population without
water, 1998
Rate of population
without
water (100
population)
GNP Group V
GNP Group IV
GNP Group III
GNP Group II
GNP Group I
Region
530.20
1,784.82
3,497.49
7,713.30
26,205.78
11,986.29
27,400,000
119,501,000
307,332,000
43,762,000
304,431,000
802,426,000
12,001,741
33,115,917
73,073,052
14,162,043
13,860,385
146,213,138
43.80
27.71
23.78
32.36*
4.55
18.22
Source: Pan American Health Organization, Special Program for Health Analysis.
* Group II included Argentina (Population, 36,123,000) and some small countries (Population, 7,639,000), as of PAHO basic data 1998.
In Argentina, 65% of the population has access to water. Because the table uses average values for countries, the numbers for Argentina
influence the rates of persons without access to water.
drinking water in rural areas is three times
higher than in urban areas (Pan American
Health Organization, 1997).
In rural areas, technical, educational, and
socioeconomic limitations present additional
challenges for securing high water quality. For
example, supply systems in poorer, rural areas are less well maintained than are those in
urban areas. In addition, the rural population
has limited knowledge about the benefits of
safe water, such as the need for adequate storage and disinfection.
Figure 7 presents the concentration curve
and the concentration index for access to water in the Region of the Americas. To estimate
these values, the groups of countries were
FIGURE 6. Percent of population without access
to drinking water in countries of Group V
(lowest per capita GNP) and Group I (highest
per capita GNP), Region of the Americas, 1995.
G N P G rou p I
G N P G rou p V
0
10
20
30
40
50
% population without water
Source: Special Program on Health Analysis, Pan American Health
Organization.
ranked by GNP per capita, from the lowest
to the highest. The concentration curve in Figure 7 suggests that in the Region of the
Americas, 20% of the population that lives
in countries with the highest GNP per capita
have only 5% of their population without
access to water. Conversely, 20% of the population of the region living in countries with
the lowest GNP per capita have 30% of the
population without access to water. A concentration index of –0.30 was estimated for
this distribution (Kunst, 1994; Mackenbach,
1997; Pan American Health Organization,
1999).
Lack of access to basic sanitation services is
directly associated with the incidence and
prevalence of waterborne diseases and other
health effects in the population. For example,
there is a strong association between infant
mortality and lack of access to drinking water, as shown in Figure 8. In areas where about
40% of the population has access to drinking
water, infant mortality is about 50 per 1,000
live births, while in areas where 100% of the
population has access to drinking water infant mortality is around 10 per 1,000 live
births (Pan American Health Organization,
1999).
The above examples clearly indicate the
need for strong policies for the provision of
basic needs, especially drinking water supply,
of marginalized populations in order to im-
Otterstetter, et al.
107
FIGURE 7. Distribution of the population without access
to water in the Region of the Americas, 1997.
Population without access to water
Cumulative percentage of persons
without access to water
1
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
0.8
1
Cumulative percentage of population by GNP per capita
Source: Special Program on Health Analysis and Division of Environmental Protection and Development, Pan American Health Organization.
the population’s ability to pay back the investments. Clean water is required for good health,
but it also is a basic ingredient for urban development and for many industrial processes
necessary to promote and sustain economic
development. The development of water supply systems also must consider the benefit to
other uses (externalities). Unfortunately, these
prove health and achieve equitable and sustainable human development, in accord with
the spirit of the Rio Declaration and Agenda
21.
Under present economic conditions and
trends, a country’s ability to invest in water
supply systems, improve coverage, and provide access to safe water depends largely on
FIGURE 8. Trends in infant mortality rate (per 1,000 live births)
and water access, Region of the Americas.
100
80
60
40
20
0
CAN EUA CUB
7
8
Infant mortality
Access to water 100 100
CHI COR URU VEN ARG PAN COL MEX DOR HON ECU
ELS BRA GUT NIC PER
10
14
14
20
23
24
25
28
34
42
43
44
44
47
48
52
55
HAI
86
91
91
100
89
79
65
84
75
83
73
77
55
53
69
67
62
66
39
108
Health Equity in Relation to Safe Drinking Water Supply
considerations are rarely given the weight
they deserve, nor is cost-sharing generally incorporated into discussions (Rogers, 1997;
World Health Organization, 1997).
ENVIRONMENTAL HEALTH
FRAMEWORK FOR DECISION MAKING
The relationship between human health and
the environment is complex, particularly since
health/environment aspects are linked to several economic and social development issues.
By and large, environmental data may be
available in most countries, as may be data
on the health situation. However, the ability
to link health and environmental data to
clarify the relationship between levels of exposure and health outcome is vital in attempting to control exposure and protect health.
Decision-makers need this information in order to assess the implications of their decisions, compare the potential effect of different decisions, and prevent costly health and
environmental damage (World Health Organization, 1996; World Health Organization,
1997; Brasil, 1999).
In order to tackle the problem, the World
Health Organization, taking as a guide the
model developed by the United Nations Development Program (UNDP) to monitor the
progress of countries towards sustainable
development, elaborated a framework for the
analysis of various aspects of health/environment situations (World Health Organization,
1995).
WHO proposed a six-level, cause-effect
framework as a way to facilitate the analysis
of the environmental-health situation. The
framework was designed to assist decisionmakers and policy-makers in setting priorities and taking action, as well as to increase
the focus on the health aspects of sustainable
human development. It can facilitate the
identification of inequalities and inequities
as well as the development of actions to improve the situation (World Health Organization, 1995).
This cost-effect framework is known as
DPSEEA, an acronym derived from its six action levels—driving force, pressure, state, exposure, effect, and action; it is a response to
Chapter 40 of Agenda 21 (Information for
Decision-making).
Driving force is the first and broadest of the
framework’s levels and refers to the general
factors that motivate and drive environmental processes, such as population growth and
economic development.
Driving forces generate human occupation
or exploitation of the environment, resulting
in pressure on the environment, which is the
second level of the framework.
Continuing pressures alter the environment’s original condition, leading to the third
level of the framework—the state of the environment. An example of this level is the degree of balance between the natural components and the level of pollutants.
Environmental conditions and the presence
of contaminants can result in environmental
hazards for humans if they generate an exposure; this is the fourth level.
If an exposure exists, a health effect is expected to develop; this is the fifth causal-chain
level. Health effects call for action, but the solution of the problem may require actions at
all levels, or at certain levels of the causal-chain
to attain the defined objective. Using the
DPSEEA framework to orient these actions is
critical if the health sector and other sectors
are to achieve sustainable development. Figure 9 shows the dynamics of DPSEEA and the
internal relations.
IDENTIFICATION OF PRIORITIES AND
ACTIONSTO REDUCE INEQUALITIES
There are several actions that may be taken
to reduce inequity in drinking water supply.
Table 3 presents examples of lines of action
that the health sector and other sectors may
take at the different levels of the framework,
emphasizing the practical application and use
of the DPSEEA framework.
Otterstetter, et al.
109
FIGURE 9. Framework for decision making to mitigate inequities
in water supply for human consumption and hygiene.
Driving force
Population growth
Economic development
Technology
Action
Economic policy
Social policy
Clean technology
Pressure
Production
Consumption
Waste release
Hazard management
State
Natural hazards
Resources availability
Pollution levels
Exposure
External exposure
Absorbed dose
Target organ dose
Effect
Well-being
Morbidity
Mortality
Environmental improvement
Education awareness raising
Treatment
Source: Adapted from World Health Organization.
The examples included in the table take into
account the importance of common lines of
action to be explained later in the document.
In applying DPSEEA to the health and environment area, it is important to consider at least
five lines of action to change the situation:
•
•
•
•
•
advocacy,
regulations,
monitoring,
dissemination of technologies, and
mobilization of resources.
LINES OF ACTION TO REDUCE
INEQUITY
DPSEEA can generally use available information at the sector, institutional, and community levels to focus efforts and resources
on priority interventions. The final actions to
reduce the distributive gaps in drinking water supply that emerge from the application
of DPSEEA should result in general lines of
action that can be grouped into the five categories below.
110
Health Equity in Relation to Safe Drinking Water Supply
TABLE 3. Actions to reduce inequity in safe water using the DPSEEA approach.
Cause/effect chain
Issues/examples
Health sector actions
Other sector actions
Driving force
• Urban and industrial development;
• Housing and sanitation policies;
• Poverty and social exclusion.
• Studies on implication of
development policies in
health;
• Proactive role of the
health sector in
promoting sustainable
development;
• Advocacy before other
sectors on adequate
policies and regulation
on water;
• Promotion of the
environmental primary
attention strategy.
• Adopt health impact
analysis in development
projects and policies;
• Include the health sector
as a major contributor to
national development
plans;
• Establish sound urban
public health development policies.
Pressure on the
environment
• Water supply for human and
industrial consumption demand;
• Housing and internal plumbing
demand;
• Sewerage and drainage systems
demand.
• Promote use of appropriate and low cost
technology for water
supply;
• Promoting healthy
housing for the poor;
• Promoting community
participation;
• Establishment of
regulation for the control
of pollution of the water
bodies.
• Implement programs and
projects for extension of
coverage;
• Implement system for the
improvement of quality
of water supply;
• Implement regulation on
population settlements
and housing.
State of the
environment
• Presence of pollutants in water
bodies;
• Pollution of drinking water;
• Storage of water for human
consumption in inadequate
manner.
• Maintain environmental
surveillance (monitoring
and control) system;
• Carry-out health
education activities for
hygiene and safe storage
of water;
• Advocate for projects on
pollution control
(wastewater treatment);
• Monitoring water quality
of the water supply
systems.
• Maintain environmental
surveillance system of
water resources;
• Implement pollution
control projects
(wastewater treatment).
Human
exposure
• Consumption of contaminated
drinking water;
• Consumption of contaminated
food.
• Implement community
based demonstration
projects;
• Carry-out public
education campaigns.
• Carry-out public
education campaigns;
• Implement community
based demonstration
projects.
Health effects
• Diseases and other effects that
can be reduced by basic
sanitation (diarrhea, hepatitis,
parasitism, cholera, and low
body weight and height
development).
• Maintain epidemiological surveillance system of
water-related diseases;
• Improvement of health
services.
• Cooperate with the
health surveillance
system;
• Improve support of
health services.
Otterstetter, et al.
Monitoring Trends in Inequities
in Water Supply
Existing inequities in safe water supply
quantity and quality are relevant in explaining several health effects that are responsible
for morbidity and mortality in the countries
of the Region of the Americas. Existing mechanisms could be used to monitor inequities in
water supply and could become powerful
tools to identify deficiencies and to measure
the health impact of improvements to the
water supply. Therefore, it is important for
countries to develop environmental and epidemiological surveillance systems.
The timely and updated data to maintain
current the “Global Assessment of Drinking
Water Supply and Sanitation Services 2000”
database is expected to be a very important
contribution to measure inequities and monitor changes in the Region.
Table 4 is an example of how DPSEEA can
be used to establish indicators to measure inequities in water supply. A careful definition
of the indicators to be used can assist decisionmakers to focus their actions and scarce resources in areas where they can make a difference in the population’s health.
Even though DPSEEA needs further evaluation and testing by international agencies
111
and countries before being widely used, some
pilot studies have already revealed that it can
be a useful tool for supporting advocacy and
dialogue among the sectors responsible for
water supply and public health (Borja, 1999).
To further support the adoption of DPSEEA,
PAHO has funded case studies, which have
led to the establishment of a set of indicators
to be used to analyze trends and generate critical information for actions.
At the international level, the database of
the “Global Assessment of Drinking Water
Supply and Sanitation Services 2000” is a major source of information. This initiative brings
together critical information for analyzing
water supply trends in the Region of the
Americas, and most of it can be reassembled
within the framework in order to make use of
the data for both the environmental and the
public health sectors. Efforts to obtain information on the situation of lower income population groups should take into account their
concerns in the decision-making process.
National institutions also have their own
databases and the same information that has
been available for years for traditional analysis of trends can be integrated into the DPSEEA
framework scheme, thus improving the planning and decision-making processes for the
water supply sector.
TABLE 4. Use of the DPSEEA framework to establish indicators to measure inequities related to safe
water.
Cause-effect
chain level
Driving forces
Pressure
State
Exposure
Effects
Actions
Indicators
•
•
•
•
•
•
•
•
•
Population Growth Index;
Percent of satisfied goals of national sanitation plan.
Percent of the population connected to a water supply system;
Median value of the consumed water in liters per inhabitant;
Median price of water expressed in percent of the median income.
Percent of water samples with concentration higher than the national standard for E. coli ;
Percent of samples without physical and chemical national standards.
Percent of population living in areas without any access to water supply.
Incidence of acute diarrhea, intestinal parasitism, cholera, and low body weight and height
development;
• Number of health professionals trained for treatment of water-borne diseases.
• Percent of municipalities with environmental surveillance system;
• Percent of municipalities with health education program.
Source: Adapted from Borja, 1999.
112
Health Equity in Relation to Safe Drinking Water Supply
Strategies for Advocacy
The health sector alone cannot carry out all
the functions required to secure a healthy human environment, but it can use advocacy to
promote actions in other sectors that will help
to reduce inequities in access to safe water
supply. There are several examples where advocacy has influenced decisions in other sectors and has resulted in public health benefits.
International agencies should play a strong
role in providing evidence and international
guidance to help country health authorities to
effectively advocate for a healthy human environment. Other activities should include
promoting intersectoral dialogue and actions;
supporting country studies to generate data
for advocacy; promoting the “Environmental
Primary Attention Strategy;” and disseminating information.
Promotion to Strengthen Regulations
The health sector should fulfill its responsibility to develop and help implement regulations at the national level that contribute to
reducing health inequities. The establishment
of water quality standards and the maintenance of surveillance systems are some of the
most important contributions that the health
sector can make to the sustainable development of nations. The use of international
guidelines for waste water and solid waste
management and for drinking water quality,
and the use of health impact assessments on
plans, programs, and projects should assist
countries in the implementation of national
regulations.
Dissemination of Technologies
The lack of appropriate and economic technologies is frequently identified as a barrier
for the development of a safe water supply.
Experiences in several of the Region’s countries have proven that investments in this area
have clearly benefited health. The identifica-
tion, selection, and dissemination of information on technology can contribute at the same
time both to reducing costs and to insuring
selection of the most suitable technology.
Mobilization of Resources
The lack of financial resources is an important obstacle to the development of water supply in countries. The health sector can provide
strong arguments to advocate for investment
projects in this area, and also can develop studies to orient projects to maximize social and
health benefits.
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after the Earth Summit. Geneva: WHO; 1997.
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Information_resources/htmdocs/execsum.htm
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for Decision-making (HEADLAMP) project, edited
by Briggs D, Corvalán C, Nurminen M. Geneva:
WHO; 1996. (WHO/EHG/95.26).
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A Report of the Health and Environment Analysis
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index.html.
ACCESS TO AND FINANCING OF H EALTH CARE: W AYS TO
M EASURE I NEQUITIES AND M ECHANISMS TO REDUCE THEM
Daniel López Acuña,1 César Gattini,1 Matilde Pinto,1
and Bernt Andersson1
The objectives of health reform in the Americas include improving equity in service delivery, improving efficiency in management,
and increasing the effectiveness of actions—
all of which are necessary to meet the health
needs of the population. Within this context,
equitable access to effective health services is
one of the guiding principles of Latin American and Caribbean health sector reform.
The First Summit of the Americas, held in
Miami, Florida, in 1994, established a plan of
action to guide national health sector reforms,
including a specific initiative (Initiative 17) for
achieving equitable access to basic health services. The central objective of the Latin American and Caribbean Health Sector Reform Initiative, which was launched in 1997, is to
provide regional support to the promotion of
equitable access to basic quality services in the
Region of the Americas.
As part of the initiative, PAHO has developed a methodology to monitor and evaluate
health sector reforms in Latin America and the
Caribbean. This methodology entails the
preparation of profiles on the countries’ health
systems and services as a way to establish the
current health status baseline, in order to measure the impact of reforms. Additionally,
PAHO is developing an instrument to moni-
INTRODUCTION
Health systems and services primarily aim
at contributing to the promotion and restoration of health status, as well as engaging in
disease prevention and palliation for the
whole population. However, health needs
vary from person to person, which implies that
there is a need for different types of interventions, both within and outside the health sector. Health care delivery then becomes an organized answer to various health needs
through differential health care interventions.
Conditions in the health services and the
population’s health needs are subject to multiple factors related to the socioeconomic context. Socioeconomic development is linked not
only to better health (lower health care needs),
but also to higher financing and availability
of health service resources, and to better access to health care.
The measurement and analysis of inequities
in access to and financing of health care, including determinant factors influencing supply and
demand of health care, are essential for monitoring the implementation of mechanisms
aimed at reducing those inequities.
1
Division of Health Systems and Services Development,
Pan American Health Organization.
115
116
Access to and Financing of Health Care
tor the effects of reforms on equity in access
and utilization of health services.
This chapter examines the assessment of
inequities in access to and financing of health
care and the ways to measure and analyze inequities; it also presents a proposal to reduce
inequities in both access to and financing of
health care.
ASSESSING EQUITY IN ACCESSTO AND
FINANCING OF HEALTH CARE
Assessing inequalities in access to and financing of health care involves the measurement and analysis of inequities, beginning
with a measurement of disparities, or inequalities. An analysis of inequities involves applying a value-laden judgement to variations beyond certain range that are considered unfair
or unjust, under normative criteria, and/or the
lack of correspondence between the patterns
of distributions in health care resources and
health care needs.
The concept of inequity involves the notions
of vertical and horizontal equity in health care.
This, in turn, involves acknowledging that
different health needs must be treated differently (vertical equity) and that people with
equal needs ought to be treated equally (horizontal equity), regardless of ability to pay or
any other socioeconomic characteristic.
The analysis of equity-related variations—
i.e., those disparities or inequalities that have a
connotation of inequity—must consider the
health system framework in which the variations occur. This supports the analysis of inequities within real settings. The choice of ways
to measure and analytical methods will depend
on the measurement purposes, information
availability, and the background of the real setting where variations are being analyzed.
Differential health situations, especially
avoidable morbidity and mortality, are determined by multiple factors, with health care
being just one of them. There are multiple
models supported by statistical associations
and causal relationships which give accounts
of the relative weight of the factors that affect
differential health status of the population;
these factors include socioeconomic context,
physical and geographical environment,
lifestyles and health behaviors, biological and
demographic conditions, and health care. Most
of these factors are also determinants for differential access and use of health care.
Multiple perspectives and measures are
then needed to address this issue comprehensively. We need to combine them all within a
coherent conceptual and methodological
framework. Such an approach to address the
problem of inequities in access and financing
should take into account that:
• From the supply side, several institutional
factors lead to the availability of health services to different target populations.
• From the demand side, several factors facilitate access to services according to need,
regardless of ability to pay.
• The utilization of health services represents
effective access to health care, assumed to
be the result of the interaction between supply and demand factors.
Barriers to health care—such as geographical, economic, cultural, and economic obstacles—need to be taken into account, but
there also are other factors that influence access to and utilization of health services. The
whole set of factors that influence the use of
services and the satisfaction of health care
needs within an iterative circle of need→demand→use, makes the analysis of equitable
cross-sectional distributions of health care
more complex.
Most of these factors are interrelated and
play a role in a process whereby health needs
are sometimes expressed as health demands,
some of which result in the utilization of personal and public health care, provided it is
available and accessible. Therefore, access to
health care cannot be assessed through a
single, distinct measurement of a discrete
event, as is the case for most health outcome
measures.
López Acuña, et al.
In the pursuit of equity, the challenge for
health systems is to attain a balance between
the health needs of the population and the
availability of organized resources supporting
the provision of services to satisfy those needs.
Equity in health care is, therefore, pursued
through three components:
1) a needs-based role for health services, which
seeks to deliver services according to need,
irrespective of sex, age, ability to pay, ethnicity, culture, or place of residence.
2) a constant pursuit of allocative efficiency,
which searches for the best possible combination and distribution of health care
benefits by setting priorities in the allocation of resources according to the epidemiological profile and cost-effectiveness of
the interventions (health value for money);
and
3) the search for productive (or technical) efficiency, to ensure that the available resources
can support the best possible provision of
care, adapted to the populations’ needs and
demands.
Social, economic, and health disparities between different areas and population groups
influence the delivery of health care. Underprivileged areas tend to have a higher burden
of disease, lower availability of resources,
lower financing and access, shortages of health
care personnel, lower prestige, and a limited
capacity to solve health events that require
more complex, technological levels of care; this
is described as the inverse health care law
(Hart, 1971).
Multiple factors related to socioeconomic
development and incentives to providers
(public or private) influence the supply of services. These factors include the financing of
the system, the level of investment in the sector, the training of qualified personnel for the
health services, and the allocation and efficient
use of existing resources.
Measurement and analysis of inequities in
access to and financing of health care is both a
problem- and policy-oriented issue, and it can
117
become a tool in the search for solutions to
inequities, such as removal of barriers to access, specific investment in health care, and
the search for improvement of efficiency and
effectiveness of health services.
MEASURING AND ANALYZING
INEQUITIES IN ACCESSTO AND
FINANCING OF HEALTH CARE
Important preconditions for the adequate
assessment and analysis include the clarification of the purpose of measurement and the
availability of appropriate information, including characteristics of the health system to
be analyzed.
The availability of information should ideally cover a wide range of data from both the
supply and demand sides, including the
population, health status, health services (including access, use, and financing of health
care) as well as the determinants for variations
of all these factors.
Two main sources of information are used
in measuring access to health care. The first is
household surveys and other surveys that
gather information on health needs and demands, patterns of utilization of services, and
problems faced by the individuals in accessing health services. The second source is the
use of routine statistics gathered within the
health system, including data from health information systems, such as morbidity and
mortality statistics.
The measurement of variations in access to
health care must take into account the issues
mentioned in the preceding paragraph and
must establish meaningful parameters for
comparison within a country and among
countries. This involves selecting variables
and categories of analysis such as geographic
areas, income quintiles, educational level, race,
ethnicity, type of insurance coverage, or institutional affiliation, provided that the information from either surveys or health care providers’ statistics can be broken down by those
categories.
118
Access to and Financing of Health Care
To obtain a comprehensive picture of health
care inequities that focus on access and financing, one must compare measurements of different dimensions of the process: availability
of resources, access to health care, and utilization. The analysis is greatly enriched when
variations in the distribution of these resources
are compared to differential patterns of health
care needs.
The coexistence of public and private services in most countries, involving different
health care networks that provide services to
different populations sharing a common geographical area, implies the need to integrate
information on those different providers and
target populations. It also implies the requirement of different information sources, integrated under common criteria and standards.
Availability of Health Care Resources
Availability of resources (at the geographical and institutional level) can be measured
using a variety of indicators that are generally produced by all countries. Indicators such
as those listed below must be stratified by
various population groups in order to make
distributional comparisons.
• Health expenditure and sources of financing:
• public health expenditure per capita,
• household contribution to sector financing, and
• financing in personal care and public
health.
• Availability of physical and human
resources:
• doctors or nurses per 10,000 inhabitants
and
• hospital beds per 10,000 inhabitants.
Administrative data is normally available
for geographical areas, but often only for public resources. Information is not so readily
available for the private sector. Geographical
areas can be homogeneous and give a good
picture of social or economic inequities, if the
area is populated by one ethnic group or by
people in the same income group. However,
an area often can encompass a mixture of
ethnicity and socioeconomic groups, or it has
no registered information. Data are often not
available for different income groups, ethnic
groups, or professions; one may have to rely
on special studies or surveys to obtain this
data. One strategy is to find ways to disaggregate routine data to smaller geographical
areas.
As an example of data supporting the comparison of resources per population, Figure 1
shows the availability of hospital beds in Latin
American and Caribbean countries.
Measuring Access to Health Care
Access to health care often is measured only
by geographic and economic barriers, including insurance coverage. Cultural and social
factors also present access barriers to care,
however. Measurement of the effect of cultural
and social factors in access involves a sociological approach to the pathways to health
care, which is not necessarily reflected in geographic and economic measures.
Geographic Access to Health Care
The assessment of geographic access is commonly approached by measuring the time
individuals must take to cover the distance between their households and the health services, at least primary health care facilities.
This indicator is subject to limitations of interpretation in relation to the concept of access. However, this indicator could become a
useful proxy for geographical access in countries or areas where limitations of health care
geographical coverage are important, due to
the existence of rural and dispersed populations or the lack of health care centers.
Beyond simple geographical distance to
health services, variations in access measured
by this indicator depend on such factors as
availability of proper transportation or roads
and the existence of natural obstacles (rivers
or mountains). This also means that geo-
López Acuña, et al.
119
FIGURE 1. Hospital beds per 1,000 inhabitants, in Latin American
and Caribbean countries, trends 1964 to 1996.
7.0
6.0
ARGENTINA
BOLIVIA
BRAZIL
CHILE
COLOMBIA
CUBA
ECUADOR
MEXICO
PERU
URUGUAY
VENEZUELA
5.0
4.0
3.0
2.0
1.0
0.0
1964
1967
1974
1978
1984
1991
1996
Source: 1964–1991: Health Conditions in the Americas, PAHO, 1998.
graphic access can change over time, as roads
or transportation conditions may improve.
Financial Factors Related
to Health Care Access
Degree of Social Protection in Health
One of the variables indicating inequities in
health care is the affiliation of various groups
with social insurance for health. Salaried workers and their dependent families who work in
the formal economic sector normally have the
obligation to make financial contributions in
order to be covered by public health insurance
(or some scheme of social security) or private
insurance. In Latin America, it is estimated that
about 55% of the population is covered by a
social insurance scheme for health care.
Low-income workers in the informal sector are for the most part not affiliated with any
public or private insurance. Their only protection for health comes from direct out-ofpocket payments for health care to private or
public facilities or from subsidized care in
public sector facilities provided through governmental policy. Health coverage for this segment of the population is generally less comprehensive than that available for people who
work in the formal sector.
Although the situation may vary somewhat
from country to country, generally those excluded from health insurance schemes are
found among the poor, the elderly, women and
children, indigenous groups, workers in the
informal sector, the unemployed, and the rural population. Therefore, it may be helpful to
analyze data according to categories that highlight these socioeconomic groups, and to examine differences between the population
covered and not covered by the different types
of schemes.
120
Access to and Financing of Health Care
Financial Burden Associated with Access to
Health Services
The financial burden includes the cost of
direct out-of-pocket payments, fees, and
drugs; from the household perspective, there
also is a cost for travel and lost income, which
adds to a total expense for health that is higher
than the flow of funds that go to the health
system. No routine data is normally available,
so in this case also, one must rely on studies
and surveys.
The significant household participation in
health sector financing is an aspect of financing inequities. Household expenditure includes contributions to any health insurance
as well as out-of-pocket expenditures. Information on National Health Accounts for eight
Latin American and Caribbean countries estimated that household participation in health
sector financing fell within a range from 31%
in Bolivia to 79% in the Dominican Republic
(Table 1). These results contrast with those in
more developed countries: in the United Kingdom, Spain, France, the Netherlands, Italy, and
Denmark, for example, household expenditures represent between 8.4% and 30.0% (Wagstaff and Doorslaer, 1999).
This financing pattern is inequitable, since
expenditures for health services represent a
greater proportion of the income for poor
families than for wealthier ones. By relating
patterns of private health expenditure to the
TABLE 1. Household participation in health
sector financing, selected countries in Latin
America and the Caribbean, 1999.
Country
Bolivia
Dominican Republic
Ecuador
El Salvador
Guatemala
Mexico
Nicaragua
Peru
Household participation in
health sector financing (%)
31
79
33
53
55
64
32
37
Source: LAC/HSR Initiative, PAHO/USAID. National Health Accounts: Eight country studies in Latin America and the Caribbean;
1999.
level of per capita income in countries of the
Region, an inverse relationship can be observed (with some exceptions) between the
percentage of private health expenditure and
total health expenditure as it relates to per
capita GDP.
UTILIZATION OF HEALTH CARE
The utilization of health services is influenced by health needs, gender, socioeconomic
status, ethnicity, and cultural factors. An additional challenge for the measurement of access is to take stock of the differential patterns
of utilization of various services, i.e., ambulatory care, hospital care, emergency medical
services, immunization, rehabilitation services, prenatal care, etc. Such an effort calls
for the development of a core set of indicators
of access to health care that is clustered by
types of services and sensitive enough to allow for monitoring and evaluation of trends
and changes in this area.
Some of the indicators that can be used to
measure the utilization of health services are:
• outpatient visits per capita of target population,
• utilization of hospital beds per 100 of target
population,
• coverage of prenatal care,
• coverage of professional childbirth delivery,
and
• coverage of immunizations.
Table 2 shows the number of medical consultations per inhabitant in Peru’s departments, grouped according to poverty index.
The availability of data is the major shortcoming for measuring inequities in access to
health care at different levels within a country. To measure access, utilization indicators
such as the number of outpatient medical visits per person or hospital admissions per person are commonly used. Data on utilization
assume that data collected by health centers
refers mainly to the target population within
López Acuña, et al.
121
TABLE 2. Selected indicators of health and health care in departments
grouped in quintiles ranked by poverty, Peru, 1997.
Indicator
Q1
Q2
Q3
Q4
Q5
Population data
Population (millions)
Poverty (%)
Life expectancy (years)
3.9
65.9
62.8
3.7
57.8
65.8
3.7
52.4
66.4
4.8
40.8
70.4
8.3
28.5
76.6
Utilization indicators
Doctors/1,000 population
Hospital beds/1,000 population
Medical consultations/inhabitant
Hospital admissions/1,000 population
3.3
1.1
0.6
17.0
5.0
1.5
0.8
26.6
6.2
1.3
1.0
32.9
8.9
1.9
1.3
48.7
18.6
2.4
1.9
63.4
Source: Elaborated from MINSAL Perú - OPS (1998). Situación de salud de Perú. Indicadores básicos
1997.
a defined catchment area (which has to be
verified). However, this assumption is limited
by the cross-boundary flow of patients.
These indicators are based on routine data;
however, national information systems on utilization of services seldom include socioeconomic data or data on race, ethnicity, culture,
or religion of users (patients visiting hospitals
or health centers), and do not include data of
potential users within the target population
who do not have access.
Survey data can then be used to characterize a given area according to categories of variables such as the population’s socioeconomic
status, race, ethnicity, culture, or religion, as
well as by coverage by social insurance for
health. Data from surveys is complementary
to routine data; both could be used jointly
when exploring the characteristics of those
using and not using health services within a
catchment area, or comparing usage between
different areas.
PAHO’s Division of Health Systems and
Services Development (HSP) is currently
working on an instrument for monitoring equitable access to basic health services that
takes into account the issues raised in this
paper. It will be field-tested and made available to Member Countries as soon as it is revised. The instrument includes indicators of
health outcomes, utilization of services, and
availability and accessibility to resources, as
well as structural indicators.
Countries in Latin America and the Caribbean have different levels of socioeconomic
development, ill-health status, and availability and use of health care, as well as different
patterns of geographical variations in these
variables. However, it is possible to find similar patterns across countries, as described in
the inverse care law.
This can be illustrated with some selected
data from indicators of socioeconomic circumstances, health, and health care, based on data
already available for geographical areas
within those countries.
Figure 2, based on data from Peru’s 25 departments, ranked by poverty, demonstrates
the relationship between the population’s socioeconomic development (represented here
by the reduction of poverty in geographic areas) and infant mortality rate (a proxy for
health needs), as well as access to and use of
services (represented by the ratio of medical
consultations and hospital admissions per
population). Improvements in health and
health care occur in areas with greater socioeconomic development, while more deprived
areas have the lowest levels of health and
health care.
The distributional pattern tends to be systematic, supporting the inverse care law. One
risks bias in these comparisons if causality is
assumed, but research on causality is hindered
by the circularity of health care needs, demand, and use. The context of multiple and
122
Access to and Financing of Health Care
FIGURE 2. Differential pattern of health (infant mortality rate) and
access/ use of services (medical consultations and hospital admissions)
in departments ranked by poverty, Peru, 1997.
Times national average of indicator
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Departments ranked by poverty
Infant MR
Med. Consultations
Hosp. Admissions
Source: MINSAL-OPS Perú. Indicadores básicos situación de salud 1997.
FIGURE 3. Public and private hospital admissions
per 100 population, by residence, in groups of
communes ranked by potential years of life lost
(0 to 64 years),a Chile, 1992.
30
Admissions per 100 population
interrelated macro determinants of health
makes it difficult to search for attributable
impact of health services. There are only a limited number of studies and most of these are
cross-sectional, which makes it difficult to infer causal explanations. From the knowledge
in the current literature, one can make educated guesses to analyze variations in health
care and those factors which are assumed to
be determinant on access to and financing of
health care services.
The analytical description of differential use
of services according to differential needs for
health care may be illustrated in data such as
those used in Figure 3—this figure shows differences in the ratio of public and private hospital admissions per 100 population in groups
of communes in Chile in 1992. These groups
are ranked by potential years of life lost (PYLL)
from 0 to 64 years of age, taken as a proxy for
health care needs. Quintile 1 is the group of
25
20
15
10
5
0
Q1
Q2
Q3
Q4
Q5
Quintiles of communes ranked by PYLL (Q1 the highest)
Source: Gattini, C., 1996.
Ratio PYLL 0–64 years per 1,000 population, used as proxy for
health care needs.
a
López Acuña, et al.
communes with the highest PYLL and admissions have been measured by commune of
residence.
In this example, the group of communes with
the lowest health care needs (Q5) has the highest ratio of hospital admissions per 100 population, mainly by getting access to private hospitals and specialties in public hospitals. The
other quintiles (Q1 to Q4) have similar ratios
of hospital admissions. Admissions to general
medicine increase clearly towards quintiles
with higher PYLL, compensating for the progressive reduction of admissions to public hospital specialties and private hospitals.
A similar pattern could be seen when communes are ranked by socioeconomic development, due to the relationship between socioeconomic factors and differential health care
needs (if represented by PYLL). These data
reinforce the importance of locating general
hospitals in poorer and rural areas, as well as
locating general medicine services within
more complex hospitals, where needs are
higher.
REDUCING INEQUITIES IN ACCESSTO
AND FINANCING OF HEALTH CARE
The identification of mechanisms to reduce
these inequities calls for a systemic examination to address the underlying causes of avoidable limitations to access in certain population
groups. Some of these problems can be effectively solved within the boundaries of the
health care system, while others will require
the participation of other institutions in the social sector at the government level, particularly
regarding the role of public sector financing.
Inequities in access and financing are due
to factors that may reinforce each other’s impact. In general terms, health care financing
options are not neutral regarding equity. Progressive financing is the most equitable
method of financing health services. It can be
achieved through direct public funding (with
revenue from taxes), through social health insurance schemes that cover the entire popu-
123
lation, or through a combination of these two.
Direct user fees constitute the most regressive
and inequitable method of health care financing (Dahlgren, 2000). Experience indicates that
high user fees pose significant economic barriers to access to health services.
A country’s health care financing strategy
should be designed by selecting the combination of mechanisms that simultaneously promote financial sustainability and provide equity. Studies of patterns of health care services
utilization indicate that among those with
perceived illness, “financial problems” are an
important reason for not seeking care when
needed. These financial problems are in part
explained by financing strategies that require
patients to make financial contributions, as
well as by the lack of adequate insurance available to the population. The areas of health system organization and health care financing
strategies can provide mechanisms to reduce
disparities that are inequitable.
A systemic strategy to increase access to
services should simultaneously implement
mechanisms to increase the availability of providers (with an emphasis on the areas which
present shortages of provision) and increase
expressed demand to satisfy health needs. Increasing demand should be accomplished by
lowering financial barriers, expanding social
protection, and improving users’ accurate perception of illness.
Proposals for the expansion of social protection in health must address factors both
external and internal to the health sector. External factors exist largely outside the health
system, and include the society’s overall socioeconomic status, level and distribution of
poverty, state inefficiency in both collecting
and distributing resources, and model of development. Internal factors are closely linked
to the health system. Obviously, the health sector is not powerless in responding to external
factors, nor can it necessarily modify internal
factors at will. A primary challenge is to determine at which level of dialogue issues
should be addressed when cooperating with
external actors.
124
Access to and Financing of Health Care
Among internal factors, there are structural
barriers that are due to the system’s degree of
fragmentation. Usually, health care is provided by the following four subsectors within
the health system.
a. The public sector, usually provided by the
central government, is based on overall
taxation and is free to all users.
b. Social security, usually provided by specialized institutions, is based on payments by
formal-sector workers and employers (although sometimes voluntary membership
is possible); it is free but restricted to members (and occasionally their families).
c. The private sector, usually based on a payper-service system or funded by insurance
schemes where a periodic fee or premium
is collected, offers services restricted to paying patrons.
d. The voluntary sector, usually provided by
nongovernmental organizations (NGOs) or
community services (including either insurance or services, or both), is mainly oriented
to the poorer population. This sector compensates for the exclusion or lack of coverage by the more “conventional” sectors
mentioned above. For this reason, this sector is also known as alternative or complementary to the conventional sectors.
REDUCING BARRIERS
TO EFFECTIVE ACCESS
Structural Barriers
There are three levels of intervention to reduce structural barriers:
1. Improving access within the mandate of
each subsector (an internal question).
2. Strengthening the sector’s leadership to effectively reach agreement among the first
three subsectors (the conventional subsectors) to unite or at least cooperate to
avoid duplicating actions and coverage.
3. The growth of the voluntary subsector can
be understood because it is not clear how far
the conventional subsectors can respond and
provide access to the entire population in an
effective and efficient manner while respecting cultural values. The question, then, is not
how to avoid the voluntary subsector (where
it is justified), but rather how to ensure that
it provides a reasonable level of health to
the population it affects. Furthermore, this
subsector is unlikely to be able to afford all
levels of attention. Thus, the extension of
social protection in health will have to include the articulation of the conventional and
voluntary sectors for services that are beyond
those the latter can reasonably provide (i.e.
spinal cord surgery). By the same token, the
insurance component of the voluntary sector will need to be linked to the national (public and/or private) insurance system for the
purposes of reinsurance and coverage of
catastrophic situations that might ruin the
voluntary system.
Financial Barriers and Financing
Inequities
A review of the health care financing components in a given country, along with an
analysis of information on utilization patterns
by specific groups (the poor, the elderly, the
unemployed, indigenous peoples, etc.), will
provide an initial assessment of inequities in
health financing as well as financial barriers
to access to care. The concept of inequity in
financing is related to what proportion of
household income each income group must
devote to health care. Mechanisms should be
implemented to reduce the share of financing
among low-income households, whether
through health insurance premiums (private
or public), payment of fees to formal providers (in the public or private sector), payment
to informal providers, or self-medication.
In the course of identifying mechanisms to
reduce inequities in health financing, the role
of public financing in the redistribution of resources will have to be given significant attention. Public financing can be targeted to
reduce low-income families’ financial contri-
López Acuña, et al.
butions when those contributions reduce access or increase inequities.
To attain the goal of guaranteeing access
regardless of a family’s ability to pay, a combination of traditional mechanisms and
complementary financing mechanisms should
be employed. Traditional mechanisms include
(a) public financing (through taxes), (b) user
fees, (c) private health insurance, and (d) national health insurance. Complementary
mechanisms are those aimed at compensating
vulnerable groups for the effects of financial
barriers, which lower their demand for health
care.
Among traditional financing mechanisms,
user fees have proven to reduce access to
health care, while access to private (for-profit)
health insurance has no potential to reduce
inequity, since ability to enroll is determined
by ability to pay. Complementary mechanisms are subsidies to the provision of care
to vulnerable groups for reasons such as poverty, medical condition, or age. They can be
implemented by publicly financing a social
insurance scheme targeted to a specific beneficiary population. By definition, subsidies
are to be paid using public resources, which
requires that providers who normally charge
for their services be financially compensated
for providing services to the beneficiary
populations. This is a crucial point in the
analysis of providers’ behavior, and it directly
affects the possibility of increasing availability of services.
REDUCING CULTURAL AND
ETHNIC BARRIERS
Studies of utilization patterns for health services often face difficulties regarding differing perceptions of illness and attention to preventive care among different population
groups. Studies of health needs show that lowincome groups express demand below their
relative need. Thus, some mechanism is
needed to narrow the gap between need and
actual demand.
125
This issue is closely related to the organization of health systems, insofar as systems
should be responsive to users’ knowledge and
perception of health problems. In some countries, responsiveness will include an ability to
deal with language barriers. The creation of a
population of educated consumers requires a
core strategy of health education.
INCREASING AVAILABILITY
OF HEALTH CARE SERVICES
Availability of services is closely related to
availability of financial resources. A set of incentives that promote health care provision to
population groups who have lower access will
encourage providers to increase supply to areas or population groups with reduced access.
Provider payment mechanisms can be successfully used to influence the availability and
makeup of services to be offered. These
mechanisms may include differential payment
to foster provision in specific geographical
areas as well as among priority populations.
Better utilization of available and limited
resources can effectively increase the availability of health care. A more productive combination of inputs involved in the health care
delivery process can help achieve technical
efficiency, so that more services can be offered
using the same amount of resources. By the
same token, improvements in health service
management can translate into successful increases in health care availability.
Another strategy would involve revising
the health care model to make it more responsive to the epidemiological profile of the population to be served, as well as following criteria of cost-effectiveness in defining the
package of care to be provided.
Because there are many factors that can
cause inequities in access to care, multiple dimensions of the problem must be considered
in attempting to reduce gaps in access to care.
It also is important to identify the institutional
factors that hinder or support equitable access
policies in real settings. All this requires an
126
Access to and Financing of Health Care
integrated information system that covers
multiple dimensions, uses several sources, and
is supported by functional networks.
Both efficiency and equity can be fostered
through a system of health care delivery
(whether public, private, or mixed) that is organized in a multilevel basis. As long as referral from one level to another is based on need,
such a system can provide appropriate access,
not only to primary health care, but also to
more complex levels of care.
CONCLUSION
In order to ensure access to health care according to need—and irrespective of age, sex,
ability to pay, ethnicity, or cultural aspects—
this discussion proposed a comprehensive
framework for equity in access to and financing of health care. The first component addresses methods to measure and analyze
avoidable disparities, which is followed by a
proposal of policies and mechanisms to reduce
inequities in access to and financing of health
care. In order to document inequities, the
chapter emphasizes the need to use a set of
complementary mechanisms, multiple indicators, and information sources on socioeconomic circumstances, health needs, allocation
of resources, and the use of health care.
However, in addition to documenting inequities, it is important to implement and evaluate mechanisms aimed at reducing disparities
in access to health services and financing of
health care.
Although there are some good indicators
of equity, health sector information systems
rarely register information about ethnicity,
income, occupancy, or any other socioeconomic characteristics on a routine basis.
Data unavailability is the major shortcoming for measuring inequities in access to
health care.
There are basically two sources of information: 1) vital statistics and data from health
sector activity registries and 2) population
surveys on access to services. From a techni-
cal standpoint, it would be ideal to combine
vital statistics and health registry data with
the data obtained through access surveys.
The most widely used way to measure equitable access involves administering surveys
to a representative sample of the population.
However, the process is expensive, involves
the participation of large numbers of personnel, and requires very complex statistical
analysis. Although some of these difficulties
may diminish somewhat as surveys are repeated, significant financial resources will always need to be outlaid for their execution.
On the other hand, routine statistics already
provide information from different sources,
but data usually do not address differential
access between subgroups in the population.
A strategy for overcoming this limitation involves collecting data that is as disaggregated
as possible for small area levels.
Several mechanisms are proposed to improve equity in health care. These mechanisms
pursue a dual purpose: creating a needs-based
delivery of services irrespective of ability to
pay, and constantly pursuing efficiency in the
allocation of resources (value for money).
Taking into account the need to reduce barriers to effective access and improve availability of health services, some of the measures
that can be implemented for ensuring and
improving equitable access to health services
are the following:
• increasing the availability of services, particularly to underserved areas;
• relying on public funds to finance the utilization of services by the most vulnerable
groups (defined by socioeconomic or epidemiological criteria);
• reducing cultural and/or ethnic barriers to
health care access and providing care in an
intercultural context;
• diminishing the segmentation of health services networks (public and private) so they
can cover different groups of the population;
• improving the integration of the health care
delivery networks, in order to facilitate access irrespective of insurance coverage;
López Acuña, et al.
• expanding social protection in health by
incorporating segments of the population
currently excluded from social health insurance; and
• reducing the financial burden for accessing
services, with an emphasis on the poor.
Monitoring equitable access to basic health
services is crucial, as is documenting the impact of different policies and strategies in
terms of effective reduction of disparities in
access to health care. All of this should be part
and parcel of PAHO’s priority lines of action
in the area of health systems and services.
REFERENCES
Dahlgren G. Efficient equity-oriented strategies for health.
Bulletin of the World Health Organization 2000;78 (1).
Gattini C. Needs and equity in health care. The case of
the National System of Health Services in Chile.
HSRU, LSHTM, U. of London; 1996. (Draft report).
Hart J. T. (1971) ‘The inverse care law.’ Lancet 1: (696) 405–
412.
127
Perú, Ministerio de Salud, Organización Panamericana
de la Salud. Situación de salud en el Perú. Indicadores
básicos 1997. MINSAL/OPS; 1998.
Pan American Health Organization. Health in the Americas, 1998 edition. Washington, DC: PAHO; 1998.
Pan American Health Organization, Division of Health
and Human Development, Public Policy and Health
Program. Health Expenditure Database. Washington,
DC: PAHO; 1998. (Latest revision, September 1998).
Pan American Health Organization, Division of Health
Systems and Services Development. Clearinghouse
on Health Sector Reform in Latin America and the
Caribbean. Washington, DC: PAHO; 1999.
Pan American Health Organization. Managing and Financing Health to Reduce the Impact of Poverty in
the Caribbean: Implementing Decentralization and
Financing Strategies while Protecting the Poor. Washington, DC: PAHO; 1999.
Wagstaff A, Van Doorslaer E. (1993) Equity in the finance
and delivery of health care: Concepts and definitions.
In Van Doorslaer E, Wagstaff A, Franz R. (eds.) Equity in the finance and delivery of health care. An international perspective. Commission of the European Communities HSR Series No. 8. Oxford: Oxford University
Press; 1993.
Wagstaff A, Van Doorslaer E. Equity in the finance of
health care: some international comparisons. Journal
of Health Economics 1999; May.
EQUITY AND H EALTH : A CARIBBEAN PERSPECTIVE
Richard A. Van West-Charles1
Any discussion of equity and health must
take place within a context that focuses on creating an environment that enables human beings to enjoy long, healthy, and creative lives.
Hence, the discussion of equity and health
must revolve around human development,
which denotes the process of widening people’s choices and improving their level of wellbeing and capacity for self-empowerment. In
its conceptual framework, UNDP has identified the following life conditions as critical to
well-being:
•
•
•
•
•
•
When discussing the topic of equity and
health, many are immediately drawn to focus
on poverty. In many instances, however, this
focus is motivated by benevolence rather than
development, and presents limitations in
terms of social benefit. It permits solutions to
be passive and more conscience-relieving than
dynamic and demonstrative that the existence
of poverty is a deterrent to the creation of global well-being and development. Poverty concentrates on deprivation of three essential elements: longevity; knowledge; and a decent
standard of living.
a long and healthy life,
education,
a decent standard of living,
political freedom,
guaranteed human rights, and
self-respect.
• Deprivation of longevity relates to survival
and vulnerability to death at an early age,
specifically, life expectancy under 40 years.
• Deprivation of knowledge relates to being
excluded from the world of reading and
communication.
• Deprivation of a decent standard of living
comprises three variables: percentage of
people with access to health services, of
people with access to safe water, and of malnourished children under the age of 5 years.
When one considers these life conditions,
they all seem so subjective that their interpretation varies from individual to individual,
population to population, and community to
community, based on one’s culture, belief system, resources, etc. Notwithstanding this difficulty, one can make a quick identification of
populations that exist in poverty. These populations are unable to contribute to their own
individual growth and to the growth and development of their respective communities.
1
These deprivations define vulnerable
populations who require specific investments
so they can have the opportunity to survive
and participate in the development process.
Hence, in terms of our discussion for action
on health and equity, these vulnerable populations must be identified, not because of a
PAHO/WHO Representative, Bahamas.
131
132
Equity and Health: A Caribbean Perspective
moral imperative but rather for a development imperative.
Having addressed the need to protect these
vulnerable populations, let us turn our attention to the rest of the population in terms of
equity and health in the developmental context. The barriers to an individual’s or a
population’s quest for well-being are related
to the determinants of health, including economic status, communication resources, the
environment, the health/medical system,
knowledge/access to information, and gender.
In each of these areas, barriers to the attainment of well-being can be defined, identified,
and studied epidemiologically. For example,
Epi-data, which points to an increasing incidence and prevalence of asthma, can point to
factors that require intervention and investment at different levels.
CURATIVE
As the balance of health determinants shifts,
disease processes are manifested in relation to
people’s exposure to physical, chemical, or
biological agents. Hence, the health system’s
curative component is central to the re-establishment of well-being, and the organization
of the health system becomes a pivotal consideration. But the medical model construct
cannot be considered sufficient. This paradigm
of the health system, of which the curative
component is a part, must reflect an active
understanding of the role of the determinants
in the manifestation of disease and attainment
of well-being.
HEALTH FACILITIES/ TECHNOLOGY
The relevance of health facilities and technology to health equity must be considered
within the context of the global, national, and
regional environments, and within these environments, in terms of the private and public sectors as well as the nongovernmental and
community-based organizations.
Participatory planning with the involvement of all sectors can lead to equitable development and can support environments that
promote health and well-being, resulting in
priority programs reflective of epidemiological analyses and research.
TECHNOLOGY
An important aspect of the health care delivery system in relation to health equity is the
availability of technology. The use of technology must be assessed based on its contribution to the well-being of the entire population.
Because the availability of technology is dependent on very limited resources, its equitable contribution to health depends on analyzing who is in greater need. Access issues
are relevant not only to the use of public resources to achieve health and well-being, but
also to the use of private sector resources, a
sector that is not always held to the same equity standard as the public sector. There
should be no difference in terms of the basic
permissible standards for the public sector,
private sector, and nongovernmental organizations. For example, the availability of mammography for women, be it in the public or
private sector, must meet standards for the
equitable application of the technology.
Public resources must be used first to benefit
the vulnerable groups of a society—not in a
manner which will deter the generation of
greater wealth, but with the intent of contributing to empowerment in a way that balances
with other components of the society. This obviously cannot be done solely by the sector that
is responsible for the contribution of health to
development, but rather must be accomplished
in dynamic partnership with other sectors.
The indices that will assist in the development of a formula for the maximization of resources and its greatest empowerment are:
• public expenditure ratio—percentage of
national income that goes into public
expenditure;
Van West-Charles
• social allocation ratio—percentage of public
expenditure earmarked for social services;
• the social priority ratio—percentage of social expenditure devoted to human priority concerns;
• the human expenditure ratio—percentage
of national income devoted to human priority concerns.
Clearly, depending on the philosophical forces
in a society, the analysis of these ratios can be
performed in different ways, such as focusing
on the public and/or private sectors, thereby permitting different responses, all of which may be
considered equitable. But the use of these ratios
in any analytical approach would require further analysis as to whether the socially allocated
resources are inappropriately aimed at curative
health and therefore neglect to invest in broader
determinants of well-being.
FINANCING
Discussions of financing structures for attaining health and well-being must include an
understanding of global, regional, and national financing frameworks and the values
that inform them.
Two components comprise the financing of
well-being and health. The first is based on consumer choices and expenditures on activities
related to determinants, e.g. binge dieting versus nutritious choices or water rates versus
fashion. This component depends on a high
level of literacy which, when combined with
information, creates greater opportunity for
consumers to choose healthy behaviors. The
second component is related to how the curative component of the system is financed. If we
recognize that resources are required to support a system that involves technology, and if
quality assurance is to be maintained equitably, then technology must be accessed by all of
society, and the system must have guidelines
to ensure that standards do not vary according
to individuals’ ability to pay, e.g. access to mammography for early detection of breast cancer.
133
ACCESS
Access is not determined solely by physical access, but rather can be considered to have
three components:
(a) physical access—a facility is provided where
services are offered.
(b) clinical access—the provider is available
and delivers a high standard of service in
accordance with established norms. Clinical access also depends on the setting. For
example, the operational norms and standards for an ICU vary with the mechanisms for financing in the private and public sector, or, outsourcing of staff in critical
units can undermine or compromise continuity of care that is urgently needed. This
does not mean that outsourcing is irrelevant, but rather that within the reform
agenda, guidelines need to be developed
to ensure that the financing agenda is in
sync with the developmental objectives of
equity and health.
(c) therapeutic access—many patients, especially the elderly, are unable to purchase
the pharmaceutical agents prescribed, and
as a result, the full attainment of the health
equity objective is inhibited.
In many circumstances for a significant percentage of the population (a) and (b) become
operative and (c) is very difficult to meet
whether in part or whole.
EFFICIENCY/EFFECTIVENESS
AND EQUITY
Many who have addressed the topic of efficiency and effectiveness seem to conclude that
it is difficult for efficiency/effectiveness and equity to complement each other. But achieving
equity is dependent on the effective use of resources and technical efficiency, and any equity
proposal should explain how the resources are
to be distributed, and how effective and efficient that distribution has been in the past or
134
Equity and Health: A Caribbean Perspective
can be. In the context of development, the equitable use of resources must meet certain criteria, one of which is sustainability. The search
for equity, then, must be approached through
multiple steps for any given issue that affects
human health. For example, immunization contributes to both individual and societal development. Likewise, when dealing with vulnerable populations, resources must target basic
determinants that affect individuals’ health and
that of the population at large. Hence, resource
allocations should consider that society cannot
develop if large sections live in poverty or vulnerable conditions. Also, resources must be invested within a structure that maintains human
capital. In the end, the resources must be well
targeted if efficiency and effectiveness are to
contribute to equitable development.
ANÁLISE DE EQÜIDADE – SAÚDE: BRASIL
Jacobo Finkelman1
Esse marco constitucional gerou as chamadas Leis Orgânicas da Saúde (8.080/90 e
8.142/90), o Decreto 99.438/90 e as Normas
Operacionais Básicas — NOBs, editadas em
1991, 1993 e 1996. A Lei 8.080/90 regulamenta o SUS, que é responsável, ainda que sem
exclusividade, pela concretização dos princípios constitucionais do direito à saúde. O
SUS agrega todos os serviços públicos (de
níveis federal, estadual e municipal) e os serviços privados, quando credenciados por
contrato ou convênio. As NOBs, por sua vez,
a partir da avaliação dos estágios de implementação do SUS, voltam-se mais direta e
imediatamente para a definição das estratégias aplicáveis em cada momento de construção do Sistema e dos respectivos processos para a sua operacionalização.
As mudanças institucionais propostas sinalizam para a implementação de medidas estruturais, compreendendo:3 a) um processo de
mudança cultural e de afirmação da cidadania,
em que a saúde é valor permanente e qualificador da vida; b) a consolidação de um sistema público nacional, em que as três esferas
de governo atuem de modo complementar e
harmônico, dispondo dos instrumentos de po-
MARCOS REFERENCIAIS
A reforma sanitária brasileira tem como marco de debate a 8ª Conferência Nacional de
Saúde realizada em 1986,2 propondo ampla
reestruturação financeira, organizacional e
institucional do setor público de saúde, com
três objetivos principais: a) transferir a responsabilidade da prestação da assistência à saúde
do governo da União para os governos locais;
b) consolidar o financiamento e a provisão de
serviços públicos de saúde, orientando-os para
a eqüidade, a universalidade e a integralidade
da atenção; e c) facilitar a participação efetiva
da comunidade no planejamento e controle do
sistema de saúde.
A Constituição Federal de 1988 dedicou à
saúde uma seção no capítulo da Seguridade
Social. O texto constitucional configura a saúde como um direito de todos e um dever do
Estado, sob a garantia de políticas econômicas
e sociais dirigidas tanto para a redução dos riscos de doenças e outros agravos à saúde, quanto para o acesso universal e igualitário às ações
e serviços de promoção, proteção e recuperação da saúde, num sistema único de saúde — SUS,
de caráter público, federativo, descentralizado,
gratuito, participativo e de atenção integral.
3
Brasil, Ministério da Saúde. Informe sobre a reforma do
setor saúde no Brasil. Documento elaborado para a reunião
especial sobre a reforma setorial do setor saúde, promovida pela OPAS, BID e Banco Mundial. Brasília, setembro de 1995.
Representante da OPAS no Brasil.
2
Brasil, Ministério da Saúde. Anais da 8ª Conferência
Nacional de Saúde, 17–21 de março 1986. Brasília: Centro de
Documentação do Ministério da Saúde; 1987.
1
135
136
Análise de Eqüidade – Saúde: Brasil
der necessários; c) a organização e regulamentação de um sistema assistencial privado, com
objetivos específicos solidários aos preceitos de
assistência universal, integral e eqüitativa; d) o
funcionamento competitivo dos subsistemas
público e privado, estimulador da qualificação
com redução de gastos; e) a adoção de modelos técnico-operacionais inovadores, que visem
a atenção integral, individual e coletiva; f) a
implantação de um sistema de acompanhamento, controle e avaliação; g) a introdução de
práticas de gestão descentralizada e desconcentradora, que evitem processos cumulativos
ineficazes e injustos.
O sistema brasileiro de serviços de saúde
está formado por uma rede complexa de provedores e financiadores, que abarca os segmentos público e privado. O segmento público engloba os provedores públicos dos três
níveis de governo, que no nível federal são o
Ministério da Saúde (gestor nacional do SUS),
os hospitais universitários do Ministério da
Educação e os serviços próprios das Forças
Armadas. Os níveis estadual e municipal compreendem a rede de estabelecimentos próprios
das respectivas instâncias. Esse sistema cobre
cerca de 75% da população. Os planos e seguros privados de assistência à saúde estão agrupados em quatro grandes categorias: (a) medicina de grupo, representando 47% do mercado
de serviços privados; (b) cooperativas médicas,
com 25% do mercado; (c) planos de saúde de
empresas, com 20% do mercado; e (d) segurosaúde, com 8% do mercado. A cobertura dos
planos e seguros privados atinge 20% da população brasileira.
Os marcos referenciais apresentados pressupõem clara intencionalidade política e
institucional, no sentido de dotar o país de
condições para promover a eqüidade possível no campo da saúde. No entanto, a intencionalidade doutrinária tem encontrado
dificuldades de contextualização no quadro
de limitações econômico-fiscais existentes,
gerando certo grau de frustração de expectativas, apesar de significativos avanços
quantitativos alcançados na cobertura dos
serviços.
ABORDAGENS SOBRE A EQÜIDADE
Uma forte característica da sociedade brasileira é a presença de altos níveis de desigualdade socioeconômica. Um recente estudo produzido pelo BID concentrou-se essencialmente
no papel da educação como gerador de desequilíbrios de renda. Não deve ser esquecido,
porém, que uma das faces mais cruéis dessa
disparidade encontra-se precisamente na área
da saúde, embora os estudos realizados na área
não tenham dado a devida importância a essa
questão.4
As medidas de desequilíbrio da eqüidade
em saúde podem compreender diferentes categorias de análise, entre elas: a) a percepção
do estado de saúde; b) a demanda por serviços; c) os gastos com saúde; d) os perfis de
saúde; e) a prestação de serviços; f) o financiamento da saúde. Essas categorias devem ser
analisadas comparativamente segundo condições sociais, econômicas e geográficas.
Há premente necessidade de esforços para
desenvolver metodologias de análise e
monitoramento das questões de eqüidade
na área da saúde, de forma a construir indicadores específicos e estudar suas correlações com a disponibilidade de renda das pessoas, em diferentes situações geográficas e
socioeconômicas.
O tópico seguinte apresenta uma apreciação linear dos indicadores disponíveis, entre
os de maior impacto, comparando-se áreas
geográficas que reconhecidamente se situam
em escalas diferentes de desenvolvimento
socioeconômico.
ANÁLISE DE INDICADORES
SELECIONADOS
Condições de vida
Análises baseadas na aplicação do Índice de
Desenvolvimento Humano — IDH, utilizado
4
Campino ACC et al. Equity in Health in LAC – Brazil.
1998. (Documento fotocopiado).
Finkelman
pelo Programa das Nações Unidas para o Desenvolvimento — PNUD, situam o Brasil entre os países de médio desenvolvimento humano em 19975 (índice de 0,739), ocupando o
79º lugar no ranking mundial.
• A comparação do IDH entre as grandes regiões e os estados pode ser analisada em
estudo divulgado em 1998 pelo PNUDIPEA, com base em dados de 1991, que
mostra disparidades significativas (IDHM).6 O Brasil e todas suas regiões apresentam-se no estrato de médio desenvolvimento, com expressivas variações regionais,
desde o Nordeste (0,517) até a Região Sul
(0,777). Em relação às unidades da federação, apenas o Distrito Federal situou-se no
estrato superior de desenvolvimento humano (0,806), seguido dos estados de São Paulo, Rio Grande do Sul, Santa Catarina e Rio
de Janeiro, com índices superiores a 0,780.
Quatro estados apresentam valores abaixo
de 0,500, situando-se, portanto, no estrato
inferior de desenvolvimento humano:
Maranhão, Piauí, Alagoas e Paraíba. Próximos ao limite inferior do estrato intermediário, situam-se os estados do Rio Grande
do Norte, Sergipe, Bahia e Ceará, com índices inferiores a 0,540. Ressalte-se que todos
os oito estados com os menores índices estão localizados na Região Nordeste.
• A renda média dos 10% mais ricos é cerca
de 30 vezes superior à dos 40% mais pobres,
enquanto que em países com grau de desenvolvimento comparável ao do Brasil é
apenas 10 vezes maior.7 Os 50% mais pobres tiveram, entre 1960–1990, sua participação na renda nacional reduzida de 18%
para 12%, enquanto a renda dos 20% mais
5
Programa das Nações Unidas para o Desenvolvimento
(PNUD). Relatório do Desenvolvimento Humano 1999.
Lisboa: Trinova Editora; 1999.
6
IPEA, PNUD, IBGE, FJP-MG. Atlas do desenvolvimento humano no Brasil. CD-ROM, 1998.
7
Programa das Nações Unidas para o Desenvolvimento
(PNUD), Instituto de Pesquisa Econômica Aplicada
(IPEA). Disparidades sócio-econômicas. Em: Relatório sobre o desenvolvimento humano no Brasil. Brasília: 1996.
•
•
•
•
•
•
137
ricos elevou-se, no mesmo período, de 54%
para 65%.
Em 1997, a razão de renda entre os 20% de
renda superior e os 20% de renda inferior
nas areas urbanas do país foi de 18,9 na
média nacional, variando de 26,4 no Maranhão a 9,7 em Roraima.8
O perfil da concentração de renda no país
pode ser apreciado na análise do coeficiente de GINI para 1997. Para o Brasil o coeficiente se situa em 0,588, variando de 0,556
no Sul a 0,606 no Centro-Oeste.9
Em 1990, o salário médio das mulheres
correspondia a 63% do recebido pelos homens. As disparidades étnicas evidenciamse nos menores rendimentos percebidos por
pretos e pardos, contingente que representa 45% da população do país e cujo salário
médio correspondeu, em 1990, a 68% dos
recebidos pelos brancos.7
Na média brasileira, os pobres (indivíduos
com renda familiar per capita de até meio
salário mínimo) constituíam, em 1997,
28,4% da população, 45,1% dos quais residentes na região Nordeste. Nas médias regionais, o Nordeste apresentava-se com
52,2% de pobres na composição de sua população total, seguindo-se o Norte, com
34,5%; o Centro-Oeste, com 22,6%; o Sudeste, com 16,0%; e o Sul, com 19,1%. Entre os
estados, a proporção de pobres variou de
9,9% em São Paulo a 64,2% no Maranhão.10
Em 1995, 10% das crianças de 7 a 14 anos
não freqüentavam a escola, proporção que
atingia 15% na região Nordeste. 11
A taxa de alfabetização da população com
15 ou mais anos de idade era de 85,3% em
1997, com equivalente distribuição por se-
8
Fundação IBGE. Razão de renda. Em: Rede Interagencial
de Informações para a Saúde (RIPSA). Indicadores e dados
básicos Brasil, 1998. Brasília: IBGE; 1999.
9
Fundação IBGE. Pesquisa Nacional de Amostra por
Domicílios (PNAD). 1997.
10
Fundação IBGE. Taxa de pobreza. Em: Rede Interagencial de Informações para a Saúde (RIPSA). Indicadores e
dados básicos Brasil, 1998. Brasília: IBGE; 1999.
11
Fundação IBGE. Diretoria de pesquisas. Em: Pesquisa
Nacional de Amostra por Domicílios (PNAD). Síntese de
indicadores 1995. Rio de Janeiro: IBGE; 1996.
138
•
•
•
•
Análise de Eqüidade – Saúde: Brasil
xos. A Região Sul apresentava a taxa mais
elevada do país (91,7%) e a Nordeste a mais
baixa (70,6%), destacando-se o estado do
Maranhão com a taxa de 64,2%, a menor do
país.12
Em 1997, 34,9% da população com 10 ou
mais anos de idade tinham menos de 4 anos
de estudo, proporção que variava de 53,4%
na Região Nordeste a 25,8% na Região Sul.
Os estados do Maranhão e Piauí apresentavam os menores níveis de escolaridade
(59,7% e 59,0%, respectivamente), enquanto no Distrito Federal apenas 19,0% da população nesse grupo etário tinha menos de
quatro anos de estudo.13
Da população entre 10 e 14 anos de idade
em 1997, 16,9% estavam ocupadas (trabalho infantil), percentual que se eleva a 24,0%
na Região Nordeste, atingindo 37,7% no
estado do Maranhão. As menores taxas
corresponderam à Região Sudeste (10,8%)
e ao Estado do Rio de Janeiro (5,1%).14
Dados de 1990 relacionam o trabalho
infanto-juvenil com a renda familiar,7 mostrando que a taxa de atividade das crianças
de 10–14 anos era de 23% entre as famílias
pobres, e de apenas 4,5% entre aquelas com
rendimento familiar per capita acima de
dois salários mínimos.
A expectativa de vida ao nascer era de 67,8
anos em 1997, sendo de 64,1 para homens e
de 71,7 para mulheres, mostrando uma
sobrevida de 7,6 anos a favor do sexo feminino. Comparando regiões e estados, observa-se que a expectativa mais baixa encontra-se no Nordeste (64,8 anos), sendo a
menor no estado de Alagoas (59,3).15 A Região Sul apresenta a melhor expectativa de
12
Fundação IBGE. Taxa de alfabetização. Em: Rede Interagencial de Informações para a Saúde (RIPSA). Indicadores e
dados básicos Brasil, 1998. Brasília: IBGE; 1999.
13
Fundação IBGE. Níveis de escolaridade. Em: Rede
Interagencial de Informações para a Saúde (RIPSA). Indicadores
e dados básicos Brasil, 1998. Brasília: IBGE; 1999.
14
Fundação IBGE. Trabalho infantil. Em: Rede Interagencial de Informações para a Saúde (RIPSA). Indicadores e
dados básicos Brasil, 1998. Brasília: IBGE; 1999.
15
Fundação IBGE. Esperança de vida ao nascer. Em:
Rede Interagencial de Informações para a Saúde (RIPSA).
Indicadores e dados básicos Brasil, 1998. Brasília: IBGE; 1999.
vida (70,3 anos), mais elevada no Rio Grande do Sul (71,0).
• A taxa de fecundidade total foi calculada,
para 1997, em 2,4 filhos por mulher ao longo de todo o período reprodutivo, com variações de 3,3 na Região Norte (máximo de
3,6 no Acre) a 2,1 no Sudeste (mínimo de
2,0 no Estado do Rio de Janeiro).
• A proporção da população com 65 e mais
anos de idade alcançou 5,4% na média nacional em 1996, com valores extremos nas
regiões Norte (3,3%, com 2,4% em Roraima)
e no Sudeste (5,8%, com 6,7% no Rio de
Janeiro).
Situação de saúde
• A mortalidade infantil no Brasil é estimada
em 37,4 por mil nascidos vivos para 1997,
variando de 58,3 na Região Nordeste a 24,0
na Região Sul. Os valores extremos entre os
estados são observados em Alagoas (74,1) e
no Rio Grande do Sul (19,7).16
• No grupo de menores de 5 anos, 5,7% dos
óbitos informados no Brasil em 1997 foram
devidos à doença diarreica aguda. Esse
percentual é mais elevado na Região Nordeste (9,3%) e mais baixo nas regiões Sudeste (3,2%) e Sul (3,8%).17
• A prevalência de déficit ponderal em menores de 5 anos de idade foi estimada para
1996 em 5,7% na média nacional, variando
de 8,3% na Região Nordeste e de 7,7% na
Região Norte, até 2,0% na Região Sul.18
• Na Região Nordeste concentraram-se 98,4%
dos casos de cólera registrados no país em
1997, expressando condições de vida parti16
Fundação IBGE. Estimativas de mortalidade infantil.
Em: Rede Interagencial de Informações para a Saúde (RIPSA).
Indicadores e dados básicos Brasil, 1998. Brasília: IBGE; 1999.
17
Brasil, Ministério da Saúde, CENEPI. Mortalidade
proporcional por doença diarreica aguda em menores de
5 anos. Em: Rede Interagencial de Informações para a Saúde
(RIPSA). Indicadores e dados básicos Brasil, 1998. Brasília:
Ministério da Saúde, CENEPI; 1999.
18
BENFAM. Pesquisa nacional de demografia e saúde.
Em: Rede Interagencial de Informações para a Saúde (RIPSA).
Indicadores e dados básicos Brasil, 1998. Brasília: BENFAM;
1999.
Finkelman
cularmente favoráveis à transmissão da
doença na região. 19
• A prevalência de hanseníase em 1997 situou-se, na média nacional, na taxa de 5,4
por 10 mil habitantes, variando de 15,0 na
Região Norte a 2,7 na Região Sul. O estado
com maior taxa foi Mato Grosso, na região
Centro Oeste (19,0). Seguem-se os do Amazonas (17,4) e Roraima (16,2). No Maranhão,
na Região Nordeste, a taxa foi de 14,5%.
Todos os estados da Região Norte apresentam taxas superiores a 12,0. Os estados do
Rio Grande do Sul e Santa Catarina apresentam taxas inferiores a 1,0, considerandose a doença já eliminada como problema de
saúde pública.
• A incidência de câncer cérvico-uterino, que
é passível de prevenção na atenção básica à
saúde, apresenta elevadas taxas nas regiões
Norte (54 casos por 100 mil habitantes),
Nordeste (45,2) e Centro Oeste (42,8), em
contraste com as regiões Sudeste (14,8) e Sul
(27,7). No Norte e no Centro Oeste, representa a principal causa entre todos os tipos
de câncer, na população geral.20
• 22,1% dos nascidos vivos informados em
1996 provieram de mães com menos de 20
anos de idade. Esse percentual foi de 30%
na Região Norte, atingindo valores de 30,5%
em Rondônia e Tocantins. As regiões Sudeste e Sul apresentaram taxas de 19,6% e
20,6%, respectivamente.21
•
•
•
Recursos e cobertura
• No último levantamento realizado no Brasil, em 1992, havia 36,4 leitos hospitalares
19
Brasil, Ministério da Saúde, CENEPI. Incidência de
doenças transmissíveis. Em: Rede Interagencial de
Informações para a Saúde (RIPSA). Indicadores e dados básicos Brasil, 1998. Brasília: Ministério da Saúde, CENEPI;
1999.
20
Brasil, Ministério da Saúde, INCa. Incidência de
neoplasias malignas. Em: Rede Interagencial de Informações
para a Saúde (RIPSA). Indicadores e dados básicos Brasil, 1998.
Brasília: Ministério da Saúde, INCa; 1999.
21
Brasil, Ministério da Saúde, CENEPI. Percentual de
nascidos vivos segundo idade das mães. Em: Rede
Interagencial de Informações para a Saúde. Indicadores e
dados básicos Brasil, 1997. Brasília: Ministério da Saúde,
CENEPI.; 1998.
•
139
para cada 100 mil habitantes. 22 Porém, as
taxas observadas nas regiões Norte e Nordeste (22,3 e 30,4 respectivamente) eram
bem inferiores às do Sudeste (40,9), Sul
(39,8) e Centro Oeste (41,7). Nova pesquisa
está sendo concluída pelo IBGE, com dados
atualizados disponíveis até o final de 1999.
O percentual de óbitos informados sem assistência médica atingiu 20,5% em 1997, no
total do país. O percentual por grandes regiões variou de 31,7% no Nordeste a 17,0%
na região Sul. Os seguintes estados apresentaram uma proporção mais elevada de óbitos sem assistência médica, indicando dificuldade de acesso a serviços médicos: Acre
(49,4%), Paraíba (48,3%), Maranhão (46,7%)
e Piauí (46,3%). O estado do Rio Grande do
Sul (10,3%) e o Distrito Federal (11,3%) apresentaram as melhores taxas. 23
A cobertura da população urbana servida
por sistemas de abastecimento de água em
rede geral alcançou 76,1% em 1997, variando de 61,3% na Região Nordeste a 87,2% na
Região Sudeste. Entre os estados, a cobertura variou de 42,8% no Maranhão a 93,0%
e 92,3%, respectivamente, em São Paulo e
no Distrito Federal. 24
A cobertura com serviços adequados de esgotamento sanitário (ligação em rede ou fossa séptica) alcançou no país a média de 60,0%
em 1997, variando de 33,6% na Região Nordeste a 80,9% na Região Sudeste. Entre os
estados, as piores coberturas encontram-se
no Amapá (12,6%) e em Tocantins (14,0%), e
a melhor no Distrito Federal (95,6%).
A cobertura por coleta regular de lixo foi de
74,0% na média nacional em 1997, variando
de 61,8% na Região Norte a 85,8% na Região
Sul. Destacam-se com maiores coberturas o
22
Fundação IBGE. Pesquisa de asistência médicosanitária. Em: Rede Interagencial de Informações para a Saúde
(RIPSA). Indicadores e dados básicos Brasil, 1998. Brasília:
IBGE; 1999.
23
Brasil, Ministério da Saúde, CENEPI. Proporção de
óbitos sem assistência médica. Em: Rede Interagencial de
Informações para a Saúde (RIPSA). Indicadores e dados básicos
Brasil, 1997. Brasília: Ministério da Saúde, CENEPI; 1998.
24
Fundação IBGE. Indicadores de saneamento básico.
Em: Rede Interagencial de Informações para a Saúde (RIPSA).
Indicadores e dados básicos Brasil, 1998. Brasília: IBGE; 1999.
140
Análise de Eqüidade – Saúde: Brasil
Distrito Federal (95,5%) e São Paulo (94,4%)
e, no outro extremo, o Maranhão (23,4%).
Financiamento/ alocação
(a) Gasto federal/estadual/municipal com
saúde em relação ao gasto total; (b) alocação
de recursos em saneamento básico; (c) gasto
com saúde em relação ao PIB; (d) alocação
PAB; (e) financiamento do setor. Para os indicadores sugeridos, os dados ainda não estão
disponíveis por grandes regiões e estados.
PRIORIDADES E POSSIBILIDADES PARA
A COOPERAÇÃO DA OPAS
A Representação da OPAS vem desenvolvendo, em ação conjunta com o Ministério
da Saúde e com apoio da Oficina Central, o
projeto Rede Interagencial de Informações para a
Saúde — RIPSA, que visa a disponibilizar um
conjunto de indicadores básicos selecionados,
preparar informes de situação conjunturais e
prospectivos, e reunir bases documentais aplicadas. O sistema está direcionado para a análise de aspectos relevantes para a estruturação
e avaliação de políticas e ações públicas de
interesse para a saúde, assim como para acompanhar as tendências dos problemas que a
OPAS e os governos membros têm como competência manejar. Nos próximos anos, devem
desenvolver-se para consolidar a RIPSA, continuar o processo de aperfeiçoamento de indicadores e dados básicos, validar as bases de
dados disponíveis e produzir informes analíticos sobre as condições de saúde.
Ainda no campo da informação, a cooperação deverá voltar-se para desenvolver
metodologias para a análise de desigualdades
e iniqüidades em saúde, mediante a identificação e acompanhamento de indicadores das
condições de vida prevalentes. Para isso, a
Representação está promovendo parcerias
com entidades nacionais especializadas em
pesquisa econômica e social, como o IPEA, a
Fundação SEADE-SP e a USP.
A OPAS tem a responsabilidade de cooperar, também, no desenvolvimento de estudos
de caso sobre o impacto de medidas de intervenção adotadas para reduzir as desigualdades e iniqüidades em saúde. Essa linha de trabalho envolve o estabelecimento de parcerias
com entidades nacionais vocacionadas para a
realização de pesquisas aplicadas à análise e
avaliação de ações e serviços de saúde.
No campo do controle de doenças e agravos à saúde, busca-se revigorar as ações de
cooperação para o enfrentamento de grandes
problemas persistentes (malária, dengue,
doença de Chagas, cólera, lepra e tuberculose), dar suporte aos esforços nacionais para a
eliminação de doenças evitáveis por imunização (sarampo e tétano neonatal), e apoiar
ações voltadas ao controle de problemas emergentes (aids, entre outros) que requerem iniciativas no campo do desenvolvimento científico e tecnológico.
As ações relativas ao item anterior devem
estar balizadas no aprimoramento do sistema
de vigilância epidemiológica/vigilância da saúde pública, de forma a proporcionar informação epidemiológica oportuna e base metodológica para o desenho e implementação de
medidas de prevenção e controle de doenças,
assim como de promoção da saúde. Cumpre à
OPAS relevante papel de apoio às iniciativas
nacionais nessa área.
Outro ponto focal importante da cooperação refere-se à promoção de programa de
vigilância da qualidade de insumos para a
saúde, em especial aqueles incluídos nas competências de fundos rotativos administrados
pela OPAS. Destacam-se como insumos principais: vacinas e soros, sangue e hemoderivados, medicamentos estratégicos, dispositivos de diagnóstico e produtos destinados ao
controle vetorial.
Cabe ainda à OPAS promover o debate sobre o modelo de atenção à saúde e de organização de serviços, no contexto dos marcos
referenciais de desenvolvimento do sistema de
saúde brasileiro, no sentido de contribuir para
o seu contínuo aperfeiçoamento.
EQUIDAD EN M ATERIA DE SALUD Y O PORTUNIDAD
VIDA EN VENEZUELA Y COLOMBIA
DE
Hernán Málaga,1 Marisela Perdomo,2 Ángela González3
y Helena Restrepo3
Se presentan en este trabajo los resultados
de dos estudios llevados a cabo en Colombia
y Venezuela con objeto de analizar las inequidades en salud, en particular en materia
de acceso a los servicios de salud y a servicios
de salud de igual calidad, y proponer una estrategia de justicia social y de reforma del
sector encaminada a corregirlas.
En Venezuela, el estudio se realizó en 1992,
sobre la base de datos del censo de 1981 relativos a 707 parroquias con una población de
15 millones de personas (1). El estudio sobre
Colombia, llevado a cabo en 1998, se basó en
el censo de 1993, que estimó una población
de 38 millones de personas (2). El análisis de
las inequidades tomó en cuenta las divisiones
políticas y el porcentaje de población con necesidades básicas insatisfechas (NBI) en cada
unidad geográfica poblacional, agrupadas en
Venezuela y Colombia en 10 y 4 estratos socioeconómicos respectivamente.
En Venezuela, 38% de las parroquias pertenecen a estratos con un índice de NBI de 70%
a 100%, frente a 23% de los municipios de Colombia. El 8% de los municipios de Colombia
presentan un índice de NBI inferior a 30%,
frente a 10% de las parroquias de Venezuela.
El 10% de la población venezolana vive en
parroquias con un índice de NBI de 70% a
100% , frente a 12% de la población colombiana. El 30% de la población venezolana vive en
zonas mayormente desarrolladas, frente a 49%
de la población colombiana.
En Colombia, el hacinamiento es más frecuente en los municipios con un índice de NBI
superior a 70%. En las zonas rurales, los servicios de recolección de basura son prácticamente nulos. La educación presenta una correlación con el desarrollo; la instrucción
secundaria y superior tiene una correlación
positiva, y el analfabetismo, negativa.
EL MODELO RURAL
Al analizar la mortalidad por estratos socioeconómicos, se observa que en Venezuela el
porcentaje correspondiente a la mortalidad
por enfermedades transmisibles varía entre
8% y 26%; la mortalidad infantil presenta valores que oscilan entre 10 por 1.000 nacidos
vivos y 30 por 1.000 nacidos vivos, y la mortalidad de niños de 1 a 4 años varía de 0,25 a 2,5
por 1.000. El 80% de los casos de tétanos
Representante de OPS/OMS en Colombia.
FUNDEPI, Venezuela.
3
Instituto Nacional de Salud, Colombia.
1
2
141
142
Equidad en Materia de Salud y Oportunidad de Vida en Venezuela y Colombia
neonatal se presenta en comunidades con un
índice de NBI superior a 70%.
En Colombia, el porcentaje de enfermedades transmisibles oscila solo de 8% a 10% entre los estratos que presentan menos de 30%
de población con NBI y los que tienen más de
70%, pero la proporción de defunciones por
diarrea varía de menos de 1% a 2,5%. La escasa correlación probablemente se explique por
el hecho de que el porcentaje de defunciones
en instituciones de salud varía de 25% a 50%,
y el de defunciones sin certificación médica
oscila de menos de 1% a más de 28% en los
municipios con más de 70% de población con
NBI. Hay igualmente una correlación entre el
desarrollo y el diagnóstico inexacto de la causa de muerte que oscila entre 1% y 18%, debido sobre todo a que el subregistro de dicha
causa se estima en 86% en el estrato más pobre frente a solo 16% en los estratos más desarrollados (3).
EL MODELO URBANO
En Colombia y Venezuela, la mayoría de los
municipios o parroquias con altos índices de
NBI presentan una elevada proporción de población rural. La búsqueda de mejores oportunidades explica en parte el rápido crecimiento
poblacional en las grandes ciudades de ambos
países; pero las personas que emigran encuentran deficiencias en lo concerniente a la vivienda, el saneamiento ambiental, el suministro de
agua, tanto en cantidad como en calidad, y los
servicios de alcantarillado y recolección de basura. Se reproduce así el panorama nacional,
con enfermedades relacionadas con la pobreza, como concluye un estudio efectuado en
Barquisimeto, Venezuela (4), según el cual la
mortalidad infantil varía del 10 por 1.000 nacidos vivos a más de 30 por 1.000 en los barrios
más carenciados. De acuerdo con este estudio,
el bajo peso al nacer se relaciona con las condiciones de vida, como lo demuestra el hecho de
que la mayor cantidad de niños con menos de
2,5 kg de peso nacen en barrios con un índice
de NBI superior a 90%. Otros estudios realiza-
dos en Venezuela indican que la talla de los
niños que pertenecen a estratos ubicados en los
extremos varía de 1,15 m a 1,22 m a los 7 años
de edad. Méndez Castellanos señala que esto
se traduce en 20 años de diferencia en cuanto
al desarrollo biológico entre ambos estratos.
Otros datos indican que en Caracas la diferencia entre estratos socioeconómicos en cuanto a
la esperanza de vida al nacer varía de 64 a 74
años de edad (5).
En las grandes ciudades también se advierte una correlación entre el desarrollo y las enfermedades cardiovasculares y el cáncer. En
Venezuela, la mortalidad por enfermedades
cardiovasculares varía entre 35% en las ciudades más grandes y 12% en las más pequeñas. Las neoplasias presentan el mismo cuadro, y si se estudia el cáncer del cuello del útero
se puede ver que gran parte del problema radica en las condiciones de pobreza estructural (6). Los mismos resultados se dan en Colombia, donde se advierte una correlación
entre el infarto del miocardio y el desarrollo.
En ambos países, la inestabilidad social
favorece las enfermedades de transmisión
sexual, así como el incremento de los problemas de alcoholismo, drogadicción, crímenes
y violencia. En Venezuela los accidentes de
vehículos de motor, resultantes de actos de
negligencia y violencia, representan 25% del
total de años potenciales de vida perdidos, y
su prevalencia es mayor en las ciudades con
un índice menor de NBI (7). En Colombia los
homicidios tienen una correlación con el desarrollo, y en las grandes ciudades se puede
observar que los estratos más pobres acusan
mayor cantidad de muertes (8).
CONCLUSIÓN
En Colombia y Venezuela, las prioridades
sanitarias nacionales declaradas son aumentar la equidad en salud y asegurar el acceso a
servicios de salud y a servicios de salud de
igual calidad. En el primer caso, la solución
es una estrategia de justicia social, y en el segundo, de justicia sanitaria.
Málaga, et al.
ESTRATEGIA DE MUNICIPIOS
SALUDABLES
Para impulsar la estrategia de justicia social
se ha puesto en marcha el proyecto de municipios saludables (9), en el que la atención primaria de salud busca resolver los problemas
sanitarios esenciales en el ámbito local. Esto se
ve favorecido por el proceso de descentralización en ambos países y la transferencia de
competencias en salud a los municipios. Se privilegia la promoción de la salud y las acciones
preventivas, y se ratifica el derecho de todos
los habitantes a la salud y a la universalidad
de la cobertura, combatiendo las desigualdades sociales y promoviendo la participación
ciudadana. La función de liderazgo la ejerce el
alcalde, que es quien convoca a todos los sectores de la sociedad. Mediante esta estrategia,
y como parte de la misión de salud pública, se
busca asegurar las condiciones para el desarrollo de una vida saludable (10). Las principales
líneas de acción son la formulación de políticas públicas saludables, la creación de ambientes sanos, el fortalecimiento de la acción comunitaria, la reorientación de los servicios, y el
desarrollo de habilidades personales para lograr cambios en el modo de vida (9) y las oportunidades de vida (11).
Un buen ejemplo de políticas públicas saludables es la prohibición del uso de la pólvora
en la época de Navidad y Año Nuevo en Bogotá, Colombia, medida que ha logrado reducir
la cantidad de niños quemados de 200 a menos de 60 (12). También se ha implantado una
política de restricción de la portación de armas,
que permitió la disminución de los homicidios
con armas de fuego (13). Sobre la base de esta
experiencia, una reciente decisión del Presidente de la República impulsa la implantación de
esta política en 59 ciudades del país.
Para analizar los problemas de salud hemos
recurrido al modelo de Lalonde (14), que facilita el desarrollo de políticas de salud. El control del embarazo en la adolescencia constituye un ejemplo de la aplicación de este modelo.
Por ejemplo, tomando en cuenta que el embarazo, que se correlaciona en forma inversa con
143
el desarrollo, es más prevalente en jovencitas
que inician su actividad sexual a temprana
edad, la intervención modifica el ámbito biológico, el modo de vida. En este sentido, el
hecho de estar ocioso explica gran parte del
problema y es igualmente relevante el hecho
de que la mayor incidencia de embarazo en la
adolescencia se observa en muchachas que
abandonan los estudios antes de 6 años. Estas
variables, junto con algunas respuestas limitadas por parte de los servicios de salud, explican el problema y crean posibilidades de
intervención (15).
Con objeto de intervenir ante un problema
hemos utilizado el método del marco lógico
para diseñar proyectos. Por medio de esta metodología, en Venezuela se estableció un banco con 256 proyectos en 33 de los 64 municipios que están aplicando la estrategia: 36% de
los proyectos pertenecen a la esfera de saneamiento básico, 24% a prevención y promoción,
11% a educación, 10% a empleo, y 19% a desarrollo de servicios públicos, incluidos los servicios de salud (16). La ejecución de estos
proyectos y programas en el Municipio de
Versalles, Colombia, ha afianzado la democracia, favoreciendo la plena participación de la
comunidad, ya que es esta la que elabora el
plan local de desarrollo. Un efecto indirecto
de esta estrategia ha sido la disminución de
los homicidios.
REFORMA DEL SISTEMA DE SALUD
Para superar el problema de falta de equidad en el acceso a los servicios de salud, Colombia ha implementado la Ley 100, pero
como resultado de los primeros tres años de
aplicación, y en un contexto regido por el libre mercado, se han ampliado las brechas,
porque las ciudades más grandes recibieron
más dinero del régimen subsidiado, mientras
que los departamentos más pobres tienen
menos población afiliada al sistema de seguridad social. A su vez, esto ha incrementado
la inequidad en la cobertura de inmunizaciones debido a la diferencia en el desarro-
144
Equidad en Materia de Salud y Oportunidad de Vida en Venezuela y Colombia
llo de los servicios locales de salud, y así han
caído las coberturas de vacunación contra la
poliomielitis en todos los departamentos. Este
descenso ha sido mayor en los departamentos con elevados índices de NBI (17).
El Plan Nacional de Desarrollo para los años
1999–2000 prevé el incremento de cupos en la
cobertura del régimen subsidiado. Este incremento se hará teniendo en cuenta los niveles
de NBI y de menor cobertura sanitaria de los
diferentes municipios, con miras a corregir
el desequilibrio existente entre las diferentes
regiones del país. El nivel nacional, por conducto del Fondo de Solidaridad y Garantía
(FOSYGA), destinará más recursos para los
municipios con mayores porcentajes de población con NBI y menor cobertura, a fin de cumplir con el principio de equidad y obligatoriedad
que establece la Ley 100 de 1993.
•
ASPECTOS RELACIONADOS CON
LA COOPERACIÓN TÉCNICA
Los principales aspectos relacionados con
la cooperación técnica que se ha decidido fortalecer o desarrollar con objeto de aumentar
la equidad en salud y el acceso y utilización
de los servicios de atención de salud son:
• Focalizar la cooperación técnica en los departamentos y municipios más pobres del país.
• Incluir entre los compromisos de consultores y profesionales nacionales objetivos de
disminución de inequidades.
• Desarrollar un sistema de información municipal que comprenda datos de determinantes sociales y ambientales de problemas en salud y promueva el trabajo
intersectorial.
• Fomentar la cooperación horizontal mediante la Red Colombiana de Municipios
Saludables por la Paz.
• Promover el respeto universal a los derechos humanos, afianzando los procesos de
paz y propiciando el incremento del acceso
a servicios de salud y educación en las zonas excluidas, por ejemplo mediante pro-
•
•
•
•
puesta de asignación de recursos del régimen subsidiado a departamentos y municipios con mayores porcentajes de NBI y
menos afiliados al sistema de seguridad
social, rearticulación de los sistemas locales de salud, abastecimiento universal de
agua potable por regímenes de condominio
y tecnologías apropiadas, etcétera.
Reducir las inequidades individuales y sociales por medio de intervenciones preventivas y de promoción de la salud, incluida
la capacitación de nuevos actores: alcaldes,
secretarios municipales de salud, gerentes
de Entidades Promotoras de la Salud (EPS)
y de Administradoras del Régimen
Subsidiado (ARS), y directores de Instituciones Prestadoras de Servicios de Salud
(IPS). Por ejemplo: disminuir la relación
entre pobreza estructural y coberturas de
inmunización, introducir el enfoque de
Atención Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI) en el Plan
Obligatorio de Salud (POS), municipios
saludables por la paz en los municipios excluidos, CARMEN en grandes ciudades,
programas de control de malaria, tuberculosis y lepra en poblaciones vulnerables, etc.
Asesorar la elaboración de planes de desarrollo de recursos humanos en los niveles
departamentales con participación de los
nuevos actores.
Construir un banco de proyectos municipales y propiciar el liderazgo de la Primera
Dama, con el propósito de buscar financiamiento para intervenciones locales en
municipios y comunidades excluidas.
El incremento del desplazamiento de población a causa de la violencia ha incrementado
las inequidades en el acceso a los servicios
de salud. Por ley, la respuesta del Gobierno
a esta población sobrepasa la oferta existente en el POS del régimen subsidiado, y se
ha creado así un régimen paralelo, por lo
que debe propiciarse la elaboración de un
modelo cuya aplicación ayude a resolver
este grave problema.
Fomentar la cooperación técnica entre países, sobre todo en las fronteras, con el pro-
Málaga, et al.
pósito de disminuir inequidades en salud,
e intercambiar experiencias de estrategias
de reforma que hayan ayudado a disminuir
las diferencias.
• Divulgar resultados de intervenciones locales, departamentales y nacionales, que reduzcan las inequidades.
REFERENCIAS
1. Universidad Central de Venezuela, Ministerio de
Sanidad y Asistencia Social. Perfiles de mortalidad
según condiciones de vida: experiencia en Venezuela.
Boletín Epidemiológico 1993;14(3):11–14.
2. Departamento Autónomo Nacional de Estadística,
Ministerio de Salud, Organización Panamericana de
la Salud. Condiciones de vida y salud en Colombia.
Informe Preliminar. Santa Fe de Bogotá, 1998.
3. Departamento Autónomo Nacional de Estadística,
Organización Panamericana de la Salud. Mortalidad
según condiciones de vida en Colombia. Jornada
Colombiana de Epidemiología, Santa Fe de Bogotá,
1998.
4. Ludewig C, Finizola B, B Gil M, Rivera E, Ugel E,
Zeeman P. Propuesta para el análisis de la situación
según condiciones de vida de la población para el
apoyo a la gestión en niveles locales. IV Reunión
Científica Nacional de Epidemiología, San Cristóbal,
Venezuela, 1994.
5. Méndez Castellanos H, Paez J. Las circunstancias
de enfermarse y morir en Caracas. Estudio sobre
mortalidad diferencial en el área metropolitana de
Caracas. Archivos Venezolanos de Puericultura y Pediatría 1998;61(1):16–26.
6. Venezuela, Ministerio de Sanidad y Asistencia Social,
Dirección de Oncología. Epidemiología y la prevención
del cáncer uterino. Caracas: Ministerio de Sanidad y
Asistencia Social; 1991. (Informe fotocopiado).
7. Venezuela, Ministerio de Sanidad y Asistencia Social.
Políticas de salud en Venezuela. Caracas: Editorial
Gráficas, Chemar; 1992.
145
8. Guerrero R. La violencia como problema de salud
pública en la Región de las Américas. El caso Colombia. En: Memorias de la Conferencia Prevención de
la violencia: una oportunidad para los medios de
comunicación. 1998. pp. 41–49.
9. Organización Panamericana de la Salud. Municipios
saludables: una estrategia de promoción de la salud en la
Organización Panamericana de la Salud en el contexto local. Washington, DC: OPS; 1992.
10. Mann E. Medicine and public health ethics and human rights. Hasting Center Report 1997;27(3):6–13.
11. Kadt E, Tasca R. Promover la equidad, un nuevo enfoque
desde el sector salud. Washington, DC: Organización
Panamericana de la Salud; 1993. (Serie Salud en el
Desarrollo).
12. Colombia, Instituto Distrital de Cultura y Turismo,
Secretaría Distrital de Salud. Impacto de la restricción
para venta y uso de pólvora en Santafé de Bogotá. El
Observatorio de Cultura Urbana 1997;1(3):1–8.
13. Acero H, Martínez H, Suárez GI, Hernández W.
Prevención de lesiones de causas externas en Santafé
de Bogotá. Boletín CRNV 1996;17(Dic):61–62.
14. Lalonde M. El concepto de “campo de la salud”: una
perspectiva canadiense. En: Organización Panamericana de la Salud. Promoción de la salud: una
antología. Washington, DC: OPS; 1996. (Publicación
Científica 557).
15. Costagliola A. Factores de riesgo del embarazo precoz
en el Municipio Zamora del Estado Falcón, Venezuela [tesis de grado]. Caracas: Universidad Central de
Venezuela; 1995.
16. Mandl J, Toba M, eds. Tomo II: Red Venezolana de
Municipios hacia la Salud. En: Municipios hacia la
salud: la experiencia venezolana. Caracas: Organización
Panamericana de la Salud, Ministerio de Sanidad y
Asistencia Social; 1999.
17. Restrepo H, ed. Experiencias de municipios saludables
por la paz, Colombia. Santa Fe de Bogotá: Trazo Digital
Ltda.; 1999.
18. Málaga H.. Perspectivas de la epidemiología en la
reforma de la seguridad social. Revista de Salud Pública
1999;1(2):128 B,136 pp.
AGUA PARA TODOS EN EL PAÍS
DE LA FANTASÍA
Paulo C. Pinto1
nes en sus procesos de reforma, la tendencia
podría indicar un movimiento común hacia
nuevos modelos de gestión que incorporan al
sector privado.
En Fantasía, la transformación del sector de la
salud se ha orientado a redefinir los papeles de
sus actores, básicamente el Estado, que asume
las funciones de regulación y control, y el sector
privado, a cargo de la prestación de los servicios. Con arreglo a este modelo, se han creado
entes reguladores encargados de ejercer las funciones mencionadas por medio de dos instrumentos fundamentales: los marcos regulatorios
y los contratos de concesión. De acuerdo con la
política de la Administración Nacional, una de
las primeras empresas públicas privatizadas fue
Obras Sanitarias de Fantasía (OSF). Así, se tomó
la decisión de concesionar a un consorcio privado (Aguas de Fantasía, AF) la provisión de agua
potable y saneamiento en la capital y ciudades
vecinas, cuyo ingreso per cápita era el más significativo del país.
La reforma llevada a cabo consistió en el
diseño de un nuevo marco institucional que
incluyó la separación de las funciones de
prestación de las de regulación, así como la
creación de un marco regulatorio del servicio.
Esta tarea posibilitó la transferencia de OSF al
sector privado (AF) y, simultáneamente, el establecimiento del Ente Regulador de Aguas
de Fantasía (ERAF). La experiencia de la con-
Al parodiar la Ficción, la Realidad muchas
veces nos ofrece incontables oportunidades de
buscar alternativas. En “la historia interminable”,2 donde la Fantasía y la Creatividad van
adelante y buscan soluciones, la Nada intenta
dominar el escenario y establece fronteras a
la Imaginación.
LA MODERNIZACIÓN DEL ESTADO
A consecuencia de las reformas que han tenido lugar en distintos países de América Latina, el Estado ha pasado a ejercer nuevas funciones. En muchos de ellos, el proceso de
privatización procuró vender la imagen de
ineficiencia del Estado y de profesionalismo
de las empresas privadas. En varios casos, las
reformas han llevado aparejada la transferencia de la gestión de los servicios al sector privado, dejando en manos del Gobierno ciertas
tareas relativas a la política y planificación
sectoriales, así como a la regulación y control.
En otros, las políticas y acciones de planificación han sido postergadas. Aunque los países
han avanzado en distintos grados y direccio1
División Salud y Ambiente, Organización Panamericana de la Salud.
2
El autor alude a Fantasía, el mágico mundo de lo posible creado por Michael Ende en su novela, La historia
interminable (Madrid, Alfaguara, 1987). [N del E]
146
Pinto
cesión de OSF sirvió como punto de partida
para la transformación de los servicios en otras
zonas del país.
Si bien ha habido importantes adelantos en
cuanto a la ampliación y la calidad de los servicios prestados, el modelo puesto en marcha
aún no ha generado los mecanismos adecuados para incrementar significativamente el
acceso de los sectores carenciados a los servicios. De hecho, las renegociaciones del contrato de concesión han estado signadas por las
dificultades manifestadas por las empresas
para cumplir sus obligaciones de ampliación.
En este contexto, deben introducirse nuevos mecanismos en el modelo, reorientando
las acciones del Estado tendientes a lograr la
cobertura universal de los servicios, mediante la asignación de una alta prioridad al mejoramiento del acceso a estos por parte de los
sectores más pobres de la población.
LA TRANSFORMACIÓN Y LOS
SECTORESVULNERABLES
Se necesitan modelos capaces de crear mecanismos adecuados y eficientes que permitan
extender los servicios a las zonas marginales,
teniendo en cuenta que el operador es una
empresa privada. Aunque existen algunos elementos comunes, cuando la prestación está a
cargo del Estado, este puede fijar las metas de
ampliación de los servicios, con lo cual desaparecen los problemas de incentivos inadecuados.
En los últimos tiempos, se ha difundido
mucho el concepto de desarrollo sostenible,
entendiéndose por tal el desarrollo que permite alcanzar el bienestar de las generaciones
actuales sin comprometer el desarrollo de las
generaciones futuras. Últimamente, el concepto ha cobrado gran relevancia, y el control de
la contaminación se está tornando prioritario
para muchas naciones.
Sin embargo, existe controversia en torno al
concepto de desarrollo sostenible. Por ejemplo,
la Comisión Mundial sobre el Medio Ambiente y el Desarrollo (Comisión Brundtland) condiciona el desarrollo sostenible en América
147
Latina a la posibilidad de encontrar nuevos
esquemas para satisfacer las necesidades básicas de la población, en especial de los sectores
de bajos recursos que habitan zonas urbanas.
La Comisión mencionada profundiza el concepto, planteando un “desarrollo humano sostenible” basado en la urgente erradicación de
la pobreza y la solución de los problemas ambientales en las zonas urbanas marginales.
Esta relación entre la disminución de la pobreza y el mejoramiento ambiental también
ha sido planteada por instituciones internacionales, tales como la OPS/OMS, el Banco
Mundial y el Banco Interamericano de Desarrollo, que han privilegiado el tema de la
pobreza en la agenda sanitaria y ambiental
de la Región.
La temática del desarrollo sostenible y las
oportunidades de alcanzarlo aparece claramente en las zonas urbanas de países en desarrollo. Por lo común, los sectores más perjudicados son los de menores recursos, que
sufren en forma directa los efectos de la contaminación y tienen menos posibilidades de
acceder a servicios básicos, tales como agua
potable y saneamiento. En consecuencia, una
vez afectados por la degradación ambiental,
no cuentan con los medios para solucionar los
problemas ocasionados.
En el ámbito de la concesión de OSF, los
principales problemas sanitarios y ambientales están relacionados con los recursos hídricos
y los servicios de saneamiento: elevados tenores de contaminación orgánica y tóxica de
acuíferos subterráneos, ríos y arroyos (en algunas épocas del año se supera la carga contaminante de los líquidos cloacales); escasa
cobertura de servicios, en especial servicios
sanitarios; amplios sectores de la población
con necesidades básicas insatisfechas.
Estos problemas se han agudizado tanto que
los factores de localización que habían sido
atractivos para la población —acuíferos subterráneos accesibles y de óptima calidad para
el consumo humano, características de absorción de los suelos, aptos para la construcción
de pozos y cámaras sépticas, presencia de ríos
y arroyos capaces de actuar como cuerpos re-
148
Agua Para Todos en el País de la Fantasía
ceptores de efluentes cloacales—, hoy en día
se tornan circunstancias negativas, debido a
la degradación de sus condiciones naturales
y el alto grado de contaminación que presentan, así como a las bajas coberturas de los servicios de saneamiento básico.
Es sabido que los inconvenientes que sufren
estas zonas se deben más al crecimiento rápido de las ciudades —que sobrepasa la capacidad de los gobiernos de planificar, financiar y
construir nueva infraestructura—, que a su
tamaño. A ello se suman las dificultades para
mantener la infraestructura existente.
La problemática que afecta a esta área no es
privativa de Fantasía. La contaminación del
aire, el suelo y el agua en varias ciudades de
las Américas ha alcanzado niveles críticos.
Como ya se señaló, la mayor incidencia de la
contaminación es en la población de bajos recursos, y estos sectores han reconocido que la
contaminación constituye uno de sus problemas más importantes. En encuestas realizadas en Fantasía se comprobó que los sectores
de bajos recursos estaban dispuestos a pagar
importantes sumas (en relación con sus ingresos) a cambio del mejoramiento de las condiciones ambientales de la zona y el acceso a los
servicios básicos.
Sin duda, las políticas de ampliación de los
servicios de agua potable y saneamiento, y las
inversiones en mejoras ambientales en torno
a estos servicios, están estrechamente relacionadas con el concepto de desarrollo sostenible, que es más abarcativo que la correspondencia tradicional entre el acceso a los
servicios y la salud. En cualquier caso, resulta
claro que se requiere una intervención del Estado para establecer las políticas correspondientes. Cuando la prestación de los servicios
ha sido concesionada a una empresa privada,
es necesario establecer los mecanismos e incentivos adecuados.
EL SISTEMA REGULADOR DE FANTASÍA
La regulación es una función indelegable
del Estado, mediante la cual este puede corre-
gir comportamientos monopólicos a partir del
establecimiento de normas que orientan o
restrinjen decisiones empresarias públicas o
privadas.
El desarrollo de los procesos de reforma
sectorial en Fantasía ha provocado cambios en
los modelos de gestión de los servicios de saneamiento, pues se han puesto en práctica
objetivos empresariales e incentivos a la eficiencia susceptibles de crear conflictos de interés entre los prestadores y los usuarios en
cuestiones relacionadas con el equilibrio económico-financiero, los niveles de inversión, la
calidad de los servicios prestados, o las tarifas. Debido a la posición dominante de los
prestadores, los usuarios y la comunidad en
su conjunto cuentan con recursos limitados
para su protección y defensa.
En este contexto, la regulación de los servicios se concentra en reducir el riesgo de
estos conflictos y los comportamientos abusivos resultantes de las posiciones monopólicas. Los sistemas de regulación deben
aplicar normas que privilegien en forma distinta los tres aspectos principales del servicio público en los que pueden originarse comportamientos perjudiciales en relación
con el costo, la calidad o la cantidad. Es claro
que la aplicación de una norma que exige
costos mínimos a los usuarios puede inducir
niveles inadecuados de calidad del servicio,
así como establecer parámetros exigentes en
términos de calidad puede inducir altos costos y tarifas.
LA EVOLUCIÓN DE LOS SERVICIOS
EN FANTASÍA
El contrato de concesión en Fantasía estableció una serie de objetivos relacionados con la
mejora de la calidad de los servicios, el incremento de las coberturas de agua potable y saneamiento, y la concreción de determinadas
inversiones. Al comparar la situación del comienzo de la concesión con la correspondiente
a la finalización del primer quinquenio, de
manera sintética puede señalarse lo siguiente:
Pinto
149
• Los servicios mejoraron significativamente,
tanto en relación a la calidad del agua distribuida como a algunos parámetros físicos,
a saber: presión del agua; control de las descargas cloacales; tratamiento de las aguas
residuales, y otros;
• La población con servicio de agua potable
aumentó un 13%, y la incorporada al sistema de alcantarillado cloacal, 6%. Aunque
se trató de aumentos importantes, no se alcanzaron las metas establecidas en el contrato de concesión.
ventaja aparente de este sistema radica en que
aparecen nuevas fuentes de recursos, ajenos
a los que puede generar la empresa concesionaria, y el problema que podría surgir es,
nuevamente, el de las dificultades de los sectores de bajos recursos para pagar las cuotas
correspondientes.
Una de las cuestiones críticas relacionadas
con la ampliación de los servicios fue el fracaso del denominado “cargo de infraestructura”, una contribución que los nuevos usuarios
debían pagar a la empresa concesionaria en
concepto de acceso a los servicios (fijado en
$ 500 y $ 1000, por conexión de agua y alcantarillado, respectivamente). Cuando la ampliación alcanzó a los sectores de bajos recursos,
surgieron problemas de cobro de la contribución mencionada, en razón de los costos
elevados, que estos sectores no estaban en
condiciones de cubrir. Esto llevó a una renegociación del contrato entre el Estado y la
empresa concesionaria, AF, que finalizó con
la promulgación de un decreto en el que se
estableció que la amplicación de los servicios
debía financiarse mediante el denominado
cargo al servicio universal ($ 1,0 por servicio,
por mes), que los usuarios existentes pagarían
como parte de su tarifa.
Sin embargo, por diferentes razones, este
esquema de subsidios cruzados para financiar
la ampliación de los servicios también fue dejado de lado, proponiéndose actualmente un
sistema de financiamiento con la participación
de otros actores interesados en la solución.
Consiste en el establecimiento de convenios
entre el municipio y los habitantes de la zona
a la que se va a extender el servicio, de acuerdo con los cuales este selecciona una empresa
constructora que ejecuta las obras y las transfiere al concesionario privado y, una vez habilitado el servicio, los usuarios pagan en cuotas las inversiones correspondientes. La
La situación descripta, que ha enfrentado la
concesión de Fantasía, coincide con la de otras
ciudades de la Región, con modelos de prestación de servicios, tanto públicos como privados. Surgen, entonces, las siguientes preguntas, para los casos en que los servicios han sido
dados en concesión a una empresa privada:
CUESTIONES PARA RESPONDER EN LA
AMPLIACIÓN DE LOS SERVICIOS A LAS
ZONAS MARGINADAS
• ¿Cómo generar recursos para la ampliación
de los servicios en las zonas marginales?
• ¿Debe el Estado intervenir en el financiamiento cuando el prestador es una empresa privada?
• ¿Es viable que las obras de ampliación las
ejecute el Estado y luego las transfiera a la
empresa concesionaria para su explotación?
• ¿Que mecanismo es más eficiente: los subsidios cruzados o los subsidios directos?
• ¿Cuáles deben ser los incentivos y obligaciones que deben establecerse, de manera
que las empresas ejecuten la ampliación
de los servicios de acuerdo con las metas
establecidas?
• ¿Cómo puede organizarse la comunidad?
(esquemas de aporte de materiales y mano
de obra)
• ¿Cuáles son las tecnologías apropiadas?
• ¿Pueden establecerse niveles de servicio
diferenciados?
• ¿Cuáles deben ser los arreglos institucionales?
• ¿Cuáles son las funciones del Estado (en sus
diferentes niveles), del ente regulador, de
la empresa privada, de las organizaciones
no gubernamentales y de la comunidad
organizada.
ÉTICA, EQUIDAD Y PRÁCTICA EN
I NSTITUCIONES DE SALUD
LAS
Fernando Lolas Stepke1
que, tomando distancia de las solicitaciones
de lo inmediato, contempla la totalidad de las
capacidades del intelecto y encuentra el significado en esa contemplación. No en vano la
voz teoría recuerda al teatro, aquel sitio privilegiado en que el mundo y la gente se ofrecen
como espectáculo a la mirada.
Por cierto, en las disciplinas científico-naturales tiene la voz teoría la acepción más
modesta de compacto resumen de observaciones que permite predicción y anticipación. Sin
embargo, es la noción intuitiva de teoría como
aprehensión de totalidades significativas la
que quisiera destacar en esta ocasión.
Gracias al saber teórico, y al tipo de praxis
reflexiva que él permite, podemos des-cubrir lo
obvio, revelar las implícitas certidumbres que
impregnan nuestras prácticas habituales y los
axiomas de nuestro quehacer y, cuando es exitoso el esfuerzo, deshacer las inercias del hábito y poner en entredicho lo que parece simple.
Gracias a la pupila teórica podemos “desenmascarar lo real”, mostrarlo en la infinita variedad de sus circunstanciales apariencias y
reforzar con ello la eficacia de nuestros actos.
Por eso es tan valioso, y por valioso escaso,
el privilegio de tomar distancia de las incitaciones de lo inmediato y retirarse a la reflexión.
Este interludio, que es retiro y trabajo teórico,
es un bien mayor. Permite esa cronofilia benéfica del ocio regio, que ama al tiempo y per-
PREÁMBULO
El Director de la Oficina Sanitaria Panamericana (Organización Panamericana de la Salud), George A. O. Alleyne, ha pensado que
algunas de mis reflexiones previamente publicadas podrían resultar de interés para este
público.2 Hoy nos congrega una dimensión
valórica del trabajo de la Organización que requiere tiempo y reflexión para ser correctamente aprehendida. En realidad, el tema de
la equidad es una vía de entrada al universo
conceptual y moral de los supuestos que animan dicho trabajo.
NADA HAY MÁS PRÁCTICO QUE
UNA BUENA TEORÍA
Para caracterizar el saber teórico, decía Ortega y Gasset que era aquella forma de saber
1
Director del Programa Regional de Bioética, Organización Panamericana de la Salud. El texto reconstruye la conferencia pronunciada el 28 de octubre de 1999 en la reunión
de gerentes de la OPS que se realizó en Washington, D.C.
Las afirmaciones son de la exclusiva responsabilidad del autor y no suponen reconocimiento ni respaldo institucional.
2
Algunos de los temas y argumentos se encuentran,
entre otros, en los libros: Notas al margen, Editorial Cuatro Vientos, Santiago de Chile, 1985, Proposiciones para una
teoría de la medicina, Editorial Universitaria, Santiago de
Chile, 1992, Ensayos sobre ciencia y sociedad, Estudios Sigma,
Buenos Aires, 1995, Más allá del cuerpo, Editorial Andrés
Bello, Santiago de Chile, 1997.
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mite superar la cronofobia de la acción urgente, en que el apremio no admite opciones.
Quienes laboran en el campo de la salud encuentran a menudo que carecen de tiempo y
de quietud para rescatar la misteriosa energía
de lo nuevo y revitalizar las fuentes del entusiasmo. Lo importante no es siempre lo más
urgente. Y la teoría es importante.
Lo es por varios motivos. Es, primeramente, inevitable. Todo el mundo construye teorías, da ciertas cosas por supuestas, anticipa
el desarrollo de los acontecimientos sobre la
base de algún modelo o principio. No hay saber enseñable que carezca de teoría, pues para
enseñar se precisa un esquema global de aquello que se enseña. Y, finalmente, como ya señalamos, la teoría proporciona los cimientos
de toda práctica reglada. Al hacer, agrega el
saber y convierte la acción experta en un saberhacer. Este es el fundamento de las profesiones modernas basadas en las tecnociencias y
deudoras de su empiria sistemática.
De allí la conclusión: nada hay más práctico que una buena teoría.
LA EXPLICITACIÓN DE LOS
CONCEPTOS ÉTICOS ESTAREA
DE LA REFLEXIÓN
Particular relieve tiene, en este contexto, que
se nos invite a reflexionar sobre filosofía moral. Hoy preferimos para ese viejo menester el
término ética, que es a la moral lo que la
musicología a la música, esto es, su fundamentación racional y su sustrato teórico. No
es tanto explicar lo que hacemos en términos
de maldad o bondad cuanto explicitar los términos que usamos y dar razón de nuestro
comportamiento, lo que constituye lo más
esencial del discurso ético contemporáneo.
Refraseado como bioética en el ámbito de las
tecnociencias sobre la vida y la salud es, como
toda disciplina, un discurso. Esto significa la
fusión de hablante y de lengua en formas
creativas y novedosas, con una retórica y un
interés social, y, sobre todo, con la facultad de
crear los objetos de los cuales hablar. Una disci-
151
plina es un discurso que genera aquello de lo
que habla, lo construye para la mirada, lo
desconstruye para el análisis y lo reconstruye
para la acción.
En el caso de la bioética en tanto que discurso, a las acepciones tradicionales de ética
como costumbre o hábito, y ética como carácter, ha venido a agregarse, en mi opinión de
modo sustantivo, la dimensión dialógica.
Bioética es, por ende, un discurso constitutivamente dialógico, una narrativa social que
ilumina el imaginario moral de nuestras prácticas y las somete al juicio y a la crítica.
Todas las formas de filosofía moral —o ética en sentido amplio, incluida la mutación
bioética— tienen entre sus metas definir y
explicitar dos conceptos: el de lo bueno y el
de lo justo. Al hacerlo, derivan hacia principios universales, generales y públicos, que
señalan las formas usuales de fundamentar y
aplicar las nociones esenciales.
Lo bueno puede ser predicado con independencia de lo justo. Definido en primer término, aparece lo justo como el modo adecuado
de lograr lo bueno, y todas las doctrinas teleológicas de la moral comparten ese carácter.
Lo bueno puede ser definido en relación a la
perfección o virtud (perfeccionismo), en relación al placer (hedonismo), en relación a la
felicidad (eudemonismo), por citar algunos de
una larga lista de ejemplos.
Otros autores, de persuasiones diferentes,
sugieren una definición procesal y contractual
de la justicia. Esto significa, por una parte, renunciar a compartir una narrativa fundante
que nos vinculara a todos en la convicción y
certidumbre de lo bueno y, por ende, digno
de ser buscado. Las sociedades contemporáneas son mosaicos de pluralidades. Pluralismo moral que nos convierte, en el decir de
Tristram Engelhardt, en “extraños morales”.
Pero también, y no tan independiente del primero, pluralismo epistémico, que hace diferente el saber según el contexto y el grupo social
que lo atesora y perfecciona.
Pienso que la popularidad de la teoría de
la justicia de John Rawls se debe, aparte de
su intrínseca geometría y articulación, a res-
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Ética, Equidad y Práctica en las Instituciones de Salud
ponder a este carácter formal —procedimental— de la concepción de lo justo y al
empleo de la metáfora del “velo de la ignorancia”, que Rawls declara esencialmente
kantiana.3 Según esta noción, una sociedad
ideal, en su punto de partida, está conformada por seres racionales, desinteresados, libres
de odio y envidia, que deciden ponerse de
acuerdo sobre los principios de justicia que
deberían adoptar. En esa búsqueda, llegan a
los famosos dos principios que Rawls enuncia, el de la libertad y el de la diferencia, que
en la ficción de esa utopía serán escogidos
como los que mejor aseguran la convivencia.
Para abordar el problema de la equidad,
las nociones de lo bueno y de lo justo son indispensables y debieran ser explicitadas por
todo aquel que desee hacerlo. La esencia de
la doctrina de Rawls es que la justicia es, fundamentalmente, equidad. Y equidad significa algo así como imparcialidad y proporcionalidad apropiada en la distribución de los
bienes, los honores y los beneficios. No igualdad, sino distribución proporcionada a los
merecimientos debidos a cada uno. Se dirá,
entonces, de una diferencia que es inequidad
cuando es injusta, y puede serlo por ser innecesaria, evitable, involuntaria o atribuible
a algún agente. Sobra agregar que las personas y los grupos siempre se caracterizan por
sus distinciones y diferencias, y afirman su
identidad por medio de ellas. Algunas distinciones no comportan diferencias. Algunas
diferencias no llegan a frasearse como distinciones. Pero, de entre las diferencias, las
que son injustas por los motivos indicados
son llamadas inequidades.
Estas diferencias injustas en los servicios de
promoción, protección y recuperación de la
salud, estas inequidades, son, sin duda, un excelente motivo para la acción de instituciones
de servicio público. El modo en que se aborde
su análisis o se promueva su disminución o
3
Rawls J. A Theory of Justice. Cambridge, Massachusetts:
Harvard University Press; 1971. [Versión en español: Teoría de la justicia. 2a ed. México: Fondo de Cultura Económica; 1995.]
remoción, siempre es un tema moral. Lo que
importa examinar no es solamente su forma o
sus manifestaciones. Interesa también estudiar
cómo podrían encararse las acciones en el seno
de las distintas sociedades, y qué discurso debe
emplearse para convencer a quienes toman
decisiones políticas sobre cuáles son los modelos apropiados de intervención.
Sabido es que al respecto se ofrecen varias
alternativas. Tal vez la más obvia sea el pensamiento utilitarista, que busca el máximo
bien para el mayor número, prestando atención escasa a la distribución de ese bien. Así,
por ejemplo, el observar un aumento en el
promedio de la esperanza de vida mediante
intervenciones apropiadas convencería a un
utilitarista sobre la bondad de su acción. Aunque ello pudiera implicar pérdida de otros bienes y aunque fuera inequitativo el beneficio.
Por otra parte, aunque se promuevan fines
sociales puede existir, soterrado, un pensamiento individualista que, bajo la consigna del
igualitarismo, se resigne a una acción que no
toma en cuenta las notables disparidades de
oportunidad y acceso en materia de educación
que padecen numerosas sociedades y grupos
en nuestra Región.
El análisis podría extenderse. Sin embargo, el punto es el siguiente: toda reflexión y
toda teoría cumplen su propósito si contribuyen a explicitar los supuestos que implícita o explícitamente fundamentan las conductas. Explicitar no consiste solo en explicar:
consiste en “abrir” cada concepto del lenguaje
común o del técnico, examinar sus resonancias, estudiar sus connotaciones y abrirse a
sus infinitas posibilidades en la imaginación
social.
DE LAS INSTITUCIONES SOCIALES
QUE SATISFACEN DEMANDAS
Las necesidades y los deseos de las personas, cuando son reconocidos y se anhela su
satisfacción, pasan a constituirse en demandas.
Estas son, por tanto, necesidades y deseos que
para su satisfacción exigen un esfuerzo deci-
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dido y consciente. Cuestan dinero o tiempo.
Quienes resuelven demandas gozan de los
reconocimientos de los grupos humanos: prestigio, dinero, poder, amor.
Una institución social es un agregado de personas, relaciones entre personas, objetos, conceptos y recursos, que responde a una demanda social. Responder a una demanda significa
que hay interés en su existencia, e interés significa relación (Inter-Esse, entre seres) de personas con personas y de personas con cosas.
Del estudio de las instituciones se infiere que
materializan sistemas de reglas relacionales de
naturaleza pública, esto es, evidenciable, y que
su acción consiste casi siempre en la creación,
el perfeccionamiento o la aplicación de una o
varias tecnologías.
La voz tecnología tiene en este contexto un significado preciso. Significa, como su etimología
más auténtica sugiere, logos de la técnica. Esto
es, técnica —un hacer—, con un contexto racional que la dota de significado social —un saber—. Decíamos antes: saber-hacer. Las profesiones modernas y el saber experto que valoran
hoy las sociedades son amalgamas de saber y
de hacer. Ni pura técnica ni pura teoría. Una
mezcla. Una proporción adecuada de ambas.
Las instituciones sociales de servicio sirven
mediante tecnologías. Por ejemplo, tecnologías productivas, que producen bienes (poiesis)
o procesos sociales (praxis). Tecnologías
semióticas, que trabajan con signos y símbolos, produciéndolos, modificándolos o eliminándolos. Tecnologías organizacionales, que se
refieren a la constitución y distribución del
poder y al establecimiento de jerarquías. Y tecnologías del sí mismo, que establecen y modifican identidades.
Sostengo que estas cuatro clases de tecnologías están involucradas en todo tipo de institución social en grados y proporciones diferentes según sus finalidades. Es hasta posible
argumentar que una misma institución, a lo
largo de su historia, puede cambiar su tecnología dominante y, con ello, su carácter.4 Lo
Cf. Lolas F. Medical praxis: an interface between ethics,
politics, and technology. Social Science and Medicine
4
153
esencial no es hacer aquí una taxonomía
institucional —puede ello tener inmenso beneficio—, sino destacar que una institución
social nace en respuesta a una demanda (necesidad o deseo con precio), materializa un
interés de la comunidad (garantía de su existencia), y manipula tecnologías.
INSTITUCIONES SOCIALESY SU
VIRTUD PRIMORDIAL: LA JUSTICIA
Dice John Rawls que la primera virtud de
toda institución social es la justicia, así como
la verdad es la virtud primordial de los sistemas de pensamiento.
Entre las creencias y las normas, en el amplio espacio de la convivencia y del diálogo,
las instituciones suelen convertir los ideales
en principios prácticos y las ideas en acciones. Una nueva concepción del mundo, por
ejemplo, fruto de las instituciones académicas,
influye sobre procesos sociales a través de
personas que la transforman en inspiración de
sus actos. Un valor religioso, que las iglesias
transforman en culto y ritual, compite con
otros valores para determinar la conducta de
los individuos. Y así, en general, puede descubrirse que las instituciones, por obra misma de su existir, manifiestan la textura valórica
de la sociedad mayor, y esta puede estudiarse
con provecho atendiendo al tipo, variedad y
calidad de las instituciones sociales.
Cuando se examina el trabajo de algunas
instituciones sociales, suele describírselo en
términos tales como “operacionalizar” conceptos y diseñar estrategias de aplicación de
conocimientos para intervenir en la marcha de
la sociedad. Tal es el caso de las organizaciones vinculadas a la salud y el bienestar. Como
la mayoría de ellas basa su eficacia en procesos cognoscitivos y en sus resultados, los examinaremos brevemente en el contexto del trabajo institucional.
1994;39:1–5. Lolas F. Theoretical medicine: a proposal for
reconceptualizing medicine as a science of actions. The
Journal of Medicine and Philosophy 1996;21:659–670.
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Ética, Equidad y Práctica en las Instituciones de Salud
INVENCIÓN, INNOVACIÓN,
TRANSFORMACIÓN SOCIAL
Los procesos que influyen en la salud y el
bienestar pueden englobarse en tres grandes
grupos. Por un lado, la invención, que siempre
lo es de conceptos e ideas. Puede definírsela
como la creación de posibilidades de experiencia, como un aumento del “input” potencial
de un sistema de creencias y acciones. Un concepto como el de átomo, por ejemplo, es una
invención fértil porque permite acomodar
muchos hechos perceptivos y de experiencia,
o incluso anticipar hechos que no existen aún.
La invención siempre es un proceso teórico,
un anticipar experiencias posibles. Cuando
Ortega y Gasset habla de los conceptos, en
realidad piensa en ellos como herramientas
para construir mundos. Los conceptos, en tanto invenciones, son “constructos”. Son construidos y construyen. La fuerza indiscutible
de las tecnologías sanitarias procede de invenciones afortunadas.
El proceso de innovación consiste en aumentar
el “output” de una determinada construcción
conceptual. Es, por ejemplo, el perfeccionamiento de técnicas. Es incrementar el campo de aplicaciones de una teoría. Es, en síntesis, sacar el
máximo provecho a lo que ya existe, mejorar en
sentido cualitativo y cuantitativo lo que se tiene.
La mayor parte de los instrumentos y artefactos
que hoy empleamos son perfeccionamientos
innovadores de algo que ya existía.
Hay un tercer conjunto de procesos que no
se dejan describir en los términos empleados
para hablar de innovación e invención. Aunque es posible que, en último análisis, toda
transformación social dependa de uno de aquellos dos procesos, es preferible —heurísticamente preferible— mantener una designación
especial para las mutaciones del alma colectiva que pueden preceder, acompañar o seguir a
la invención y la innovación. La conveniencia
de separar la transformación social se
ejemplifica al considerar que inventos fascinantes, de evidente utilidad, no tuvieron eco en la
sociedad de su tiempo, y que, a la inversa,
modificaciones del escenario social hicieron
imperativa la aparición de ciertos inventos o la
innovación de algunas técnicas. Es probable
que el sustrato en que acontece la transformación social sea ese magma germinal indiferenciado que los autores franceses han llamado
“mentalidad”. Una forma especial de existir las
comunidades, una modulación del ser humano social que constituye una manifestación
peculiar susceptible de cambio, progreso y retroceso. La historia de las mentalidades es la
historia de las posibilidades diferentes de habitar el mundo y de dotar de sentido a la información, el conocimiento y las emociones. La
transformación de las mentalidades es un proceso que analíticamente podemos independizar de la innovación y la invención.
Estos tres tipos de procesos, invención, innovación y transformación social, pueden concebirse ligados en secuencia lineal. Clásicamente se ha pensado que la invención —la ciencia
pura y la investigación fundamental— precede a la innovación, y que esta no es sino su aplicación que produce transformación social al ser
generalizada o hecha industria. Pasteur decía:
“no existen la ciencia y la técnica, solo la ciencia y las aplicaciones de la ciencia”.
Hay varios motivos para dudar de esta secuencia lineal. Aunque no procede discutirlo
aquí, baste observar que la innovación produce más innovación, y a veces decide el curso de
la invención. La ciencia moderna sería impensable sin tecnologías apropiadas para sus cada
vez más exactas preguntas. No toda invención
fructifica o es aceptada socialmente, y ello se
demuestra con el ejemplo de la energía nuclear
aplicada a usos pacíficos, que siendo tecnología apropiada y brillante demostración de ingenio, supone riesgos que algunas sociedades
rechazan. Ya hemos mencionado la fascinante
hipótesis de que la transformación espiritual
de una sociedad, una mutación de su sensibilidad o mentalidad, haga necesario cierto tipo
de invención o demande algunas innovaciones
específicas.
Por lo tanto, es posible proponer que en lugar de una secuencia nos encontramos con un
interminable ciclo de recurrencia entre la invención, la innovación y la transformación
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social. Cada proceso está determinado y a su
vez codetermina los otros. El resultado final
quizá no pueda ser retrotraído a una causa
única ni anticipado como consecuencia simple de un solo conjunto de procesos.
DEMANDAS ÉTICAS AL TRABAJO
INSTITUCIONAL
La mejor manera de anticipar el futuro es
inventarlo. Si algo caracteriza la actual demanda de reflexión y de diálogo bioético es la comprobación de que serán efectivos no solamente si reaccionan frente a yerros o excesos sino,
y muy especialmente, si los anticipan y previenen. La actitud proactiva en filosofía moral
puede caracterizarse como el intento por iniciar el ciclo invención-innovación-transformación en el plano de la sensibilidad vital, o al
menos considerar esta desde que se piensa en
nuevos conocimientos o se realizan innovaciones técnicas. Así, por ejemplo, sabido es que
una innovación en medicina crea condiciones
problemáticas respecto del acceso a ella. Es
obvio que la racionalidad tecnocrática, al hacerse hegemónica, empieza a responder a sus
propias exigencias y se libera de compromisos con la demanda que la hizo necesaria.
Muchos adelantos llamados médicos son en
realidad tecnocráticos y no responden ya a
la inicial demanda de atención sanitaria.
Piénsese tan solo en la mayor resolución de
los aparatos de imaginología que incrementan
a veces marginalmente la precisión diagnóstica, pero que la industria hace creer que son
fundamentales para la atención correcta. O
considérese que, al bajar el “umbral tecnológico de detección de anomalías”, muchas condiciones asintomáticas (alto colesterol sanguíneo, presión arterial elevada) se convierten en
auténticas “enfermedades” que exigen intervención. Paradójico es, pero real, que muchos
perfeccionamientos e innovaciones, aparentemente susceptibles de ser reconstruidos como
respuestas a la demanda inicial (atención de
salud), en último análisis son inherentes a la
dinámica de una institución social distinta, el
155
sistema tecnológico y su correspondiente
tecnocracia dominante. La reflexión ética
proactiva es hoy día indispensable para anticipar y, ojalá, atenuar la patogenicidad del
progreso y la inevitable faz jánica de las tecnociencias: como el dios Jano, sus resultados tienen dos caras y pueden ser deletéreos o benéficos, dependiendo de muchos factores, la
demanda entre otros.
Es también un imperativo ético que las instituciones de servicio aclaren los alcances de
su acción y despierten expectativas razonables
sobre su efectividad y eficacia. Articular las
demandas significa justamente eso: ser realista en lo que se ofrece y no despertar esperanzas vacías de contenido. Toda institución que
construye futuro debe hacerlo con la responsabilidad inherente a su credibilidad y al respeto que inspira. No hay que olvidar que tanto como el resultado de una intervención
técnica importa su significado social, y este
opera en el plano de la sensibilidad vital, de
la mentalidad y del espíritu comunitario.
Siempre hay un “doble efecto”: por un lado,
el resultado concreto, por otro, el simbólico. A
veces prevalece este último, y una institución
que demuestra ser eficaz por cifras interesantes de reducción de morbilidad y mortalidad
puede carecer de crédito público por razones
que nada tienen que ver con su competencia.
Cada institución de servicio en el campo de
la salud, al articular la demanda y definir el
ámbito de sus intervenciones define al mismo
tiempo la efectividad de su acción posible. Llamo efectividad al resultado de la acción óptima
en condiciones ideales, es decir, tal y como lo
imaginan los planificadores. Como es sabido,
se trata de útiles ficciones y nunca se dan
integralmente en el mundo real. Cuando hablamos de este, la efectividad se transforma en
eficacia, es decir, el real resultado en condiciones reales. Obsérvese que la eficiencia es el cumplimiento de la eficacia, y es un valor ético tanto como organizacional o administrativo. No
se está obligado a realizar el mejor de los mundos posibles, sino a perfeccionar el más concreto de los mundos reales. Nunca la ética ha
significado prometer y realizar imposibles.
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Ética, Equidad y Práctica en las Instituciones de Salud
Hacer transparente la toma de decisiones es un
imperativo ético porque la justicia, primer
valor de toda institución social, se basa en
buena medida en la imparcialidad. La publicidad, aunque el término sea engañosamente
trivializante, es una obligación ética que en las
instituciones de servicio adquiere importancia en diversos planos. Sin duda en el plano
técnico, pues muchas de las acciones de tales
instituciones consisten en transformar los datos en informaciones, y estas en conocimiento. Hay aquí un imperativo ético, una verdadera “eticidad” del saber que debe estudiarse
y perfeccionarse. El servicio sanitario es tanto
una conversión de ideas en acciones cuanto
un adaptar estas al cambiante escenario de las
demandas humanas. Hablar de equidad requiere tener en cuenta que se trata de un
constructo de extrema labilidad, móvil como
una veleta, que requiere conciencia vigilante
y absoluta transparencia en los conceptos y
sus aplicaciones.
Hay en toda institución de servicio que perfecciona sus conceptos y sus técnicas el riesgo
propio de las expertocracias, al que ya nos
hemos referido diciendo que el sistema tecnológico empieza a responder a su grupo de referencia, la tecnocracia, y olvida su papel mediador del bienestar humano. También las
tecnologías “blandas”, de la organización y la
gerencia, tienen ese riesgo. Embelesados por
sus logros, conscientes de su autosuficiencia,
los gerentes y administradores pueden fácilmente olvidar el fin último de su trabajo. No es
éste perfeccionar sus instrumentos, realizar
proezas de eficiencia, lograr excelentes índices
de costo/beneficio, sino simplemente, servir al
bienestar y la salud. Necesitamos, hoy más que
antes, una reflexión que se concentre en los fines y
no solamente en los medios. Una ética de fines no
es necesariamente una ética comprometida con
una narrativa exclusiva y excluyente. Los fines
no son patrimonio exclusivo de ninguna religión o ideología. Los fines son también materia de consenso social, y, por ende, de diálogo.
También, por cierto, de adecuados procedimientos para precisarlos, legítimos en tanto que
voluntariamente formulados y aceptados por
toda la comunidad.
Toda la comunidad implica participación. En
ninguna otra esfera se demuestra mejor la veracidad del aserto “saber es participar” que
en la sanitaria. Saber es “tomar parte” en el
diálogo social y ser reconocido como poseedor de la capacidad de dialogar. La ética del
discurso no es sino el sencillo reconocimiento
de que la praxis comunicativa supone agentes morales y epistémicos reconocibles en tanto capaces de diálogo eficaz y no solamente
como reflejos o receptores de conocimiento
experto. La tradicional verticalidad del discurso profesional y técnico ha sido erosionada por
la necesaria horizontalidad que demandan las
más importantes acciones en salud. Nada saca
un gobierno invirtiendo en costosos aparatos
si la gente no puede participar en su uso adecuado. La equidad es aquí equidad de acceso al
conocimiento, con las particularidades de este
según el contexto en que se forja y aplica. Está
demostrado que la jerga expertocrática, que
desdeña o ignora el sentir de las personas a
las que dice servir, se esteriliza y aísla, haciéndose al final inútil. El imperativo bioético del
diálogo adquiere una máxima prioridad en el
diseño del futuro.
Las instituciones sociales que laboran en pro
de la salud y del bienestar deben demostrar su
eficiencia con respuestas acordes a demandas razonables. Ya esta afirmación es compleja, toda
vez que lo razonable de una demanda suele
ser materia de discrepancias entre los que la
experimentan y los que debieran satisfacerla.
Lo que “tratamiento adecuado” significa en
Manhattan, es distinto en Bucaramanga. El lenguaje de la oferta no siempre concuerda con el
de la demanda, y el resultado de esta discrepancia es frustración e insatisfacción de usuarios y proveedores de servicios. Planificar sin
actuar no satisface adecuadamente y es imperativo ético demostrar con acciones lo que se
predica.
Queda para el final la más crítica, la más
importante y definitiva de las exigencias éticas: se resume ella en la excelencia técnica. Nada
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que se haga en forma imperfecta, liviana, descuidada, puede ser moralmente aceptable, así
sea inspirado por la intención más beneficiadora que se pueda imaginar, o signifique en
realidad un alivio para los que sufren. Como
debe leerse el juramento hipocrático es que no
puede haber un médico bueno si antes no se es
buen médico. La competencia técnica es el primer imperativo ético de todas las profesiones
y oficios creados para ayudar a las personas.
El compromiso es mantener constante el afán
de perfección.
LO PROPIO, LO BUENO, LO JUSTO
En modo alguno agotan las reflexiones precedentes las cuestiones que genera la pregunta por la impronta ética de una institución de
servicio. Más bien quedan como provisional
incitación a un desarrollo deseable.
Tener espacio para la reflexión y la práctica
de la teoría es un privilegio, pero también una
obligación. Obliga en realidad a una postura
permanentemente crítica de lo que se hace, de
sus motivaciones y de sus resultados.
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El resumen de este ejercicio es simple y directo. Las acciones han de ser apropiadas, en el
sentido de cumplir con las exigencias del buen
arte. Lo propio es el primer valor, el valor técnico, lo bien pensado y ejecutado. La mathesis.
Lo bien hecho está bien porque cumple con
el recto proceder, pero también porque consigue buenos resultados. Entre ellos, hacer bueno al agente que ejecuta la acción, ser su camino y posibilidad de perfección, su askesis.
La acción correcta de una institución de servicio y ayuda debe ser además justa. La justicia, primera virtud de toda institución social
en tanto que tal, debe extenderse a sus acciones hacia la comunidad. Y justas son las acciones que, si se generalizaran, acrecerían los
beneficios, el bienestar y la felicidad del cuerpo social.
Tales son, en suma, las dimensiones del juicio bioético: lo propio, lo bueno y lo justo.5
Pienso que las demás pueden derivarse de
ellas.
5
Cf. Lolas F. Bioética y antropología médica. Santiago de
Chile: Editorial Mediterráneo; 1999.