Millennium Development Goals. Progress towards the right to health in Latin America and the Caribbean
Enormous differences in health within and between countries intertwine closely with degrees of social disadvantage, and when people's health is at the mercy of their individual situations, health-care inequalities can entail dramatic individual risks and costs. Promoting health equity can also be defended on the grounds that it simultaneously fosters economic development, since investments in health and its determinants contribute to economic growth, productivity and prosperity. On the other hand, economic growth by itself without appropriate policies to ensure reasonable fairness in the way its benefits are distributed, and lacking social protection systems, contributes little to health equity.
According to a well-established normative definition (Whitehead, 1991), health inequities can be understood as differences that are unnecessary and avoidable and, furthermore, unjust. This is why the Millennium Development Goals and their indicators are so important. They establish a "civilizing minimum" of well-being for all citizens, set out a road map and a deadline for efforts to open up greater opportunities to those denied them and, as an ethical imperative, provide a catalyst to rally the forces of solidarity in society behind public policies capable of attaining them.
In 2005, all United Nations bodies working in Latin America and the Caribbean came together under the auspices of the Economic Commission for Latin America and the Caribbean (ECLAC) to create a systematic, integrated and shared vision of the Millennium Development Goals (United Nations, 2005). Now, again under ECLAC coordination, and with the support of other United Nations bodies, the Pan American Health Organization (PAHO), the World Food Programme (WFP), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA) and the United Nations Children's fund (UNICEF) have conducted a review of progress towards the health-related Goals in Latin America and the Caribbean, the obstacles to their attainment and the suitable policies needed, and analysed prospects for the future.
As determinants of health conditions in the population, poverty, undernutrition and hunger are crucial obstacles to the effective enjoyment of health as a citizens' right; hence the vital importance of reviewing progress and obstacles in these areas. The report highlights some very positive trends, such as the reduction in indigence in the region up to 2007, although, with very few exceptions, this unfortunately cannot be put down to rising earnings. It is due to rising employment, boosted by the demographic dividend (falling numbers of dependent family members) and rising non-wage income, particularly from public and private transfers such as poverty reduction programmes and remittances. Labour income, however, has increased only in a few countries and has not contributed significantly to poverty reduction. As unusually abrupt food price rises in certain circumstances can trigger a rapid increase in extreme poverty, hunger and undernutrition, the book analyses the interactions between agricultural and energy markets as well as those between agricultural and non-agricultural commodity markets and financial markets, that explain food price hikes around the world.
Around 2005, just over 10% of the region's inhabitants lived in housing and family conditions that left them unable to meet a basic set of needs in the form of shelter and protection from the elements. The situation differs greatly from one country to another and between urban and rural areas; in some countries over 35% of the population have unmet basic needs, while in others, fewer than 5% of inhabitants suffer from these privations. Housing conditions and access to basic services (drinking water, sanitation, and electric power) are far more of a problem in rural areas, and the public investment required to improve them is substantially higher because of the wide geographical dispersion of households or their remoteness from public or private service networks.
Regional average figures on progress towards the health-related Goals in the 1990-2007 period -with two thirds of the time allotted for achieving the Goals having passed- conceal large disparities between countries. The situation of underperforming countries varies greatly, and some of them do not even seem to be getting any closer to meeting the goals. The Latin American and Caribbean countries have taken major steps in the effort to combat generalized undernutrition and meet the target of eradicating hunger, although in some of them, the proportion of people who are underweight for their age remains very high, and there needs to be a forthright commitment to the goal of eradicating hunger. Child mortality has declined substantially and life expectancy at birth has increased; in 2007, child mortality was the lowest in the developing world and was dropping faster then in any other region. But maternal mortality is a cause for concern and shows that further efforts are needed; although the figures drifted downwards in the region between 1997 and 2005, the ratio and absolute number of maternal deaths have barely shifted. Where prenatal care and assisted childbirth are concerned, there are situations and countries where major improvements are needed, although a given proportion of assisted births does not guarantee lower maternal mortality, as this also depends on the effectiveness and quality of health care as well as other socio-economic and environmental factors. In relation to the efforts to combat disease provided for in the Goals, this report discusses the progress achieved in reducing the incidence of malaria and tuberculosis in the region, and examines the measures that have made this possible.
A number of empirical findings clearly reveal a complex web of interrelationships between the numerous causes determining the well-being and health of the population. Econometric measurements described in this survey (for a set of countries where demographic and health surveys are available) demonstrate empirically the need to tackle the socio-economic inequalities underlying the uneven distribution of health determinants in our region. Descriptive and econometric measurements of data derived from household income and expenditure surveys are used to analyse the varying levels of direct health spending (out-of-pocket expenditure) by households and its unequal distribution and to examine unequal levels of suppressed demand for such spending , even when households lack medical coverage or health insurance.
As a rule, public spending on non-contributory health care in the region since the 1990s has behaved in a highly procyclical way, since lower fiscal priority has been given to it than to other social sectors such as education, social welfare and, most particularly, social security. This report, while recognizing the difficulties involved in an exercise of that kind, uses a model that estimates the disability-adjusted life years (DALY) lost in the countries to project the additional interventions necessary to attain some of the targets of the Goals in 10 countries and their costs, and extrapolate these results to the whole region.
Lastly, the report analyses the match between system financing and the aim of attaining higher levels of solidarity in social protection systems, avoiding risk selection and moving towards guaranteed equitable coverage. It also offers some reflections on the legal, institutional and organizational framework and the optimum deployment of human health-care resources required to integrate primary care into health systems in a new way, in order to guarantee coverage and universal access to services that are comprehensive, integrated and appropriate and to address other determinants of health and equity. This complex agenda must tackle not only financing constraints, but also policy and institutional weaknesses.
Alicia Bárcena Executive Secretary Economic Commission for Latin America and the Caribbean (ECLAC)