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Health policies in Latin America
HEALTH
POLICIES
IN LATIN AMERICA*
RAUL VARGAS Regional
Adviser
in Health
Planning,
PAHO/WHO
Abstract-The third Special Meeting of the Ministries of Health of the Americas in 1972 approved the Ten-Year Health Plan for the Americas. This new approach to health policies emphasized the extension of coverage to previously undeserved populations. This international commitment, reaffirmed in 1977, reflected in the firm decisions of each government to carry out strategies involving the provision of primary health care: community participation; reform and restructuring of health services organizations and administrations: differentiation of levels of care and regionalization: development of physical, financial and human resources.
Convened by the Pan American Health Organization (PAHO) in October, 1972. the Ministers of Health of the Americas held their Third Special Meeting in Santiago. Chile. where they studied and approved the Ten-Year Health Plan for the Americas 1971-1980. This plan expressed the intended coordinated efforts of the countries to improve the health conditions of the people of the Region as a whole. The Ten-Year Plan proposed a set of goals and recommendations dealing with almost every conceivable aspect of the health systems’ structure and operation and suggested targets for health status to be attained in terms of averages for the region. The Plan itself sets as a fundamental requirement for’meeting the recommended goals and targets “the definition in each country of a health policy consistent with the economic and social development which clearly specifies the goals and the required structural changes”. Why did the Ministers assign such importance to the definition of a health policy? In most cases, it was probably due to their experiences with health planning process in the various countries of the Region. The use of the term “development” in international circles started in the late 1940’s to designate a process that can be promoted and guided within each country through the rational action of economic planning. This approach persisted during the 1950’s, strengthened by the work of the United Nations Economic Commission for Latin America (ECLA). both at a conceptual level and in practice through the direct assistance given to individual countries in the development of their economies. This approach to the problems of underdevelopment, based mainly in the manipulation of economic factors, failed to produce adequate solutions. The expected “take off’ did not materialize, even though satisfactory levels of economic growth were attained in a few cases, because previously unforeseen dynamic factors of social change (such as higher rates of population growth, urbanization, modernization and an increased political consciousness) entered the picture and necessitated different approaches. The Charter of Punta de1 Este, signed in August * Originally prepared for the Joint National Meeting of the Latin American Studies Association and the African Studies
Association.
69
1961, was a milestone in the evolution of the new ideas about integrated development, and of the role of planning as a method and a tool for change, as well as an instrument for conceptual systematization. The idea of structural change gained in importance not only as an essential factor in stepping up the rate of development, but also as a basic concept that should be promoted in its own right, quite apart from its implications for the economy. Subjects such as income redistribution, fair distribution of goods and services, agrarian reform and tax reform, which involve deeply rooted forms of social and political organization, were treated openly and the need for integrated social and economic development planning was recognized. The Charter of Punta del Este included a health section with recommendations and goals for the levels of health to be attained by 1970. This section, known as the Ten-Year Public Health Program for the Americas, urged the countries to prepare national health pians within the framework of general socioeconomic development plans. PAHO was given the.responsibility of cooperating with the countries in this endeavor, and to that end, in collaboration with the Center for Development Studies (CENDES) of the Central University of Caracas (Venezuela), designed a method to prepare national health plans that was rapidly disseminated regionally through special courses, seminars and other training activities. Planning consultants were assigned to provide technical assistance to the countries and a First Special Meeting of Ministers of Health of the Americas was convened in Washington (August 1963) to outline a regional strategy for health planning. By 1964, most countries had adopted a national policy aimed at the preparation of national health plans and had variously organized the operation of their planning processes. The general principles that guided the PAHO/CENDES method. with its strong component of economic thinking, were adopted in most cases. Especially important were the notions of “planning for health” instead of “planning for health services”, and the deep-rooted desire to increase et-hciency of use of health facilities and resources. During the decade of the sixties health planning in Latin America was enthusiastically undertaken and evolved under the assumption that the existing health resources and the way in which they were distributed
70
KAUL
and used were the expression of the real (albeit implicit) health policy of each country. The fact that the configuration of most of the prevailing health systems was actually the final outcome of an intermeshing of a wide variety of previous policies was not paid much attention. Therefore, planning was mostly oriented to the attainment of higher levels of effectiveness and efficiency in the use of available resources. By the late 1960’s enthusiasm for health planning had partially faded; criticism mounted, and the whole held of planning had to be reassessed and reoriented in light of experience. There was a proliferation of national health plans prepared by “scientific and rational” health planners that were imperfectly implemented or not implemented at all. It was then understood that planning is not the exclusive domain of planners any more than administration is the exclusive concern of managers and administrators. The crucial role of the policy decision-maker was appreciated and the whole process of policy formulation examined as an integral part of the national political system’s processes. A clearly stated and well-formulated health policy to guide the planners and administrators was then recognized as essential in planning for the health sector. One of the several criticisms of the health planning processes as they had been going on in the countries was that health planners had dedicated too much of their time to the diagnostic stage, and in effect, in some instances the national plans did not proceed beyond that stage. However, this concentration on diagnosis proved to be quite helpful. insofar as the lengthy studies that were made revealed most of the underlying problems and constraints for the develop ment of the health sector. Some of these problems affected the planning processes themselves and often prevented implementation of adequately formulated plans. With or without national plans there was no doubt that as a whole the Region had improved its level of health substantially since the end of the Second World War, especially in terms of lowering mortality and preventing, arresting and curing certain diseases. Mortality due to infectious diseases among children under five years of age decreased by 48% in Latin America between 1956 and 1966; over the same period diseases of the respiratory system decreased by 26x, and those of the digestive system mainly gastroenteritis, by 44%. Similarly morbidity and mortality due to diseases preventable through vaccination showed considerable reductions, as did malaria and smallpox (erradicated since 1971). In 1972, at their Third Special Meeting, the Ministers of Health showed a great concern for continuing and accelerating the decreasing trends of mortality and morbidity, which is reflected in the goals and recommendations of the Ten-Year Health Plan for the Americas. However the consensus among the Ministers was that the substantive goals for further reducing morbidity and mortality could be no more than wishful thinking, unless the strategies to attain such goals were stated and carried out. It was at this point that the “lengthy and useless” information provided by the processes of planning entered the picture, and the following issues became clear.
V ARGAS
1. In contrast to the European experience. where the most important decline of mortality ocurred prior to the availability of modern medical knowledge and technology, the gains in Latin America were to a large extent associated with the new applied medical knowhow, antibiotics, vaccines. drugs. insecticides and to a certain extent. basic sanitation services. 2. As suggested by the information compiled by PAHO in 1971, almost 401; of the population of Latin America does not have access to existing medical facilities. Hospitals, health centers, medical posts and other institutional or “formal” types of services are out of reach for these people because of their social, economic, cultural or geographic isolation. They are a certain number of marginal urban dwellers-the poor, the unemployed and the rural migrant-and the large proportion of rural population that only partially and sporadically have been in contact with any kind of health services. 3. It is evident that the net gains in the national health indices had been largely due to improvement in the health status of the mostly urban population with ready access to health and basic sanitation services. To continue this pattern of provision of services mainly to this portion of the urban population neglecting the rural and the economically disenfranchised urban areas would only lead to diminishing increments of improvement in the national health status (the law of “diminishing returns”) and to rising expenditures as the cost of medical services of the type offered to satisfy the mostly urban demand rises faster than genera1 inflation. 4. Aside from the purely economic and mathematical aspects, the political and ethical faces of the problem were fundamental. The principle of “social justice” in the distribution of services that had apparently guided the planning efforts of the 1960’s as expressed in the PAHO/CENDES method had been in practice only partially implemented. It is true that some increased availability of services was obtained through rationalization of organization and greater efficiency in the use of existing resources: however the absolute gains were diluted by the urban population growth and by the increasing demand for services. Rural-urban inequity persisted. In 1970 there were 5000 units providing elemental health services to the 453/, of the total population of Latin America who lived in localities of less than 2000 inhabitants. whereas there were almost 13.000 units to provide medical care of all types to the 429: who lived in the cities of 20.000 or more inhabitants. In light of the situation, deficient coverage of the health services revealed itself as the most crucial issue to be faced by most of the countries of Latin America. There was no doubt in the minds of the Ministers of Health of the Americas when they accepted and adopted as the central goal of the Ten-Year Health Plan for the Region the “extension of coverage, including minimum comprehensive services, to all the population living in accessible communities of less than Zoo0 inhabitants, and provision of basic and specialized services to the rest of the population by means of a regionahzed health system” assigning priority to the control of communicable diseases. maternal and child care and family welfare. nutrition and basic sanitation.
Health policies Again the expression of this Regional goal could have been no more than wishful thinking if at the same time the instruments for its implementation were not provided. Thus the same Plan contains recommendations to ensure the achievement of its proposals in the form of instrumental policies dealing with: (a) The installation and development in each country of an appropriate health system. (b) The establishment and expansion of the health planning process as an integral part of socioeconomic development and the organization of systems of information, evaluation and control. (c) The undertaking of research mainly addressed to ascertain the effects of various alternatives within the sectoral policy, to increase productivity and effectiveness of services, and to study costs and financing. (d) The increase of the operational capacity at the institutional and the sectoral level as a whole through coordination or integration of health institutions; the strengthening of administrative, sectoral and institutional reform: and the formulation and execution of programs for the delivery of services, development of the infrastructure, investments and financing. (e) The development of human resources, with goals for the training of all kinds of health personnel and recommendations to improve their geographic and institutional distribution. (f) The development of physical resources and the increase of the installed capacity with recommendations for their use and distribution. (g) The development of financing systems. (h) The development and use of health technologies appropriate to the conditions of each country with a view to increasing the coverage and productivity of the services. As soon as the Ten-Year Health Plan was formalized by the Ministers’ Meeting in Chile and incorporated by the Directing Council of PAHO as the expression of the health policy for the Region as a whole, the countries engaged themselves in the task of defining or adjusting their national health policies. Of the 22 countries which participated in the first evaluation of the Ten-Year Health Plan, 16 had already defined or adjusted their national health policies in 1974, and the rest of them were in the process of doing so. All the national policies formulated thus far are consistent with the recommendations and with the areas of priority stated by the Ten-Year Health Plan. In fact most countries have adopted the structure of the Ten-Year Plan as a framework and its goals are references for the study and selection of their national goals. To this end several countries found useful a guide for the analysis and incorporation of the goals of the Ten-Year Plan in the national health policies that was prepared in 1973 by the Secretariat of PAHO, as well as the systematization of theory on policy formulation that was prepared for three special courses that were offered between 1971 and 1974 by the Pan American Health Planning Center. There is a noticeable difference between the health policies of the 1960’s and the new policies of the 1970’s. The former are mostly the product of the analyses made by health planners of available resources
in
Latin America
71
and their allocation and use; they reveal the strong influence of the. economic thinking of the times, and their propositions, mainly related to the attainment of higher degrees of efficiency from existing resources. seldom refer to any radical change in the prevailing structure of the health systeqs. In contrast the policies of the 1970’s are propositions originating with the policy decision-makers themselves. They are based upon a great deal of information gathered through better channels of communication and they are oriented to the conceptual framework of the systems-analytic approach. Furthermore, while continuing to stress improved efficiency. the new policies interweave concepts of growth change, unified development. community participation, technological innovation and social satisfaction around the central theme of extension of coverage. But perhaps the most striking feature of these policies is the firm decision of the governments to carry them out, as expressed by the Ministers of Health in their Fourth Special Meeting (Washington, September, 1977). Starting from a simple numerical relationship between resources and population, or services and population, coverage has developed into a very complex concept embedded in the context of unified development. Coverage is the product of an effective and systematic provision of basic health services designed to satisfy the needs of the entire population. Such services should be continuously available at locations accessible to everybody; they must be acceptable to the community and should ensure the access of patients to the different levels of care of the health services system. Thus the concept of coverage implies a dynamic balance between the needs and aspirations of the community expressed in the demand for services in the one hand, and the available resources with their various technological and organizational combinations to satisfy such demand on the other hand. Therefore, the final expression of coverage will vary from country to country, or even from one community to another within the same country, depending upon felt health needs and the characteristics of socioeconomic development. All the health policies in Latin America at present aim for the coverage of the entire population. A variety of approaches have envolved, but with varying degrees of emphasis, most countries have adopted the following strategies. (a) Provision of primary health care Primary health care refers to activities aimed to meet the basic needs of the community, including some that can be performed through traditional or folkloric means (traditional community health system). Thus the notion of primary health care implies the recognition of the traditional or informal health system through wliich the community cares for the health of its. members. This system has always been present, and co-exists with the formal, scientific, institutional health services system, though often in the rural areas it is the only one in operation. The strategy of primary health care requires the acceptance of the traditional system, the understanding of its ways, the improvement of quality of its performance and its proper articulation with the formal
72
RAUL VARGAS
systems. It also requires an inter-sectoral approach at the community level because meeting basic needs implies many actions not within the scope of work of the health sector. (b) Community participation Community participation is a process of self-transformation of individuals according to their own needs as well as the needs of their community. This process creates in the individuals a positive attitude toward their own as well as their community’s well-being and the ability to act consciously and constructively in the general development. “Enabling participation” is the expression used to properly designate this strategy, which with approaches depending upon the prevailing social, cultural. and political patterns of organization. is being implemented in several countries. (c) Organization of the health services system The institutional health system of most countries is not adequately organized to meet the requirements of extension of coverage. The several agencies that comprise the health sector have different interests have various degrees of efficiency in their performance, obey not too clearly stated policies, operate without coordination among themselves and are often very poorly managed. The strategy of organization of the health services system is addressed to rectify all these conditions through organizational reform and restructuring. (d) Organization of levels of care In general the most frequent health needs require simple services provided through a combination of unsophisticated resources and technologies, whereas the less frequent require the combination of more specialized and complex resources and technologies. An efficient institutional response is hierarchical provision of care. At each level a different mix of resource inputs will be optimal. The first level of care is the least complex, and in general serves as the point of contact of the health system with the community. The definitions of the levels of care vary from country to country depending upon the nature of the health problems, the available resources and the type of organization of the health services system. However, it must be born in mind that “level of care” is not synonymous with type of health unit, establishment, or personnel rendering services. In fact it is possible for a health unit to provide care of various levels in the same location. (e) Regionalization and referral systems Functional regionalization of health services is the technical and administrative expression of the hierarchy of services. Regionahzation implies the organization of services according to levels of care, making possible a better geographic distribution of health facilities. The first level of care should be provided by health units of any size and complexity within easy reach of the population. The number of points of contact of the institutional system with the population is thus maximized. Other levels of care of higher complexity are also designed to attend to the needs of the entire
population, but are more centrally located in the larger health centers and hospitals with more specialized personnel and equipment. Geographically they will be located in the larger communities. towns and cities. Functional regionahzation must ensure the access of all members of the community to the different levels of care according to their needs. For this purpose a referral system has to be organized and effectively operated. It works both upward and downward aiming to provide each patient with no more and no less than the care he needs in order to maximize efficiency at all levels. In this manner there need be no compromise between quantity (provision of care to the entire population) and quality (sophistication and intensity of services for the cases requiring such high ratios of inputs per patient). (f) Administration A substantial increment in the operative capacity of the health system is required in a relatively short time if a process of extension of coverage is to be initiated. The administrative development for this purpose implies important changes in the organizational patterns, as well as the introduction of adequate administrative systems for management information coordination, programming supervision control, evaluation and administration of personnel and of physical and financial resources. Administrative development has been a real preoccupation for the governments of Latin America in recent years. The processes of extension of coverage pose some different dimensions to the problem. whose solution will require creative imagination of managers and health administrators in the years to come. (g) Development of physical resources Physical resources in Latin America are often scarce and poorly managed and maintained. Many hospitals need replacement, adaptation or transformation, and in most countries the situation is such that new investments either for building of health centers and hospitals or for the recovery of installed capacity will have to be urgently made if any progress is to be expected in the process of extension of coverage. (h) Development ofjnancial
resources
Both for the operation of the existing services as well as for new investments, governments are studying different financial sources, such as the extension of social security to larger population groups. direct payment of services and health insurance. For investments external loans from the Interamerican Development Bank, the World Bank, bilateral cooperative programs of some governments and other agencies are being used, and planned for the next few years. by a number of countries. (i) Development of human resources Human resources is one of the most critical areas in the process of extension of coverage. It is probably the area that is most specifically dealt with in the policy statements of the countries. Doctors and nurses are still scarce, poorly distributed, and only slowly growing in numbers, Health professional education
Health policies in Latin America is not yet harmonized with the real needs of the health services systems. The strategies in regard to human resources are still being studied in several countries. However, they are leaning toward the more efficient utilization of health professionals through the use of auxiliary personnel trained to perform the simpler activities of medical care. The development of physical resources is by far the most dynamic of the strategies in use. Most countries are undertaking aggresive investment programs for which external financing is often used. The Inter American Development Rank is outstanding among the agencies to which the countries apply for external loans. A total of US $103 million in long-term loans were granted to six countries between 1973 and 1977, and another US $340 million are negotiated to be granted in 1978 and 1979 to eight countries. Other agencies such as the international assistance agencies of the USA. Canada and some European countries
Nore: This paper was originally prepared as an outline for a panel presentation by the author. The concepts herein contained have been drawn from my personal experience as a health pfanning consultant for the Pan American Health Organization although they do not necessarily reflect an official position of PAHO. The following documents bearing on the matter have been referred to in the paper: 1. Health Method.
Planning:
Problems
of
Concept
and
Scientific Publications No. 111, Pan American Health Organization, April 1965. 2. Ten-Year Health Plan for the Americas. Final Report of the 111 Special Meeting of Ministers of Health of the Americas, Official Document No. 118, Pan American Health Organization, January 1973.
73
are aiso participating; however the ID3 bans are the only ones that have the peculiarity of requiring from the Governments a commitment to implement as well other strategies aimed to extend the coverage of services. It is rather early to attempt a fair assessment of the impact of the present national health policies and strategies, although certain outstanding accomplishments can be observed in countries like Costa Rica and Honduras despite the very short period of operation of their programs (three years at the most). Criticism has been made in some international health circles to the ways in which the extension of coverage is being approached. Notwiths~ding the appropriateness of some of such criticism an essential fact remains undisputed: the policy of extension of coverage is by far one of the most effective instruments of social justice that Latin American countries have devised to achieve a redistribution of services among their peoples.
3. Basic Document of Reference:
Propositions of Change and Health Strategies for 1971-l9NO. III
Special Meeting of Ministers of Health. PAHO. 1972. 4. E~luation of the Ten-Year Heu~th Plan for the Americas. Initial evaluation Document CD24!18. XXIV Meeting of the Directing Council of the Pan American Health Organization, Mexico, D.F., August 1976. 5. Formulacidn de Politicas de Salud (only Spanish: Health Policies Formulation). Pan American Health Planning Center, PAHO, Santiago, Chile, July 1975. 6. Enfoques Actuaies acerca de1 Proceso de Planifcatidn de la Salud (only Spanish: The Process of Health Planning: New Approaches). Pan American Health Planning Center, PAHO. Santiago, Chile. January 1975.
POLICIES
IN LATIN AMERICA*
RAUL VARGAS Regional
Adviser
in Health
Planning,
PAHO/WHO
Abstract-The third Special Meeting of the Ministries of Health of the Americas in 1972 approved the Ten-Year Health Plan for the Americas. This new approach to health policies emphasized the extension of coverage to previously undeserved populations. This international commitment, reaffirmed in 1977, reflected in the firm decisions of each government to carry out strategies involving the provision of primary health care: community participation; reform and restructuring of health services organizations and administrations: differentiation of levels of care and regionalization: development of physical, financial and human resources.
Convened by the Pan American Health Organization (PAHO) in October, 1972. the Ministers of Health of the Americas held their Third Special Meeting in Santiago. Chile. where they studied and approved the Ten-Year Health Plan for the Americas 1971-1980. This plan expressed the intended coordinated efforts of the countries to improve the health conditions of the people of the Region as a whole. The Ten-Year Plan proposed a set of goals and recommendations dealing with almost every conceivable aspect of the health systems’ structure and operation and suggested targets for health status to be attained in terms of averages for the region. The Plan itself sets as a fundamental requirement for’meeting the recommended goals and targets “the definition in each country of a health policy consistent with the economic and social development which clearly specifies the goals and the required structural changes”. Why did the Ministers assign such importance to the definition of a health policy? In most cases, it was probably due to their experiences with health planning process in the various countries of the Region. The use of the term “development” in international circles started in the late 1940’s to designate a process that can be promoted and guided within each country through the rational action of economic planning. This approach persisted during the 1950’s, strengthened by the work of the United Nations Economic Commission for Latin America (ECLA). both at a conceptual level and in practice through the direct assistance given to individual countries in the development of their economies. This approach to the problems of underdevelopment, based mainly in the manipulation of economic factors, failed to produce adequate solutions. The expected “take off’ did not materialize, even though satisfactory levels of economic growth were attained in a few cases, because previously unforeseen dynamic factors of social change (such as higher rates of population growth, urbanization, modernization and an increased political consciousness) entered the picture and necessitated different approaches. The Charter of Punta de1 Este, signed in August * Originally prepared for the Joint National Meeting of the Latin American Studies Association and the African Studies
Association.
69
1961, was a milestone in the evolution of the new ideas about integrated development, and of the role of planning as a method and a tool for change, as well as an instrument for conceptual systematization. The idea of structural change gained in importance not only as an essential factor in stepping up the rate of development, but also as a basic concept that should be promoted in its own right, quite apart from its implications for the economy. Subjects such as income redistribution, fair distribution of goods and services, agrarian reform and tax reform, which involve deeply rooted forms of social and political organization, were treated openly and the need for integrated social and economic development planning was recognized. The Charter of Punta del Este included a health section with recommendations and goals for the levels of health to be attained by 1970. This section, known as the Ten-Year Public Health Program for the Americas, urged the countries to prepare national health pians within the framework of general socioeconomic development plans. PAHO was given the.responsibility of cooperating with the countries in this endeavor, and to that end, in collaboration with the Center for Development Studies (CENDES) of the Central University of Caracas (Venezuela), designed a method to prepare national health plans that was rapidly disseminated regionally through special courses, seminars and other training activities. Planning consultants were assigned to provide technical assistance to the countries and a First Special Meeting of Ministers of Health of the Americas was convened in Washington (August 1963) to outline a regional strategy for health planning. By 1964, most countries had adopted a national policy aimed at the preparation of national health plans and had variously organized the operation of their planning processes. The general principles that guided the PAHO/CENDES method. with its strong component of economic thinking, were adopted in most cases. Especially important were the notions of “planning for health” instead of “planning for health services”, and the deep-rooted desire to increase et-hciency of use of health facilities and resources. During the decade of the sixties health planning in Latin America was enthusiastically undertaken and evolved under the assumption that the existing health resources and the way in which they were distributed
70
KAUL
and used were the expression of the real (albeit implicit) health policy of each country. The fact that the configuration of most of the prevailing health systems was actually the final outcome of an intermeshing of a wide variety of previous policies was not paid much attention. Therefore, planning was mostly oriented to the attainment of higher levels of effectiveness and efficiency in the use of available resources. By the late 1960’s enthusiasm for health planning had partially faded; criticism mounted, and the whole held of planning had to be reassessed and reoriented in light of experience. There was a proliferation of national health plans prepared by “scientific and rational” health planners that were imperfectly implemented or not implemented at all. It was then understood that planning is not the exclusive domain of planners any more than administration is the exclusive concern of managers and administrators. The crucial role of the policy decision-maker was appreciated and the whole process of policy formulation examined as an integral part of the national political system’s processes. A clearly stated and well-formulated health policy to guide the planners and administrators was then recognized as essential in planning for the health sector. One of the several criticisms of the health planning processes as they had been going on in the countries was that health planners had dedicated too much of their time to the diagnostic stage, and in effect, in some instances the national plans did not proceed beyond that stage. However, this concentration on diagnosis proved to be quite helpful. insofar as the lengthy studies that were made revealed most of the underlying problems and constraints for the develop ment of the health sector. Some of these problems affected the planning processes themselves and often prevented implementation of adequately formulated plans. With or without national plans there was no doubt that as a whole the Region had improved its level of health substantially since the end of the Second World War, especially in terms of lowering mortality and preventing, arresting and curing certain diseases. Mortality due to infectious diseases among children under five years of age decreased by 48% in Latin America between 1956 and 1966; over the same period diseases of the respiratory system decreased by 26x, and those of the digestive system mainly gastroenteritis, by 44%. Similarly morbidity and mortality due to diseases preventable through vaccination showed considerable reductions, as did malaria and smallpox (erradicated since 1971). In 1972, at their Third Special Meeting, the Ministers of Health showed a great concern for continuing and accelerating the decreasing trends of mortality and morbidity, which is reflected in the goals and recommendations of the Ten-Year Health Plan for the Americas. However the consensus among the Ministers was that the substantive goals for further reducing morbidity and mortality could be no more than wishful thinking, unless the strategies to attain such goals were stated and carried out. It was at this point that the “lengthy and useless” information provided by the processes of planning entered the picture, and the following issues became clear.
V ARGAS
1. In contrast to the European experience. where the most important decline of mortality ocurred prior to the availability of modern medical knowledge and technology, the gains in Latin America were to a large extent associated with the new applied medical knowhow, antibiotics, vaccines. drugs. insecticides and to a certain extent. basic sanitation services. 2. As suggested by the information compiled by PAHO in 1971, almost 401; of the population of Latin America does not have access to existing medical facilities. Hospitals, health centers, medical posts and other institutional or “formal” types of services are out of reach for these people because of their social, economic, cultural or geographic isolation. They are a certain number of marginal urban dwellers-the poor, the unemployed and the rural migrant-and the large proportion of rural population that only partially and sporadically have been in contact with any kind of health services. 3. It is evident that the net gains in the national health indices had been largely due to improvement in the health status of the mostly urban population with ready access to health and basic sanitation services. To continue this pattern of provision of services mainly to this portion of the urban population neglecting the rural and the economically disenfranchised urban areas would only lead to diminishing increments of improvement in the national health status (the law of “diminishing returns”) and to rising expenditures as the cost of medical services of the type offered to satisfy the mostly urban demand rises faster than genera1 inflation. 4. Aside from the purely economic and mathematical aspects, the political and ethical faces of the problem were fundamental. The principle of “social justice” in the distribution of services that had apparently guided the planning efforts of the 1960’s as expressed in the PAHO/CENDES method had been in practice only partially implemented. It is true that some increased availability of services was obtained through rationalization of organization and greater efficiency in the use of existing resources: however the absolute gains were diluted by the urban population growth and by the increasing demand for services. Rural-urban inequity persisted. In 1970 there were 5000 units providing elemental health services to the 453/, of the total population of Latin America who lived in localities of less than 2000 inhabitants. whereas there were almost 13.000 units to provide medical care of all types to the 429: who lived in the cities of 20.000 or more inhabitants. In light of the situation, deficient coverage of the health services revealed itself as the most crucial issue to be faced by most of the countries of Latin America. There was no doubt in the minds of the Ministers of Health of the Americas when they accepted and adopted as the central goal of the Ten-Year Health Plan for the Region the “extension of coverage, including minimum comprehensive services, to all the population living in accessible communities of less than Zoo0 inhabitants, and provision of basic and specialized services to the rest of the population by means of a regionahzed health system” assigning priority to the control of communicable diseases. maternal and child care and family welfare. nutrition and basic sanitation.
Health policies Again the expression of this Regional goal could have been no more than wishful thinking if at the same time the instruments for its implementation were not provided. Thus the same Plan contains recommendations to ensure the achievement of its proposals in the form of instrumental policies dealing with: (a) The installation and development in each country of an appropriate health system. (b) The establishment and expansion of the health planning process as an integral part of socioeconomic development and the organization of systems of information, evaluation and control. (c) The undertaking of research mainly addressed to ascertain the effects of various alternatives within the sectoral policy, to increase productivity and effectiveness of services, and to study costs and financing. (d) The increase of the operational capacity at the institutional and the sectoral level as a whole through coordination or integration of health institutions; the strengthening of administrative, sectoral and institutional reform: and the formulation and execution of programs for the delivery of services, development of the infrastructure, investments and financing. (e) The development of human resources, with goals for the training of all kinds of health personnel and recommendations to improve their geographic and institutional distribution. (f) The development of physical resources and the increase of the installed capacity with recommendations for their use and distribution. (g) The development of financing systems. (h) The development and use of health technologies appropriate to the conditions of each country with a view to increasing the coverage and productivity of the services. As soon as the Ten-Year Health Plan was formalized by the Ministers’ Meeting in Chile and incorporated by the Directing Council of PAHO as the expression of the health policy for the Region as a whole, the countries engaged themselves in the task of defining or adjusting their national health policies. Of the 22 countries which participated in the first evaluation of the Ten-Year Health Plan, 16 had already defined or adjusted their national health policies in 1974, and the rest of them were in the process of doing so. All the national policies formulated thus far are consistent with the recommendations and with the areas of priority stated by the Ten-Year Health Plan. In fact most countries have adopted the structure of the Ten-Year Plan as a framework and its goals are references for the study and selection of their national goals. To this end several countries found useful a guide for the analysis and incorporation of the goals of the Ten-Year Plan in the national health policies that was prepared in 1973 by the Secretariat of PAHO, as well as the systematization of theory on policy formulation that was prepared for three special courses that were offered between 1971 and 1974 by the Pan American Health Planning Center. There is a noticeable difference between the health policies of the 1960’s and the new policies of the 1970’s. The former are mostly the product of the analyses made by health planners of available resources
in
Latin America
71
and their allocation and use; they reveal the strong influence of the. economic thinking of the times, and their propositions, mainly related to the attainment of higher degrees of efficiency from existing resources. seldom refer to any radical change in the prevailing structure of the health systeqs. In contrast the policies of the 1970’s are propositions originating with the policy decision-makers themselves. They are based upon a great deal of information gathered through better channels of communication and they are oriented to the conceptual framework of the systems-analytic approach. Furthermore, while continuing to stress improved efficiency. the new policies interweave concepts of growth change, unified development. community participation, technological innovation and social satisfaction around the central theme of extension of coverage. But perhaps the most striking feature of these policies is the firm decision of the governments to carry them out, as expressed by the Ministers of Health in their Fourth Special Meeting (Washington, September, 1977). Starting from a simple numerical relationship between resources and population, or services and population, coverage has developed into a very complex concept embedded in the context of unified development. Coverage is the product of an effective and systematic provision of basic health services designed to satisfy the needs of the entire population. Such services should be continuously available at locations accessible to everybody; they must be acceptable to the community and should ensure the access of patients to the different levels of care of the health services system. Thus the concept of coverage implies a dynamic balance between the needs and aspirations of the community expressed in the demand for services in the one hand, and the available resources with their various technological and organizational combinations to satisfy such demand on the other hand. Therefore, the final expression of coverage will vary from country to country, or even from one community to another within the same country, depending upon felt health needs and the characteristics of socioeconomic development. All the health policies in Latin America at present aim for the coverage of the entire population. A variety of approaches have envolved, but with varying degrees of emphasis, most countries have adopted the following strategies. (a) Provision of primary health care Primary health care refers to activities aimed to meet the basic needs of the community, including some that can be performed through traditional or folkloric means (traditional community health system). Thus the notion of primary health care implies the recognition of the traditional or informal health system through wliich the community cares for the health of its. members. This system has always been present, and co-exists with the formal, scientific, institutional health services system, though often in the rural areas it is the only one in operation. The strategy of primary health care requires the acceptance of the traditional system, the understanding of its ways, the improvement of quality of its performance and its proper articulation with the formal
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RAUL VARGAS
systems. It also requires an inter-sectoral approach at the community level because meeting basic needs implies many actions not within the scope of work of the health sector. (b) Community participation Community participation is a process of self-transformation of individuals according to their own needs as well as the needs of their community. This process creates in the individuals a positive attitude toward their own as well as their community’s well-being and the ability to act consciously and constructively in the general development. “Enabling participation” is the expression used to properly designate this strategy, which with approaches depending upon the prevailing social, cultural. and political patterns of organization. is being implemented in several countries. (c) Organization of the health services system The institutional health system of most countries is not adequately organized to meet the requirements of extension of coverage. The several agencies that comprise the health sector have different interests have various degrees of efficiency in their performance, obey not too clearly stated policies, operate without coordination among themselves and are often very poorly managed. The strategy of organization of the health services system is addressed to rectify all these conditions through organizational reform and restructuring. (d) Organization of levels of care In general the most frequent health needs require simple services provided through a combination of unsophisticated resources and technologies, whereas the less frequent require the combination of more specialized and complex resources and technologies. An efficient institutional response is hierarchical provision of care. At each level a different mix of resource inputs will be optimal. The first level of care is the least complex, and in general serves as the point of contact of the health system with the community. The definitions of the levels of care vary from country to country depending upon the nature of the health problems, the available resources and the type of organization of the health services system. However, it must be born in mind that “level of care” is not synonymous with type of health unit, establishment, or personnel rendering services. In fact it is possible for a health unit to provide care of various levels in the same location. (e) Regionalization and referral systems Functional regionalization of health services is the technical and administrative expression of the hierarchy of services. Regionahzation implies the organization of services according to levels of care, making possible a better geographic distribution of health facilities. The first level of care should be provided by health units of any size and complexity within easy reach of the population. The number of points of contact of the institutional system with the population is thus maximized. Other levels of care of higher complexity are also designed to attend to the needs of the entire
population, but are more centrally located in the larger health centers and hospitals with more specialized personnel and equipment. Geographically they will be located in the larger communities. towns and cities. Functional regionahzation must ensure the access of all members of the community to the different levels of care according to their needs. For this purpose a referral system has to be organized and effectively operated. It works both upward and downward aiming to provide each patient with no more and no less than the care he needs in order to maximize efficiency at all levels. In this manner there need be no compromise between quantity (provision of care to the entire population) and quality (sophistication and intensity of services for the cases requiring such high ratios of inputs per patient). (f) Administration A substantial increment in the operative capacity of the health system is required in a relatively short time if a process of extension of coverage is to be initiated. The administrative development for this purpose implies important changes in the organizational patterns, as well as the introduction of adequate administrative systems for management information coordination, programming supervision control, evaluation and administration of personnel and of physical and financial resources. Administrative development has been a real preoccupation for the governments of Latin America in recent years. The processes of extension of coverage pose some different dimensions to the problem. whose solution will require creative imagination of managers and health administrators in the years to come. (g) Development of physical resources Physical resources in Latin America are often scarce and poorly managed and maintained. Many hospitals need replacement, adaptation or transformation, and in most countries the situation is such that new investments either for building of health centers and hospitals or for the recovery of installed capacity will have to be urgently made if any progress is to be expected in the process of extension of coverage. (h) Development ofjnancial
resources
Both for the operation of the existing services as well as for new investments, governments are studying different financial sources, such as the extension of social security to larger population groups. direct payment of services and health insurance. For investments external loans from the Interamerican Development Bank, the World Bank, bilateral cooperative programs of some governments and other agencies are being used, and planned for the next few years. by a number of countries. (i) Development of human resources Human resources is one of the most critical areas in the process of extension of coverage. It is probably the area that is most specifically dealt with in the policy statements of the countries. Doctors and nurses are still scarce, poorly distributed, and only slowly growing in numbers, Health professional education
Health policies in Latin America is not yet harmonized with the real needs of the health services systems. The strategies in regard to human resources are still being studied in several countries. However, they are leaning toward the more efficient utilization of health professionals through the use of auxiliary personnel trained to perform the simpler activities of medical care. The development of physical resources is by far the most dynamic of the strategies in use. Most countries are undertaking aggresive investment programs for which external financing is often used. The Inter American Development Rank is outstanding among the agencies to which the countries apply for external loans. A total of US $103 million in long-term loans were granted to six countries between 1973 and 1977, and another US $340 million are negotiated to be granted in 1978 and 1979 to eight countries. Other agencies such as the international assistance agencies of the USA. Canada and some European countries
Nore: This paper was originally prepared as an outline for a panel presentation by the author. The concepts herein contained have been drawn from my personal experience as a health pfanning consultant for the Pan American Health Organization although they do not necessarily reflect an official position of PAHO. The following documents bearing on the matter have been referred to in the paper: 1. Health Method.
Planning:
Problems
of
Concept
and
Scientific Publications No. 111, Pan American Health Organization, April 1965. 2. Ten-Year Health Plan for the Americas. Final Report of the 111 Special Meeting of Ministers of Health of the Americas, Official Document No. 118, Pan American Health Organization, January 1973.
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are aiso participating; however the ID3 bans are the only ones that have the peculiarity of requiring from the Governments a commitment to implement as well other strategies aimed to extend the coverage of services. It is rather early to attempt a fair assessment of the impact of the present national health policies and strategies, although certain outstanding accomplishments can be observed in countries like Costa Rica and Honduras despite the very short period of operation of their programs (three years at the most). Criticism has been made in some international health circles to the ways in which the extension of coverage is being approached. Notwiths~ding the appropriateness of some of such criticism an essential fact remains undisputed: the policy of extension of coverage is by far one of the most effective instruments of social justice that Latin American countries have devised to achieve a redistribution of services among their peoples.
3. Basic Document of Reference:
Propositions of Change and Health Strategies for 1971-l9NO. III
Special Meeting of Ministers of Health. PAHO. 1972. 4. E~luation of the Ten-Year Heu~th Plan for the Americas. Initial evaluation Document CD24!18. XXIV Meeting of the Directing Council of the Pan American Health Organization, Mexico, D.F., August 1976. 5. Formulacidn de Politicas de Salud (only Spanish: Health Policies Formulation). Pan American Health Planning Center, PAHO, Santiago, Chile, July 1975. 6. Enfoques Actuaies acerca de1 Proceso de Planifcatidn de la Salud (only Spanish: The Process of Health Planning: New Approaches). Pan American Health Planning Center, PAHO. Santiago, Chile. January 1975.