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MILLENNIUM DEVELOPMENT GOALS: PROGRESS TOWARDS THE RIGHT TO HEALTH IN LATIN AMERICA AND THE CARIBBEAN
Portada ODM salud INGLES.pdf 27/08/2008 06:57:38 p.m.
This document, which was prepared under the supervision of José Luis Machinea, Executive Secretary of ECLAC, and
under the direction of Andras Uthoff, Officer-in-Charge, Social Development Division of ECLAC, was coordinated and
written by Ana Sojo, Social Affairs Officer, Social Development Division of ECLAC.
Specialists at the following United Nations agencies and organizations were consulted: Food and Agriculture
Organization (FAO), Pan American Health Organization (PAHO), World Food Programme (WFP), United Nations
Development Programme (UNDP), United Nations Population Fund (UNFPA) and United Nations Children’s
Fund (UNICEF).
Particular thanks is due for the support given by the following authorities: Mirta Rosés, Director, PAHO; Pedro
Medrano, WFP Regional Director for Latin America and the Caribbean; Rebeca Grynspan, UNDP Assistant Administrator
and Regional Director for Latin America and the Caribbean; Marcela Suazo, Director of the Latin America and the Caribbean
Division of UNFPA; and Nils Kastberg, UNICEF Regional Director for Latin America and the Caribbean.
Inputs were provided by Olga Lucía Acosta, Cecilia Acuña, Ximena Aguilera, Jarbas Barbosa da Silva, María Elisa
Bernal, Keith Carter, Angela Céspedes, Alvaro de Carvalho, Mirtha del Granado, Fabiana del Popolo, Christopher Drasbek,
Ernesto Espíndola, Juan Carlos Feres, Luiz Augusto Galvão, Dirk Jaspers, Maren Jiménez, Chessa Lutter, Rodrigo Martínez,
Hernán Montenegro, Sofía Leticia Morales, Mireya Palmieri, Carla Paredes, Hugo Prado, Félix Rígoli, Adrián Rodríguez,
Mariela Rossen, Magda Ruiz, Rubén Suárez and Gina Tambini.
The contributions of the following consultants are acknowledged in the body of the report: Eduardo Atalah,
Ricardo Bitrán, Liliana Escobar, Rodrigo Muñoz, Marcela Perticara, Guillermo Paraje, Marcelo Pizarro, Juanita Ubilla and
Gonzalo Urcullo.
Carlos Acosta, Omar Bello, Pedro Brito, Mark Connolly, Mariela Cortés, Rebecca de los Ríos, Martine Dirven,
Javier Domínguez, José Ferraris, Paulo Froes, Dennia Gayle, Alejandro Giusti, Juan Eduardo Guerrero, Sonia Heckadon,
Bernardo Kliksberg, Isabel Licha, Esteban Pérez, Juan Manuel Sotelo, Judith Thimke, Daniel Titelman and Cecilia Vera
made suggestions and comments on the report and/or on the consultancy material.
Statistical processing was carried out by Ernesto Espíndola, Maren Jiménez, Fabiola Fernández and Lorena Flores.
Statistical support was provided by Xavier Mancero and Nora Ruedi.
Funding was provided from the ECLAC current budget and by WFP, UNDP, UNICEF and UNFPA, without whose
assistance the preparation and publication of this report would not have been possible.
Cover design: Coka Urzúa Piffaut
Cover photograph: authorized by the Child Fund, New Zealand, www.childfund.org.nz
United Nations publication
LC/G.2364
Copyright © United Nations, August 2008. All rights reserved
Printed at United Nations, Santiago, Chile
iii
Contents
Pages
Preface to the English-language edition..........................................................................................................
7
Chapter I
HEALTH IN THE ROAD MAP OF THE MILLENNIUM DEVELOPMENT GOALS..........................................
9
Chapter II
THE ERADICATION OF EXTREME POVERTY AND HUNGER AS THE BACKGROUND
TO THE HEALTH SITUATION............................................................................................................................... 13
1. Progress towards the first millennium target............................................................................................ 13
2. Trends in hunger and malnutrition in the region....................................................................................... 17
3. Lessons from the application of policies to combat hunger
and malnutrition........................................................................................................................................ 31
Chapter III
THE HEALTH-RELATED MILLENNIUM DEVELOPMENT GOALS AND TARGETS:
COMPARISON OF PROGRESS INDICATORS IN THE REGION’S COUNTRIES............................................. 35
1. Goal 4: reduce the under-five mortality rate.............................................................................................
2. Goal 5: improve maternal health...............................................................................................................
3. Target 8 of goal 6: to have halted by 2015 and begun to reverse
the incidence of malaria and other major diseases....................................................................................
Annex.............................................................................................................................................................
35
45
52
59
Chapter IV
CHRONIC CHILD UNDERNUTRITION, ITS DETERMINANTS AND ITS EFFECT
ON FULFILLING THE GOALS.............................................................................................................................. 61
1. General trends in the levels of chronic undernutrition
in selected countries..................................................................................................................................
2. Determinants of chronic child malnutrition..............................................................................................
3. The causes of inequality in chronic child malnutrition.............................................................................
4. Determinants of changes in the inequality of chronic child malnutrition.................................................
Conclusions....................................................................................................................................................
62
66
70
73
76
Chapter V
OUT-OF-POCKET HEALTH EXPENDITURE: EVIDENCE OF PRONOUNCED INEQUALITIES.................. 77
1. Brief definition of certain concepts...........................................................................................................
2. The burden of out-of-pocket health expenditure and “impoverishment”.................................................
3. Catastrophic health expenditure and medication expenses.......................................................................
4. Inequality and repressed health expenditure.............................................................................................
5. Variables explaining the different incidence
of out-of-pocket expenses.........................................................................................................................
6. The unequal distribution of out-of-pocket health expenditure.................................................................
79
80
85
90
91
93
iv
Chapter VI
FINANCING OF THE MILLENNIUM DEVELOPMENT GOALS ON HEALTH
IN LATIN AMERICA AND THE CARIBBEAN..................................................................................................... 95
1. Trends in public expenditure on health..................................................................................................... 95
2. Estimation of the costs of attaining selected Millennium Development Goals
on health in the region............................................................................................................................... 99
Statistical appendix......................................................................................................................................... 105
Chapter VII
HEALTH SYSTEMS AND THE CHALLENGES POSED BY THE MILLENNIUM DEVELOPMENT
GOALS: MAIN HEALTH POLICY GUIDELINES................................................................................................. 111
Bibliography............................................................................................................................................................. 125
Tables
Table I.1 Latin America and the Caribbean: Millennium Development Goals and targets
analysed in this report....................................................................................................................... Table II.1 Latin America (16 countries): people in a situation of extreme poverty according
to the unsatisfied basic needs (UBN) method and with deprivations in health-related
UBN indicators, around 2005........................................................................................................... Table II.2 Central America and Dominican Republic: cost of child malnutrition, 2004................................. Table II.3 Simulation of the impact on indigence and poverty in Latin America and the Caribbean
of rising food prices........................................................................................................................... Table III.1 Infant mortality rate per 1,000 live births, worldwide and by continent,
1990-2007.......................................................................................................................................... Table III. 2 Latin America (13 countries): infant mortality rate per 1,000 live births, by ethnicity
and place of residence....................................................................................................................... Table III.3 Latin America and the Caribbean (selected countries): infant mortality by birth interval
(less than 24 months), parity and age of mother, 2002-2006............................................................ Table III.4 Latin America and the Caribbean (selected countries): emergency obstetric care services
as percentage of the minimum recommended by the United Nations, by population size.............. Table III.5 Malaria indicators in endemic countries of the region, 2006........................................................... Table III.6 Latin America and the Caribbean: prevalence and mortality rates of all forms
of tuberculosis, 1990 and 2006......................................................................................................... Table A-III.1 Evaluation of progress towards selected health-related Millennium Development Goals.............. Table IV.1 Latin America and the Caribbean (selected countries): characterization of chronic
undernutrition by categories, 1994-2005.......................................................................................... Table IV.2 Latin America and the Caribbean (7 countries): determinants of chronic child malnutrition,
1994-2005.......................................................................................................................................... Table IV.3 Latin America and the Caribbean (selected countries): trend of the determinants
of inequality in chronic child malnutrition, 1994-2005.................................................................... Table IV.4 Latin America and the Caribbean (selected countries): breakdown of variations
in the inequality of chronic child malnutrition, 1994-2005.............................................................. Table V.1 Latin America (selected countries): coverage and periods for undertaking income
and expenditure surveys.................................................................................................................... Table V.2a
Latin America (selected countries): out-of-pocket health expenditure indicators........................... Table V.2b Latin America (selected countries): out-of-pocket health expenditure indicators,
by households with and without medical insurance......................................................................... Table V.3 Latin America (selected countries): structure and level of expenditure by burden
of out-of-pocket health expenses....................................................................................................... 11
16
26
29
36
41
45
52
53
58
59
63
67
71
74
78
81
82
87
v
Table V.4 Latin America (selected countries): proportion of households declaring zero out-of-pocket
health expenses by per capita income quintiles................................................................................ 91
Table VI.1 Latin America and the Caribbean (extrapolation): main results of the costs projection
of selected health interventions to achieve selected Millennium Development Goals.................... 102
Table VI.2 Latin America and the Caribbean (extrapolation): costs projection of selected health
interventions to achieve the chosen Millennium Development Goals............................................. 103
Table VI.3 Latin America and the Caribbean (10 countries) and extrapolation for the region: total
expenditure required to increase the current coverage of selected health interventions
to a level that permits the achievement of selected Millennium Development Goals..................... 104
Table A-VI.1 Latin America and the Caribbean (21 countries): public social spending as a percentage
of gross domestic product................................................................................................................. 105
Table A-VI.2 Latin America and the Caribbean (21 countries): non-contributory per capita public
social spending on health.................................................................................................................. 106
Table A-VI.3 Latin America and the Caribbean (21 countries): non-contributory social public expenditure
in health as a percentage of gross domestic product......................................................................... 107
Table A-VI.4 Latin America and the Caribbean (18 countries): health expenditure, breakdown
by primary income quintile............................................................................................................... 108
Table A-VI.5 The costs of attaining selected Millennium Development Goals in Latin America and
theCaribbean: comparison between current estimations and CMH exercises, after
relevant adjustments.......................................................................................................................... 109
Table VII.1 Latin America and the Caribbean: interaction between public funding and social security
contributions in the health sector...................................................................................................... 115
Figures
Figure II.1 Figure II.2 Figure II.3 Figure II.4 Figure II.5 Figure II.6 Figure II.7 Figure III.1 Figure III.2 Figure III.3 Figure III.4 Figure III.5 Figure III.6 Figure III.7 Figure III.8 Latin America (17 countries): progress in reducing the number of indigent people,
1990 and 2007................................................................................................................................... Latin America and the Caribbean (32 countries): progress towards the undernutrition goal,
2001-2003.......................................................................................................................................... Latin America and the Caribbean (22 countries): progress towards the goal
for underweight among children under 5 years of age, 1990 and 1996-2006.................................. Latin America and the Caribbean (21 countries): prevalence of anaemia (HB < 11g/dl)
in children under 5 years of age........................................................................................................ Latin America and the Caribbean (22 countries): household consumption of adequately
iodized salt (15 PPM or over)............................................................................................................ Developing countries (49 countries, 86 observations): prevalence of chronic
child undernutrition and inequality of its socio-economic distribution, 1990-2005....................... The United Nations Food and Agriculture Organization (FAO) Food Price Index......................... Latin America and the Caribbean (35 countries and territories): infant mortality
per 1,000 live births, 2007................................................................................................................. Latin America and the Caribbean (35 countries and territories): progress in reducing
infant mortality, 1990-2007, and further reduction required by 2015.............................................. Latin America and the Caribbean (35 countries and territories): correlation between
the level of infant mortality in 1990 and its percentage reduction between 1990 and 2007............ Infant mortality by country and indigenous people/territory, 2000 census,
per 1,000 live births........................................................................................................................... Latin America and the Caribbean (selected countries): infant mortality rate by wealth
quintile in demographic and health surveys, recent years................................................................ Americas region: leading causes of under-five mortality, around 2005........................................... Latin America and the Caribbean: maternal mortality per 100,000 live births, 2005.................... Latin America and the Caribbean (selected countries): skilled care before
and during childbirth, 2002-2006..................................................................................................... 14
18
21
23
23
24
27
36
37
40
42
43
44
46
48
vi
Figure III.9 Figure III.10 Figure III.11 Figure III.12 Figure IV.1 Figure IV.2 Figure V.1 Figure V.2 Figure V.3 Figure V.4 Figure V.5 Figure V.6 Figure V.7 Figure VI.1 Figure VI.2 Figure VI.3 Figure VI.4 Figure VI.5 Figure VII.1 Boxes
Box II.1 Box II.2 Box III.1 Box III.2 Box III.3 Box VII.1 Box VII.2 Box VII.3 Map III.1 Latin America and the Caribbean (selected countries): births attended by skilled personnel,
by mother’s area of residence, 2002-2006......................................................................................... Latin America and the Caribbean (selected countries): contraceptive use by women
in conjugal relationships, by method and area of residence, 2002-2006.......................................... Latin America and the Caribbean (selected countries): satisfied demand for contraception, 2002-2006.
Americas region: incidence of reported tuberculosis, 1980-2005.................................................... Latin America and the Caribbean (selected countries): socio-economic distribution of
undernutrition, 1999-2005................................................................................................................. Latin America and the Caribbean (selected countries): changes in the incidence of chronic
undernutrition compared to changes in the inequality of undernutrition........................................ Latin America (selected countries): incidence of out-of-pocket health expenditure
on household payment capacity........................................................................................................ Latin America (selected countries): households that become impoverished after
absorbing out-of-pocket health expenses.......................................................................................... Latin America (selected countries): cumulative distribution of households by burden
of out-of-pocket health expenditure.................................................................................................. Argentina: cumulative distribution of households, by burden of out-of-pocket health
expenditure on payment capacity, whether or not affiliated to medical insurance.......................... Latin America (selected countries): out-of-pocket expenditure on medicines................................. Latin America (selected countries): burden of out-of-pocket health expenses by income levels............. Latin America (selected countries): percentiles of the burden of out-of-pocket expenses.............. Latin America and the Caribbean (21 countries): per capita non-contributory public
expenditure on health, 1990-1991 to 2004-2005.............................................................................. Latin America and the Caribbean (21 countries): non-contributory public expenditure
on health as a percentage of GDP, 1990-1991 to 2004-2005............................................................ Latin America and the Caribbean (21 countries): trend of non-contributory public social
spending as a percentage of GDP by sectors, 1990-1991 to 2004-2005........................................... Latin America (20 countries): annual variation of GDP and non-contributory
public expenditure on health, 1991-2006.......................................................................................... Latin America and the Caribbean (16 countries): distribution of non-contributory
public expenditure on health and primary and hospital health care by primary
income quintiles, 1997-2004............................................................................................................. Quality-of-life indicators: trends towards convergence between Latin America and
15 OECD countries........................................................................................................................... The vulnerability of the displaced population in Colombia............................................................. Social health protection for mothers, children and newborn infants: lessons learned from
the Latin American region................................................................................................................ The challenge of improving neonatal health in Ecuador.................................................................. Maternal and perinatal care in Peru.................................................................................................. Impact of combined malaria therapies.............................................................................................. Programmes to improve maternal and child health care in the region............................................ Five critical challenges and 20 regional goals on human resources for health to achieve the
Millennium Development Goals on health, agreed upon by the twenty-seventh
Pan-American health conference held in October 2007................................................................... Community initiatives that have had an influence on reducing infant and maternal mortality...... 50
51
51
55
65
66
83
84
85
86
89
92
94
96
97
97
98
99
112
19
33
38
49
54
114
119
121
Geographical coverage of the directly observed treatment, short course (dots) strategy
in the Americas, 2006....................................................................................................................... 57
Diagram VI.1 Description of the costs projection model to achieve health-related Millennium Development
Goals in the region, and related formulas......................................................................................... 101
7
Preface to the English-language edition
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.
8
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)
9
Chapter I
HEALTH IN THE ROAD MAP OF THE MILLENNIUM DEVELOPMENT GOALS
“Health is a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity”
Preamble, Constitution of the World Health Organization 1
In terms of citizenship-building, Latin America and the Caribbean entered the new millennium with a
great deal of ground still to make up. For all the hard work done, civil and social rights are far from
being a practical reality for a substantial portion of the population (ECLAC, 2000). This is why it was
so significant when, in September 2000, the international community followed up on the agreements
produced by the United Nations global conferences on social issues over the previous decade2 by
conducting a comprehensive review of the development agenda, and 189 United Nations member
States, 147 of them represented by heads of State or government, made a new global development
commitment, reflected in the Millennium Declaration.
The Millennium Declaration has become the road map used by the United Nations in its
support for member States at the national, regional and global levels, and its implementation included
the establishment of stable, consistent follow-up and accountability mechanisms. Quantitative goals
and timescales were established and, to facilitate periodic reviews of progress, 1990 was settled on as
the reference year for the decade-long series of United Nations global conferences on social issues.3
These follow-up mechanisms have been periodically reviewed and supplemented with additional
goals or indicators not originally included, such as those relating to labour markets (United Nations
Development Group, 2006). The intention is that periodic measurement should be used to quantify
attainments and identify their causes, and to gauge the further efforts required for full compliance
with the commitments accepted.
The agreements that resulted from the United Nations global conferences on social issues
in the 1990s laid the groundwork for a development agenda based on values that are providing a
new underpinning for international relations in the twenty-first century: freedom, equality, solidarity,
tolerance, respect for nature and common but differentiated responsibility. This agenda includes a
commitment to move gradually towards universal coverage of minimum standards of well-being,
something that particularly concerns developing countries; developed countries, however, have
an obligation to support these efforts and create the conditions needed to correct international
asymmetries in favour of developing countries. It takes an all-round approach to development,
seeking to universalize not only civil and political rights but economic, social and cultural rights
as well, without discrimination or exclusion. To implement this ethical and political framework, the
Declaration deals with numerous topics of collective interest which are synthesized into a variety of
goals capable of being measured with a set of established indicators.
1
2
3
The Constitution of the World Health Organization (WHO) was approved by the International Health Conference held in New York from
19 to 22 June 1946 and signed by representatives of 61 States. It came into force on 7 April 1948.
The World Summit for Children (1990), the United Nations Conference on Environment and Development (1992), the International Conference
on Population and Development (1994), the Fourth World Conference on Women (1995), the World Summit for Social Development (1995)
and the United Nations Conference on Human Settlements (Habitat II) (1996), among others.
See United Nations (2001). In addition, United Nations Development Group (2006) contains a full and technically detailed description
of the indicators.
In 2005, all United Nations bodies with a presence in Latin America and the Caribbean came
together under the coordination of ECLAC to create a systematic, integrated and shared vision of the
Millennium Development Goals (United Nations, 2005). At this time, too, some of these specialized
bodies, namely 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), once again under ECLAC coordination and with
the support of other United Nations bodies, jointly set out to review progress towards the health-related
Millennium Development Goals and the obstacles to their attainment, ascertain their causes and try to
determine what further efforts were needed to comply fully with the commitments accepted.
Health is a social right whose legal basis is expressed in a variety of obligations incumbent
upon States under the conventions, protocols and declarations establishing health as a right to which
they have subscribed.4 Over time, there has been increasing recognition of its close connection with
other aspects of well-being, since enjoyment of health is linked to enjoyment of the right to food,
sanitation, water and housing, i.e., the right to a decent standard of living. The enjoyment of health
provides an irrefutable illustration of the indivisibility and interconnectedness of an array of social
rights, summed up in the language of health policies and economics by the concept of “determinants
of health”. This is why the present report also considers other Millennium goals and targets where
they are determinants of health, analysing those concerned with indigence, malnutrition and hunger
and with access to basic social infrastructure, as crucial determinants of the population’s state of
health (see table I.1). The fact that health disparities are also determined by these factors means that
policies to address them need to be comprehensive rather than confined to the dynamic of isolated
social sectors, and must be able to act on inequality in the socio-economic distribution of health
and its determinants.
According to a now well-established normative definition (Whitehead, 1991), health inequities
can be understood as differences that are unnecessary and avoidable and, furthermore, unjust. There
is often a wrenching gap here between legal equality and social inequality, between the formal
recognition of rights and the inability of public policies to uphold them effectively. One task ahead,
therefore, is to work towards the full universalization of civil, political, economic, social and cultural
rights, and this means conjoining the rule of law with respect for freedoms, political representation
and greater access to opportunities for well-being, the productive use of capabilities, and social
protection. Civil and political rights are established as a result of political will and action, but social
rights have other conditions attached: they are part of a process, in as much as they require more and
better human, physical, institutional and financial resources if they are to pass from prescription to
fact. Where financing is concerned, for example, deciding on the level of benefits that ought to be
provided in the field of social rights is not the same as establishing guarantees of freedom, privacy or
free and informed choice in the field of civil and political rights (ECLAC, 2007a).
4
In particular, these include the WHO Constitution of 1946, the 1978 Declaration of Alma-Ata, article 25 of the Universal Declaration
of Human Rights, article 11 of the American Declaration of the Rights and Duties of Man and article 12 of the International Covenant
on Economic, Social and Cultural Rights.
11
Table I.1
LATIN AMERICA AND THE CARIBBEAN: MILLENNIUM DEVELOPMENT GOALS AND TARGETS
ANALYsED IN THIS REPORT
Eradicate extreme poverty
Goal
Target
Indicators
Eradicate extreme poverty and hunger
Halve, between 1990 and 2015, the proportion
of people whose income is less than one
dollar a day
Percentage of population below one dollar a day
at purchasing power parity (PPP) a
Goal
Target
Indicators
Eradicate extreme poverty and hunger
Halve, between 1990 and 2015, the proportion
of people who suffer from hunger
Prevalence of underweight children under 5
years of age
Proportion of population below minimum level
of dietary energy consumption (FAO)
Goal
Target
Indicators
Reduce under-five mortality
Reduce the under-five mortality rate by two
thirds between 1990 and 2015
Under-five mortality rate
Infant mortality rate
Proportion of 1-year-old children immunized
against measles
Improve maternal health
Reduce the maternal mortality ratio by three
quarters between 1990 and 2015
Maternal mortality ratio
Proportion of births attended by skilled health
personnel
Combat malaria and other diseases
Have halted by 2015 and begun to reverse
the incidence of malaria and other major
diseases
Deaths associated with malaria
Proportion of population in malaria risk areas
using effective malaria prevention and treatment
measures
Prevalence and death rates associated with
tuberculosis
Proportion of tuberculosis cases detected and
cured using the directly observed treatment,
short course (DOTS) method
Ensure environmental sustainability b
Halve, by 2015, the proportion of people
without sustainable access to safe drinking
water and basic sanitation
Sustainable access to improved water sources in
both urban and rural areas
Eradicate hunger
The right to health
a
b
Target measured by national indigence lines based on consumption of a staple basket of food.
Neither the goal nor the target is followed up, but unsatisfied basic needs related to the indicator are measured in a number of countries.
On this long and sometimes arduous road, the Millennium Development Goals and their indicators
establish a “civilizing minimum” of well-being for all citizens and set out a route and a timetable for the
effort to open up greater opportunities to those denied them. They are targets that can be used to measure
progress towards the complex goal of attaining certain basic standards of well-being and that, as an ethical
imperative, provide a catalyst so that the forces of solidarity in society can be rallied behind public policies
capable of attaining them. They thus form part of the arsenal of peace, whose purpose it is to include
all citizens in the dynamic of economic and social development in such a way that they can attain to
well-being, and to use deliberate public policy measures to check and reverse inequalities. There are no
uniform solutions, as each country will always have to take account of the resources currently and potentially
available for distribution and of a variety of economic and political constraints.
12
As determinants of the populations health conditions, poverty, malnutrition and hunger are
obstacles to the effective enjoyment of health as a citizen right. This is why it has been essential to review
progress and obstacles in this area, something that is done in chapter II. Chapter III then summarizes the
state of advance with the health-related goals and targets, using the appropriate indicators to provide a
comparative description of the progress made towards them. Progress in reducing under-five mortality,
maternal mortality and the incidence of malaria and tuberculosis is accordingly reviewed. Chapter IV goes
on to deal with the causes of chronic infant malnutrition and its socio-economic distribution in seven of the
region’s countries and demonstrates the need to act upon their socio-economic determinants and to improve
basic social infrastructure. Chapter V looks at the structure and scale of household spending on health and
catastrophic expenditures and at its effects as a factor in households’ impoverishment, by way of a proxy
indicator for the provision of health services, and of the insurance systems, highlighting the worryingly large
number of poor households in the region that lack coverage and do not seem to be in a position to afford
out-of-pocket health spending, aspects this chapter sets out to quantify. To determine the resources that have
been available to the health sector and the relative priority attached to it, chapter VI analyses progress with
social health spending in the region and the relevant constraints. It then seeks to ascertain what financial
resources would be needed to carry out a range of preventive and curative health interventions. Chapter VII,
lastly, analyses the challenges posed by the Millennium Development Goals for today’s health systems and
the trajectory of the reforms made in recent decades, with particular emphasis on primary health care and
insurance systems, and offers some guiding principles and policies in this area, taking into account aspects
such as the need for more and better human, physical, institutional and financial resources.
The main conclusions of the book have already been touched upon in the introduction. It should
be noted that this periodic progress review, was conducted with great thoroughness. The measurements
supporting the different analyses were arrived at by drawing exhaustively on the most up-to-date sources,
processing new data and exploring methods of measurement that might cast new light on the subject-matter.
Great efforts were also made to keep the analytical approach fresh and alert in the face of the challenges
that can arise from one day to the next, as happened even during the preparation of the report, for example,
with the extraordinary surge in food prices in the region and around the world.
13
Chapter II
THE ERADICATION OF EXTREME POVERTY AND HUNGER AS THE BACKGROUND
TO THE HEALTH SITUATION
As determinants of health, poverty, malnutrition and hunger are an obstacle to the effective enjoyment of
health as a citizen right. This is why it has been essential to carry out a review, sketchy as it may be in some
respects, of the progress made and the obstacles encountered in the effort to achieve these dimensions of
the Millennium Development Goals.
1. Progress towards the first millennium target
As in the first interinstitutional report (United Nations, 2005), the analysis of indigence that follows uses
the indigence lines set by the countries themselves, which are based on households’ consumption of a
staple basket of food and can also be used for comparisons between countries. Accordingly, they are not
comparable with measurements for the first target of the Millennium Development Goals when these are
carried out using the equivalent of a dollar a day per person in purchasing power parity (PPP) terms.
According to the projections for poverty as measured by incomes, 12.7% of Latin Americans were
indigent in 2007. This was a drop of 9.8 percentage points on the 22.5% who were in this situation in 1990.
With 68% of the allowed period having elapsed, this represents a linear advance of 87% towards attainment
of the first Millennium Development Goal (see figure II.1).
If this trend continues, indigence can be reduced by enough in the region to meet the 2015 target.
As in almost all other areas, however, trends are country-specific. They are positive in a substantial number
of countries, some of which account for a large share of the region’s population, and it is noteworthy
that Brazil, Chile, Ecuador and Mexico will have reached the target by 2007. The Bolivarian Republic of
Venezuela, Colombia, El Salvador, Panama and Peru, meanwhile, will have progressed by as much as or
more than expected (68%). Argentina, Bolivia, Honduras, Nicaragua, Paraguay and Uruguay, on the other
hand, have made progress but are less than halfway to the goal. Costa Rica has somewhat less ground to
make up (see figure II.1).
Unfortunately, as will be analysed later in this chapter, soaring food prices around the world are
making it harder to reduce indigence in Latin America and the Caribbean. Indeed, they are hanging like a
sword of Damocles over the region since, in certain circumstances, they could lead to a rapid expansion in
extreme poverty. In other words, surging food prices worldwide could mark a reversal of the declining trend
in indigence levels in the region, since they act as an income shock with disproportionate effects on the poor
and vulnerable. Because indigence is measured precisely by the inability of a household to consume a staple
basket of food, it increases when prices rise by more than household incomes.
Given their impact on poverty and indigence, economic performance and the distribution of the
benefits of development must be improved. As a result of poor sectors’ educational shortfalls and lack of
assets, together with the greater obstacles that interfere with their development of skills and capabilities,
people in these sectors are generally employed in precarious, low-productivity occupations. Clearly, this
limits their lifetime earning capacity. Thus, other than in Chile, Brazil and urban areas of Ecuador, it is
striking that the rise in earnings per person employed has not benefited the poorest families over the period
analysed. The poorer sections of society have usually benefited instead from higher non-working incomes
14
deriving from remittances, State cash transfers and other sources. However, remittances are an exogenous
factor that interacts with poverty (ECLAC, 2007b) and that, given the current state of the world economy,
are falling and may continue to do so for some years to come.
Figure II.1
LATIN AMERICA (17 COUNTRIES): PROGRESS IN REDUCING THE NUMBER
OF INDIGENT PEOPLE, 1990 AND 2007 a
(Percentages)
Latin America
Argentina b
Bolivia
Brazil
Chile
Colombia
Costa Rica
Ecuador b
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Uruguay b
Venezuela (Bol. Rep. of)
0
10
20
30
40
50
60
70
80
90
100
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of special tabulations of household surveys from
the countries concerned.
a
Progress is calculated as a percentage by dividing the percentage point reduction (or increase) in indigence observed over the period
by half the 1990 indigence rate. The dashed line shows the percentage improvement that ought to have been achieved by 2007 (68%).
Indigence levels in 1990 for Bolivia, Colombia, El Salvador, Guatemala, Nicaragua, Panama and Peru were established using interpolations
of measurements close to that year. The 2007 levels are projections based on the latest measurement available in each country.
b
Urban areas.
While remaining higher than in other income groups, the fertility rate of poor families has also
diminished. This “demographic bonus” has allowed women to increase their participation in the labour
market, and thus has been crucial to poverty reduction. Nonetheless, to deal with the dichotomies between
care work in the domestic sphere and employment, and given that women are disproportionately likely to
work under poor employment conditions, there need to be policies to increase female employment and
15
safeguard its quality, especially for mothers of smaller children. A vital element here will be the availability
of a fuller range of public-sector care services and the introduction of cultural changes so that the burden of
care is redistributed within families. This would also allow fertility to be maintained at a rate beneficial to
people and to society at large (ECLAC, 2007b).
As well as tracking income poverty, however, there is a need to analyse other aspects of people’s
living conditions. People may suffer from higher rates of disease or death not only because of their genetic
make-up or their access to health services, but also because of many social and economic circumstances.
Thus, it is also relevant for this report to analyse extreme poverty as measured by unsatisfied basic needs
(UBN), in order to give a picture of certain conditions that are important to health. According to this
measurement, people who cannot meet three or more types of basic needs are classified as being in a
situation of extreme poverty as measured by UBN. This is not to be confused with indigence, which is
measured by income as already described.1
As table II.1 shows, in around 2005 just over 10% of the region’s inhabitants lived in housing and
family conditions that left them unable to enjoy basic shelter and protection from the elements. The situation
differs greatly from one country to another and between the residents of urban and rural areas. For example,
whereas in Bolivia, Guatemala, Nicaragua and Peru over 35% of the population have unsatisfied basic
needs, in Argentina, Brazil, Chile, Costa Rica and Uruguay less than 5% of inhabitants suffer from these
privations. Again, housing conditions and access to basic services (drinking water, sanitation, electricity)
are far more of a problem in rural areas, and the public investment required to improve them is substantially
higher because of the great geographical dispersion of households or their remoteness from public or private
service networks. Thus, while 4.5% of people in the region suffer from extreme poverty according to the
UBN method, the figure in the countryside is close to 30%. The gap is much larger still in poorer countries
where a higher percentage of the population is rural: 20% against 76% in Bolivia, 17% against 61% in
Guatemala, 28% against 78% in Nicaragua and 14% against 77% in Peru.
Table II.1 also sets out some specific indicators in the UBN index that are most directly related to
health risks, in particular the percentage of people living in dwellings with earth floors, without drinking
water access in the home or without waste elimination mechanisms that include sanitary evacuation
systems. Across the region, about 15% of people live in homes with earth floors, 14% have no access to
drinking water in the home and 24% do not have an appropriate waste elimination system. All such living
conditions are conducive to morbidity and mortality from infectious diseases that are difficult to control
even when people have access to health services. As in other areas, national and territorial contrasts are very
pronounced and show how serious these deprivations can be in some cases, as well as how much progress
has been made in countries such as Argentina and Costa Rica, among others.
1
Traditionally households have been the UBN measurement unit. To make the UBN measurement comparable with the per capita income
poverty measurements, however, they have also been calculated on a per capita basis.
16
Table II.1
LATIN AMERICA (16 COUNTRIES): PEOPLE IN A SITUATION OF EXTREME POVERTY
ACCORDING TO THE UNSATISFIED BASIC NEEDS (UBN) METHOD a AND WITH
DEPRIVATIONS IN HEALTH-RELATED UBN INDICATORS, AROUND 2005
(Percentages)
Country b
Year
Health-related basic needs c
Extreme poverty
National
total
Geographical area
Urban
Rural
National total d
Floor
in home
Drinking water
access
Waste elimination
system
Argentina
2006
…
2.0
…
1.5
1.2
13.9
Bolivia
2004
40.9
19.8
76.1
36.5
33.1
46.8
Brazil
2006
4.4
2.3
14.9
…
14.8
26.1
Chile
2006
1.5
0.5
8.4
7.8
3.7
6.7
Costa Rica
2006
1.6
0.7
3.0
1.9
3.6
4.6
Ecuador
2002
…
7.2
…
5.6
10.6
17.0
El Salvador
2004
22.8
10.4
41.3
22.9
24.4
11.6
Guatemala
2004
41.2
17.3
61.3
39.6
13.2
54.9
Honduras
2006
25.8
8.7
40.0
25.8
15.5
26.2
Mexico
2006
8.3
3.2
17.3
7.8
9.0
17.5
Nicaragua
2001
49.0
28.3
77.9
44.9
41.0
49.5
Paraguay
2005
21.3
7.4
40.4
16.4
31.2
35.2
Peru
2003
35.9
13.9
77.2
42.6
27.3
39.2
Dominican Republic
2006
9.9
5.9
17.3
2.5
28.2
37.0
Uruguay
2005
…
0.9
…
…
1.9
6.6
Venezuela (Bol. Rep. of)
2006
7.7
…
…
7.0
9.4
8.7
c. 2005
10.3
4.5
29.4
14.6
13.8
23.7
Latin America
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of special tabulations of household
surveys from the countries concerned.
People are considered to be in extreme poverty when they have three or more unsatisfied basic needs.
The indicators included are:
- Quality of housing: material of walls, roof and floor.
- Access to drinking water in the dwelling or within the site or building containing it.
- Access to sanitation: waste elimination systems with a toilet or lavatory connected to some system of evacuation.
- Access to electricity from a public or private grid or generators.
- No overcrowding: less than three people per room.
- Access to education: children aged between 7 and 12 attending school.
- Household consumption capacity: ratio of 3 or less between the total number of household members and the total employed, and
household head with 6 years of education or more (urban areas) or 4 years of education or more (rural areas).
In Argentina, the indicators for walling materials and electricity access were not available; in Brazil, flooring material is not included;
the estimates for Costa Rica, the Dominican Republic and Guatemala did not include access to electricity; Ecuador does not include
walling or roofing materials; El Salvador and the Bolivarian Republic of Venezuela do not include roofing material; and the estimate
for Uruguay did not include the quality of the dwelling or access to electricity.
c
Percentage of people living in dwellings with earth floor, in dwellings or on sites with no access to drinking water, in dwellings
without waste elimination systems (cesspools, rivers, springs or the like).
d
Urban areas of Argentina, Ecuador and Uruguay.
a
b
17
Table II.1 also sets out some specific indicators in the UBN index that are most directly related to
health risks, in particular the percentage of people living in dwellings with earth floors, without drinking
water access in the home or without waste elimination mechanisms that include sanitary evacuation
systems. Across the region, about 15% of people live in homes with earth floors, 14% have no access to
drinking water in the home and 24% do not have an appropriate waste elimination system. All such living
conditions are conducive to morbidity and mortality from infectious diseases that are difficult to control
even when people have access to health services. As in other areas, national and territorial contrasts are very
pronounced and show how serious these deprivations can be in some cases, as well as how much progress
has been made in countries such as Argentina and Costa Rica, among others.
2. Trends in hunger and malnutrition in the region
(a) The traditional food supply and undernutrition
By global standards, the region’s food supply is fairly large. However, the countries’ ability to meet potential
demand for food differs substantially by development level, agricultural productivity and the income levels
of the population. Food and nutritional insecurity and malnutrition clearly reflect the socio-economic
inequalities that characterize the region. Thus, while the region’s output of food for human consumption
exceeds the population’s requirements by some 30%, 53 million people do not have enough to eat, 7%
of under-fives are underweight for their age and 16% are undersized for their age. As well as limiting the
effective enjoyment of citizen rights, hunger and undernutrition have permanent effects on physical and
psychomotor development and are among the principal mechanisms for the intergenerational transmission
of poverty and inequality.
Differences between and within countries are critical when it comes to analysing food insecurity in
the region. According to information from the United Nations Food and Agriculture Organization (FAO),
agricultural productivity in the region at the beginning of the current decade was US$ 3,307 per capita, but
in Haiti and Honduras it was not even half that. Between 1990 and 2002, meanwhile, the dietary energy
supply (DES) in Argentina, Brazil and Mexico was over 3,000 kilocalories a day per person, while in
Guatemala, Haiti and some areas of Nicaragua it was less than 2,200 kcal, which is just enough to meet
the minimum requirement, but at the cost of acute vulnerability. Lastly, the undernourished population,
i.e., those with not enough to eat, was to be found mainly in Brazil (15.6 million), Colombia (5.7 million),
Mexico (5.2 million), the Bolivarian Republic of Venezuela (4.3 million) and Haiti (3.8 million).2
However, five countries have already achieved the goal of halving the proportion of people suffering
from hunger by 2015 and eight have made progress equivalent to or greater than what is required in the
time that has elapsed. In four, however, the situation has worsened significantly and in 14 progress has been
inadequate or non-existent, suggesting that in some cases it will not be possible to meet this target, let alone
other, more demanding international commitments in this area (see figure II.2).
2
See FAO (2004) for further information.
18
Figure II.2
LATIN AMERICA AND THE CARIBBEAN (32 COUNTRIES): PROGRESS TOWARDS
THE UNDERNUTRITION GOAL, 2001-2003
(Percentages)
Cuba
156%
Peru
143%
Guyana
114%
Uruguay a
114%
Chile
100%
Saint Vincent and the Grenadines
91%
Saint Lucia
75%
Ecuador
75%
Costa Rica
67%
Brazil
67%
Jamaica
57%
Belize
57%
Haiti
55%
Suriname
46%
Grenada
44%
Bahamas
44%
Bolivia
36%
Colombia
35%
Paraguay
33%
Trinidad and Tobago
31%
Saint Kitts and Nevis
31%
Netherlands Antilles
Target for 2015
29%
Nicaragua
20%
El Salvador
17%
Honduras
Progress required
by 2002 (48%)
9%
Dominican Republic
0%
Mexico
0%
Argentina a
-23%
Panama
-38%
Guatemala
-88%
Venezuela (Bolivarian Rep. of) -127%
Dominica
-200%
The Caribbean
61%
Latin America
50%
-200%
Latin America and the Caribbean
50%
-150
-125
-100
-75
-50
-25
0
25
50
75
100
125
150
175
Progress, in percentages
Source: Food and Agriculture Organization of the United Nations (FAO), The State of Food Insecurity in the World, 2004. Monitoring progress
towards the World Food Summit and Millennium Development Goals, Rome, 2004.
a
Urban areas.
From the information available it can be concluded that, as with other aspects of the region’s
social development, socio-economic inequalities in the population, together with risks derived from
natural disasters, income shocks associated with surging food prices and social or armed conflict or both
(see box II.1), are crucial determinants of vulnerability to food insecurity.
19
Box II.1
THE VULNERABILITY OF THE DISPLACED POPULATION IN COLOMBIA
The official register of the Government of Colombia counts 2,169,874 forcibly displaced persons. This figure
is equivalent to 5% of the Colombian population and is the world’s second highest, after Sudan (Red de Acción
Social, 3 September 2007). Those affected are divided almost equally between women and men (48% and 52%,
respectively), 63% of whom are at the most productive age (which has had a major impact on unemployment
rates in the municipalities receiving them), while 32% are under 14 and 5.4% are over 60. The large number of
dependents, combined with poor employment conditions at the places where they settle, makes it hard to generate
income. Some groups are more vulnerable after being displaced, furthermore: ethnic minorities, which represent
8.2% of the displaced, are a clear example.
At the places of reception, unemployment rises and earning capacity declines (people earn 46% less than
in their home areas). Although they are exempted from pension payments and school fees, school attendance
among children over 12 declines, as these have to work to earn money for their households. The same is not true of
under-elevens, thanks to the higher education coverage of urban areas.
Where health services are concerned, the greater availability of these in urban areas and the obligations created
by Law 387 of 1997 have meant that coverage is higher than in the home municipalities of the displaced (74% against
53%), and indeed than among the non-displaced poor urban population (54.3%).a This seems to be the result of the
public policies designed for this purpose: enrolment in the Consolidated Registry of Displaced Population (RUPD) is
the sole prerequisite for automatic entitlement to coverage in the Subsidized Health System, with priority over other
vulnerable groups.
While about 71% of displaced households are registered in the RUPD, only 56% of those registered receive
benefits such as assisted housing and income subsidies (Ibáñez and Velásquez, 2006). Then there are displaced
people who are not registered; it is estimated that more than 86% of these (equivalent to almost 600,000 households
or 2,644,264 people) do not receive assistance of this type.
Although they are covered by the Families in Action Programme,b a World Food Programme (WFP) study
has shown that displaced people do not meet their nutritional requirements: their food intake is 350 kcal less than the
required minimum, mainly because of the average family size and the impossibility of obtaining land on which to
grow food for home consumption, as was traditionally done in their rural areas of origin.
Vulnerability increases substantially when households are headed by women because the male head of the
family has died or disappeared: while 28% of male-headed households have a home of their own in the recipient
municipality, the figure is just 13% in the case of female-headed households. Vulnerability is also increased by the
larger number of dependents in such households.
State assistance for displaced families is divided into two phases. “Humanitarian and emergency” assistance
deals with their food, accommodation, health-care and transport needs during the first three months of displacement;
the “socio-economic stabilization” phase is supposed to help them recover their financial independence by means
of income generation, occupational training and microcredit programmes, among others. However, most assistance
has been in the first stage and “stabilization programmes” have been ineffective owing to budget shortfalls, a
lack of political will and ignorance of the particular needs and conditions of the displaced population. Strikingly,
too, the regulations of the Pension Solidarity Fund of the Colombian Social Security Institute make no provision
for the displaced.
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of A.M. Ibáñez and A. Velásquez (consultants),
“El impacto del desplazamiento forzoso en Colombia: condiciones socioeconómicas de la población desplazada, vinculación a los
mercados laborales y políticas públicas”, Santiago, Chile, ECLAC, 2008, unpublished.
a
Law 387 of 1997 governs assistance for the displaced population. Where health care is concerned, it stipulates that the displaced
population will have access to the subsidized system as soon as they register in the RUPD.
National government initiative whereby children under 7 receive a nutrition subsidy and those aged between 7 and 18 from families at
level 1 of the National Information System on Social Programme Beneficiaries (SISBEN) receive an education subsidy.
b
20
(b) Malnutrition trends
Where child malnutrition is concerned, there are large divides within and between the region’s countries:
in some areas and regions, the situation is even more critical than in countries of sub-Saharan Africa, while
in others it is more akin to that of developed countries. The most vulnerable groups include those living
in poverty, indigenous people3 and families where the mother has a low educational level. Residence
in rural areas is an important factor, in conjunction with others, although large groups of malnourished
people live on the outskirts of large cities.
Although the prevalence of undernutrition has been declining steadily in recent decades, around
2002 there were still 8.8 million undernourished children in the region, and, in proportional terms, it was
still twice as high as the proportion of underweight children (15.6% versus 7.3%). Almost half of all
Guatemalan children, about 25% of Honduran, Ecuadorian, Bolivian and Peruvian children, and about
a fifth of Haitian, Nicaraguan, Salvadoran and Panamanian children are in this situation. Significant
progress has been made since the beginning of the 1990s: by 2002, the prevalence of undernutrition
had fallen from 19.1% to 15.6%. Where underweight children are concerned, however, the situation
in Panama and Argentina has worsened considerably. Twelve countries can show improvements that
are slightly better than the average, while only the Dominican Republic, Jamaica, Chile and Uruguay
improved by more than 40% over the period. Guatemala is a special case since, while there has been an
improvement, it is still the worst placed with a rate almost 18 times as high as would be expected in a
normal population (2.5%). Mexico and Brazil are in the middle of the distribution, together accounting
for 43% of all cases. If Guatemala, Peru, Colombia and Argentina are added, this proportion rises to 74%
(United Nations, 2005).4
As regards the prevalence of underweight children, or global malnutrition, which is the followup indicator for the hunger-related Millennium Goals, the region did show improvements between the
1988-1991 and 2000-2002 periods. However, 4.1 million children suffer from it, and prevalence is high
in many countries, particularly Guatemala, Saint Vincent and the Grenadines, Haiti, Honduras, Guyana,
Suriname, Ecuador and El Salvador, with rates of between 10% and 23%. The largest numbers of cases
are to be found in Brazil, Mexico, Guatemala, Colombia, Haiti and Peru, which account for 73% of the
total (see figure II.3).
3
4
Unfortunately, demographic and health survey (DHS) data that might shed light on malnutrition by ethnic group are scarce and unreliable.
The surveys of Bolivia and Peru ask whether children’s mothers speak certain languages, but this does not provide a basis for measuring
membership of ethnic groups, even as a proxy. However, it is worth mentioning what incomplete or unreliable data have to reveal about
ethnic categories. In Bolivia (2003), chronic malnutrition rates were 30.2% among the children of mothers speaking Quechua as a first
language, 24.8% among those of Aymara-speaking mothers, 19.3% among those of Guarani-speaking mothers, 32.1% among those of
speakers of other aboriginal languages and 17.7% among those of mothers who did not speak aboriginal languages; in Ecuador (2004), the
chronic malnutrition rate was 23.2% nationally, while the prevalence among indigenous people was 46.9%; in Panama (2003), the chronic
malnutrition rate was 20.6% nationally and 56.6% among the indigenous rural population; in Guatemala (2002), the ethnic variable as
measured observationally by survey field staff indicates that the prevalence of chronic malnutrition was 69.5% among indigenous children
and 35.7% among Ladino children.
The figures are presented in accordance with National Center for Health Statistics (NCHS) rules. It is possible that the new Child Growth
Standards formulated by the World Health Organization (WHO) in its Multi Centre Growth Study might modify them slightly. See the
official WHO site [online] www.who.int/childgrowth/en/.
21
Figure II.3
LATIN AMERICA AND THE CARIBBEAN (22 COUNTRIES): PROGRESS TOWARDS THE GOAL
FOR UNDERWEIGHT AMONG CHILDREN UNDER 5 YEARS OF AGE, 1990 AND 1996-2006 a
(Percentages)
122%
Mexico (2006)
102%
Dominican Republic (2002)
96%
Jamaica (2002)
82%
Bolivia (2003)
Venezuela (Bol. Rep. of) (2005)
81%
Ecuador (2006)
79%
76%
Honduras (2006)
69%
Chile (2004)
Peru (2005)
69%
Guyana (2000)
69%
62%
El Salvador (2003)
58%
Nicaragua (2001)
56%
Colombia (2005)
47%
Guatemala (2002)
34%
Haiti (2006)
31%
Brazil (1996)
21%
Panama (1997)
18%
Uruguay (2004)
3%
Trinidad and Tobago (2000)
-27%
Paraguay (2005)
-136%
Argentina (2005)
-164%
Costa Rica (1996)
Latin America and the Caribbean b
59%
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
10
Expected progress
20
30
40
50
60
70
80
90
100
Actual progress
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of figures from the Social Indicators and Statistics
Database (BADEINSO) [online] www.eclac.cl/badeinso/Badeinso.asp; United Nations, Millennium Indicators Database [online]
http://millenniumindicators.un.org/unsd/mispa/mi_goals.aspx; Opinion Research Corporation - ORC Macro, Demographic and Health
Surveys (DHS) [online] www.measuredhs.com; World Bank, World Development Indicators (WDI) [online database] www.worldbank.
org/data/onlinedatabases/onlinedatabases.html; and United Nations Children’s Fund (UNICEF), Global Database on Child Malnutrition
[online] www.childinfo.org/eddb/malnutrition/index.htm.
a
Using the most recent malnutrition figure available in each country between 1996 and 2006.
b
Weighted average of prevalence in the countries.
The Latin American and Caribbean countries have taken major steps forward in combating low
weight-for-age (see figure II.3). Unfortunately, the latest official data available from the countries do not allow
of a full comparison; they are used to establish a regional average. The regional average masks inadequate
progress in some areas in Trinidad and Tobago, Haiti, Uruguay, Panama and Guatemala. Considerable
ground has been lost even in some countries whose general malnutrition rates in the early 1990s were close
to 5%; this was the case with Costa Rica in 1996 and Paraguay in 2005.5 The 2005 figure shows a serious
setback in Argentina. The estimated improvement of 31% in Brazil reflects only the limited period under
review (1990-1996), as up-to-date figures could not be obtained. Mexico and the Dominican Republic
have already reached the target, and Jamaica will do so shortly. The Bolivarian Republic of Venezuela,
5
In Argentina, Panama and Honduras there have also been advances or setbacks with undernutrition.
22
Bolivia, Ecuador and Honduras are more than 75% of the way to the target, which they will probably reach
by 2015. Lastly, the progress made in Chile, Peru, Guyana, El Salvador, Nicaragua and Colombia has
matched or exceeded the minimum expected between measurements, suggesting they could reach the target,
except in the event of major economic or food crises, natural disasters or the suspension of current policies
and programmes.
Meanwhile, 9% of children are underweight for their age. The most critical rates are those of
Honduras (14%), Ecuador (16%) and, particularly, Haiti (21%) and Trinidad and Tobago (23%). The levels
in these last two cases exceed even those of sub-Saharan Africa. Conversely, levels are lower in Chile, Cuba
and Belize (6%) than in industrialized countries.
Micronutrient malnutrition (deficiency of vitamins and minerals), also known as “hidden hunger”,
is a serious nutritional problem.6 Deficiencies of iron and vitamin A and, to a lesser extent, iodine are
the most frequent and best documented. Iron deficiency anaemia is very widespread, particularly among
children under 2 and pregnant women (see figure II.4). In Bolivia, for example, 83.8% of under-twos, 51.6%
of under-fives and 37% of expectant women suffer from anaemia (Bolivia, 2007). In Peru, rates in these
same vulnerable groups were 66%, 50.4% and 42.7%, respectively, in 2005 (Peru, 2005). In Guatemala,
the figures were 55% of under-twos, 39.7% of under-fives and 22.1% of expectant mothers (Guatemala,
2002). Haiti and Bolivia have the joint-highest rate of anaemia in under-twos (83.3%), while in the case of
under-fives Haiti comes bottom of the regional ranking with a rate of 65.8% (Haiti, 2001).
Vitamin A deficiency is not a national public health problem in most of the countries, but the situation
is serious in the case of indigenous children and women. In Panama, for example, just 1.8% of children
under five suffer from this deficiency nationally, but the rate is 23.6% of the same age group in indigenous
districts (Panama, 1999). Information about the scale of zinc deficiency, meanwhile, is inadequate not just
in the region but worldwide, as it is difficult to measure (Sanghvi and others, 2007, p. 28). Partial studies
in some countries show, however, that this problem is very likely to be as serious as that of iron deficiency
anaemia.7 This is because zinc is obtained from the same foods as iron; furthermore, there is a direct
association between having a zinc deficiency and short stature, as well as frequent and severe infections.8
Another important micronutrient, for which there are no national studies in the region’s countries,
is folic acid, a deficiency of which is associated with congenital malformations of the central nervous
system—one of the main causes of neonatal mortality (UNICEF, 2005, 2006a and 2007a). Meanwhile,
control of iodine deficiency has fortunately seen a gradual increase in most of the countries, and consumption
of adequately iodized salt is now near-universal (see figure II.5).9 In four countries, however, consumption
of iodized salt has not increased in recent years, and while there are large differences between them, all are a
very long way from meeting the standard: Haiti, Trinidad and Tobago, Dominican Republic and Guatemala,
with 1%, 11%, 18% and 67%, respectively. In El Salvador, consumption was significantly lower in the latest
year (62%) than in earlier years, when it was in excess of 80% (UNICEF, 2007a).
6
7
8
9
The WHO Vitamin and Mineral Nutrition Information System uses the national figures given below.
This is shown by partial studies and hospital records from the countries. In Panama, these come from the provinces of Mironó and Santa
Fé; in Guatemala, from Alta Verapaz in 2005; Argentina, from the 2004 National Nutrition Survey and the Federal Health and Nutrition
Plan; in El Salvador, 2002-2004 data were provided by the Health Information Unit of the Ministry of Public Health and Social Assistance
(MSPAS). Demographic and health surveys from a number of countries show congenital malformations as being one of the leading causes
of neonatal mortality.
According to the International Zinc Nutrition Consultative Group (IZiNC) at meetings in Lima in 2005 and Istanbul in 2007.
Consumption is considered universal when more than 95% of households consume salt with an iodine content of at least 15 parts per
million (15 ppm).
23
Figure II.4
LATIN AMERICA AND THE CARIBBEAN (21 COUNTRIES): PREVALENCE OF ANAEMIA
(HB < 11G/DL) IN CHILDREN UNDER 5 YEARS OF AGE
(Percentages)
Haiti
Ecuador
Bolivia
Peru
Jamaica
Cuba a
Guatemala
Uruguay b
Venezuela (Bol. Rep. of)
Panama
Colombia
Brazil
Honduras
Costa Rica
Dominican Rep. b
Mexico
Argentina a
Paraguay
El Salvador
Nicaragua
Chile
Latin America and the Caribbean c
26.0
25.0
23.7
22.4
22.0
19.8
17.0
1.5
0
36.1
36.0
36.0
33.2
31.4
29.9
39.7
51.6
50.4
48.2
45.7
57.9
65.8
34.3
10
20
30
40
50
60
70
Source: World Food Programme (WFP), on the basis of information from the World Health Organization (WHO), Vitamin and Mineral Nutrition
Information System (VMNIS) and the latest national surveys in the Bolivarian Republic of Venezuela, Bolivia, Chile, Colombia,
Costa Rica, Ecuador, El Salvador, Guatemala and Paraguay.
Children under 24 months old in certain areas of the country.
Children in certain areas of the country.
Simple average of 21 countries.
a
b
c
Figure II.5
LATIN AMERICA AND THE CARIBBEAN (22 COUNTRIES): HOUSEHOLD CONSUMPTION
OF ADEQUATELY IODIZED SALT (15 PPM OR OVER)
(Percentages)
Chile
Jamaica
Ecuador
Costa Rica
Nicaragua
Panama
Colombia
Peru
Mexico
Venezuela (Bol. Rep. of)
Belize
Argentina
Bolivia
Paraguay
Brazil
Cuba
Honduras
Guatemala
El Salvador
Dominican Rep.
Haiti
Trinidad and Tobago
Latin America and the Caribbean a
11
1
0
62
18
67
80
92
91
91
90
90
90
90
88
88
88
100
100
99
97
97
95
78
10
20
30
40
50
60
70
80
90
100
Source: World Food Programme (WFP), on the basis of data from United Nations Children’s Fund (UNICEF), The State of the World’s
Children, 2007, New York, 2007.
a
Simple average of 22 countries.
24
(c) International comparison of inequality in respect of malnutrition
Although the population living in poverty is most vulnerable to malnutrition, the two things should not
be conflated (ECLAC, 2004; León and others, 2004). Nor is there a straightforward relationship between
the level of child malnutrition and its socio-economic distribution. International comparisons with other
developing countries show that there are countries where levels of undernutrition (children under 5 who
are short for their age) are high but relatively evenly distributed across the socio-economic strata, a pattern
that might be described as one of “mass privation”. In others, conversely, the prevalence of malnutrition
is relatively low but is heavily concentrated in the lower socio-economic strata, a pattern that might be
described as one of “social exclusion” (Paraje, 2008).10 Both patterns are found in developing countries, but
it is the second that prevails in the region.
As figure II.6 shows in relation to chronic child undernutrition, 17 of the 21 observations with
the highest levels of inequality are in Latin America and the Caribbean, which indicates the scale of the
distribution problem in the world’s most unequal region (De Ferranti and others, 2004; ECLAC, 2007b).
Chapter IV will take a detailed look at the marked inequality in the distribution of malnutrition and the factors
determining it, presenting findings that highlight the importance of reducing socio-economic inequalities if
progress towards the Millennium Development Goals is to be made.
Figure II.6
DEVELOPING COUNTRIES (49 COUNTRIES, 86 OBSERVATIONS): PREVALENCE OF CHRONIC
CHILD UNDERNUTRITION AND INEQUALITY OF ITS SOCIO-ECONOMIC DISTRIBUTION,
1990-2005
12
Quintile 1/Quintile 5 average
10
8
6
4
2
0
0
10
20
30
40
50
60
National average
Developing countries
Latin America and the Caribbean
Source: Guillermo Paraje, “Evolución de la desnutrición crónica y su distribución socioeconómica en siete países de América Latina y el
Caribe”, Políticas sociales series, No. 140 (LC/L.2878-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean
(ECLAC), 2008. United Nations publication, Sales No. S.08.II.G.17.
10
This is based on measurements carried out using demographic and health surveys (DHS), which provide information about the use of certain
physical assets, the habitability of dwellings and access to certain household services. Using this information and applying Filmer and
Pritchett’s (2001) principal component analysis-based methodology, it was possible to construct a “wealth index” and thus rank and stratify
households and individuals by their “socio-economic” situation.
25
(d) The costs of hunger and malnutrition
People whose diets are insufficient are subject to limitations on their physical, intellectual and emotional
development, and the consequences for health, education and productivity have been described in the
conclusions of numerous studies.11 Thus, 20% of all deaths among expectant mothers are associated with
iron deficiency anaemia (Brabin, Hakimi and Pelletier, 2001). Other studies reveal that infants who do not
increase in weight in the first year of life have a 50% likelihood of dying, and this increases in a range of
20% to 24% in cases of diarrhoea, malaria or measles in vitamin A deficient children. A zinc deficiency,
meanwhile, increases the risk of death by between 13% and 21% (Guilkey and Riphahn, 1998). According
to ECLAC (2007a), in 2004 there were 77,000 infant deaths in the Central American countries and the
Dominican Republic associated with low weight-for-age, i.e., 30% of the total, to which must be added
87,000 cases of acute diarrhoeic disease, 39,000 of acute respiratory infections and 30,000 of anaemia.
It has also been shown that coronary disease, type 2 diabetes, strokes and high blood pressure have their
origin in foetal and childhood malnutrition (Barker, 2004).
The effects on cognitive development have also been well studied. For example, child malnutrition
affects the proper development of the cranial circumference, with all the ensuing effects on the child’s
intellectual development and subsequent academic performance (Ivanovic, 2000). Conversely, there is
evidence for the positive effects of dietary supplements taken between 6 and 24 months of age on the school
performance of Guatemalans living in rural areas (Alderman, Berhman and Hodinott, 2004).
The negative effects of malnutrition on people’s health, education and productivity translate into
major human and economic costs not only for them personally, but also for the societies they belong to.
These can be classified into two types: direct costs incurred in preventing and recovering from malnutrition
and treating the damage caused, and indirect costs resulting from lower productivity and earnings. In some
cases these manifest themselves in the short term, but in others they arise throughout people’s life cycles and
may even be passed on from one generation to the next. Beyond the ethical imperative, therefore, eradicating
this scourge would have an enormous social impact and generate substantial savings for individuals and
entire societies.
In developing countries, the direct costs are estimated at US$ 30 billion a year, while indirect costs
(combining protein-calorie malnutrition, low birth weight and micronutrient deficiencies) represent at least
5% to 10% of GDP. In terms of higher life expectancy, conversely, the benefits of reducing malnutrition are
calculated at US$ 120 billion a year (FAO, 2004).
According to the data available, low weight-for-age in Central America and the Dominican
Republic over recent decades generated a cost that amounted in 2004 to almost US$ 6.7 billion dollars in
the form of medical treatment, educational inefficiencies and lost productivity. This sum is equivalent to
6.4% of the seven countries’ GDP that year, with national figures ranging all the way from 1.7% in Costa
Rica to 11.4% in Guatemala (see table II.2). Some 90% of these costs reflect lost productivity among the
1.7 million malnourished people of working age and the loss of an average of two years’ schooling among
those suffering from malnutrition as children (ECLAC/WFP, 2008).
11
See Martínez and Fernández (2006b) for further details.
26
Table II.2
CENTRAL AMERICA AND DOMINICAN REPUBLIC: COST OF CHILD MALNUTRITION, 2004
Total
(millions of dollars)
Costa Rica
Percentage of GDP
Percentage of public social
spending
318
1.7
9.5
EI Salvador
1 175
7.4
136.6
Guatemala
3 128
11.4
185.4
Honduras
780
10.6
80.9
Nicaragua
264
5.8
64.3
Panama
322
2.3
13.2
Dominican Republic
672
3.6
59.1
6 659
6.4
TOTAL
Source: Economic Commission for Latin America and the Caribbean (ECLAC)/World Food Programme (WFP),
The Cost of Hunger: Social and Economic Impact of Child Undernutrition in Central America and the Dominican
Republic (LC/W.144), Santiago, Chile, 2008.
If these countries succeeded in halving child malnutrition by 2015, they would save some
US$ 1 billion in 2004 dollars. If they eradicated it, the saving would be in excess of US$ 2.2 billion
(ECLAC/WFP, 2008). These figures may be compared with the US$ 2.62 billion in additional public
investment that would be required for Latin America and the Caribbean to meet the World Food Summit
target. In other words, losses of almost US$ 6.7 billion attributable to the cost of hunger in Central America,
set against an investment of US$ 2.62 billion to eradicate it throughout the whole of Latin America
(ECLAC/FAO/WFP, 2007).
(e) Income shocks due to rising food prices: the effects on poverty, hunger and nutrition
According to FAO, the increase in food prices in international markets, which began to accelerate in 2005,
is jeopardizing the region’s hard-won progress with nutrition. The rise in prices has occurred because the
pressure of demand has overwhelmed the supply of staple products, particularly, maize, rice, soy and wheat,
and it marks a major step backwards in terms of access to the staple basket of food and, more generally, of
food and nutritional security, especially among the poor who are net consumers of food, i.e., the landless,
wage earners working for low pay or under substandard conditions, and informal workers. The rise in food
prices could prevent the Millennium Development Goals relating to the reduction of indigence and hunger
from being achieved, and this would have knock-on effects for the ones concerned directly with health
(see figure II.7).
Several decades ago, Amartya Sen and Jean Dreze underlined a pertinent point: famines are not
characteristic of countries with democratic political systems (Sen, 1982). Nonetheless, given the complex
array of factors underlying the current rises in food prices, even democratic regimes will have to deal with
unprecedented strains and challenges as regards social cohesion and equity in order to avoid impoverishment
among their populations, nutritional risks and, in the worst case, famine. This is why it is urgent to find out
what factors have led to this unusual and ongoing surge in prices.
27
Figure II.7
THE UNITED NATIONS FOOD AND AGRICULTURE ORGANIZATION (FAO) FOOD PRICE INDEX
Evolution of the price index (2005=100)
300
250
200
150
100
50
Food price index
Meat
Dairy
Cereals
Oils and fats
March
February
January 2008
December
November
October
September
August
July
June
May
April
March 2007
2006
2005
2004
2003
2002
2001
2000
0
Sugar
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of Food and Agriculture Organization of the United
Nations (FAO), Crop Prospects and Food Situation, No. 2. April 2008 [online] http://www.fao.org/docrep/010/ai465e/ai465e00.HTM.
Note :
The Food Price Index is the average of 6 commodity group price indices (meat, dairy, cereals, oils, fats, sugar) weighted with the
average export shares of each of the groups for 1998-2000; it includes a total of 55 food products. The Meat Price Index consists of 3
poultry meat product quotations, 4 bovine meat product quotations, 3 pig meat product quotations, 1 ovine meat product quotation. In
all cases, these are averages weighted by assumed average trade weights. The four meat group average prices are weighted by world
average export trade shares for 1998-2000. The Dairy Price Index consists of butter, whole milk powder, skimmed milk powder,
cheese, and a value for the amount of casein in these products; the average is weighted by world average export trade shares for 19982000. The Cereals Price Index is compiled using the grains and rice price indices weighted by their average market share for 19982000; the Grains Price Index consists of the International Grains Council (IGC) wheat price index, itself an average of 9 different wheat
price quotations, and 1 maize export quotation, the base period being 1998-2000. The Rice Price Index consists of three components
containing average prices of 16 rice quotations: the components are Indica, Japonica and Aromatic rice varieties and the weights for
combining the three components are assumed (fixed) trade shares of the three varieties. The Oils and Fats Price Index consists of an
average of 11 different oils (including animal and fish oils) weighted with average export trade shares of each oil product for 1998-2000.
The Sugar Price Index is an index form of the International Sugar Agreement prices.
In fact, a very wide array of factors are involved, and their confluence has caused some to speak of
a new phase in the food crisis that will cause famines around the world not as a result of natural disasters
such as droughts, but because of food prices. FAO calculates that prices will ease somewhat once the initial
upheaval is past, but that they will remain at a higher plateau for at least 10 years. Some factors include
the financial crisis, currency volatility and the development of biofuels in developed countries; according
to studies by FAO and other international bodies, biofuels accounted for between 5% and 10% of the price
increases in 2006 and 2007, but if the United States or the European Union continues to convert more and
more agricultural output into biodiesel or bioalcohol in future, this could become a major problem in the
medium term, besides which Brazil is currently seen as the only country capable of obtaining biofuels
profitably and without subsidies. Another factor is that countries such as China and India that account
for 40% of the world population have increased their living standards substantially and with them their
28
demand for food, and this, in combination with population growth and high prices, has resulted in a
problematic equation. Furthermore, spurred partly by the current subprime or financial crisis, food products
have become a haven for investors and speculators, something that had not happened for three decades:
because food reserves are at their lowest for 30 years, an opportunity has arisen to generate profits over
the coming years and these investments have begun to push prices up. Large producers are also refusing
to export part of their output for the time being, in a return to self-sufficiency. In the short term, much will
depend on how good forthcoming harvests are and whether any natural disasters occur (Sumpsi, 2008).
This is a complex state of affairs in which prices are increasing as a result of both demand pressures
and supply constraints and, more recently, speculative factors. Volatility in energy markets, and especially
in fossil fuel prices, has fed through not only to the supply of agricultural products because of rising
production costs, but also to demand, as there are agricultural products that are a source both of food and
of energy that offers a substitute for fossil fuels. In most cases, demand is also being driven by production
and consumption subsidies and by the creation of guaranteed markets via regulations requiring the use of
vegetable oil/diesel and petrol/ethanol mixtures. In this complex situation, as ECLAC has pointed out, the
interactions between agricultural markets and energy markets have become unprecedentedly strong, as
have those between agricultural and non-agricultural commodity markets and financial markets.
Developments in international food markets are affecting domestic prices in most of the world’s
countries, and those of Latin America and the Caribbean have been no exception. Food importing countries
are having to pay ever higher prices to supply their domestic markets, but producer countries, especially
those that are also exporters, have seen domestic prices rise as well, largely owing to the powerful influence
of international prices. Beginning in early 2006, but especially since 2007, consumer food price indices
have risen in the majority of the region’s economies at an annual rate of between 6% and 20%, with an
average of about 15%. Where prices have risen by less, this is probably due to specific policies to cushion
the impact of rising staple food prices. The rise in international food prices has been particularly harsh for
those who have to spend a large proportion of their incomes on food, so that it is having a clearly regressive
impact on distribution (Machinea, 2008).12
When prices of staple foodstuffs rise, the poorest experience higher inflation than everyone else.
Not only does the distributive effect penalize those who have least, but it also leads to a net rise in the
percentage of poor and indigent people who cannot afford a staple food basket because their disposable
income has not increased. There is consequently a rise in the proportion of poor households, i.e., of those
whose current resources cannot buy a basket that includes food along with other staples. Likewise, other
vulnerable groups earning close to the poverty line are put at risk of nutritional impoverishment.
The calculations of the incidence of poverty and indigence in the countries of Latin America that
ECLAC regularly carries out can be used to simulate the potential impact of rising food prices on these
variables. Setting out from projections of indigence for 2007,13 if the prices of the foods in the basket used to
calculate indigence increase by 15% and incomes remain unchanged, the indigence rate in the region rises
by almost three percentage points, from 12.7% to 15.9% (see table II.3). In other words, a price change of
15% with constant incomes causes more than 15.7 million inhabitants of Latin America and the Caribbean
to descend into indigence. In the case of poverty, there is a comparable increase when the simulation leaves
the prices of the non-food items in the basket unchanged.
The following discussion of the effects of rising food prices on poverty and indigence in the region is taken, with very slight changes, from
Machinea (2008).
13
These are based on 2006 information and on projected changes in per capita GDP. Their purpose is strictly to provide a basis for the
simulations presented here.
12
29
Table II.3
SIMULATION OF THE IMPACT ON INDIGENCE AND POVERTY IN LATIN AMERICA
AND THE CARIBBEAN OF RISING FOOD PRICES
Rise of 15% in food prices: effects on poverty and
indigence compared with 2007
2007
No rise in incomes
Indigence
Percentage
Millions of
people
Percentage
Millions of
people
Percentage
Millions of
people
12.7
68.5
15.6
84.2
14.7
79.1
2.9
15.7
2.0
10.6
37.9
204.5
37.0
199.6
28
15
1.9
10.1
Change on 2007
situation
Poverty
35.1
Change on 2007
situation
Incomes rise 5%
189.5
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of household surveys conducted in
the relevant countries.
Note: The methodology usually employed to project poverty and indigence rates in the countries consists in applying to the
incomes measured in the survey the rate of change of per capita GDP in constant dollars that is expected between the
survey year and the year to be simulated; the resulting income vector is used to estimate poverty and indigence rates,
the value of the lines being kept constant. This same methodology was used to assess the effect of rising food prices
on poverty and indigence rates; the variant in this case consisted in raising the value of the indigence line by 15%.
The poverty line, meanwhile, is the sum of the adjusted indigence line and the cost of non-food items included in the
consumption basket, to which no price change has been applied.
This is obviously a crude calculation, as the figures and projections take no account of any changes
in personal and family incomes, alterations in the prices of non-food goods and services or the broader
effects of higher food prices on production and consumption.14 Nonetheless, it is both methodologically
relevant and useful, as it gives an idea of the scale of the impact of higher food prices in the event that there
were no change either in the prices of other products or in incomes.
Even with nominal earnings rising over the period of calculation, however, higher food prices
continue to have negative effects on poverty and indigence. This is because income increases usually take
account of the change in the average price index, which rose by less than half as much as food prices in
2007. Thus, taking the combined effect (as the simulation does) of a rise of 15% in food prices and of just
5% in household incomes, the number of people becoming newly indigent as a result of the rise in food
prices would be about 10 million, and a similar number would become poor. Then, of course, there are those
people who were already poor or indigent before these increases, and whose situation would worsen by
descending further into poverty. Unquestionably, this is a dramatic situation for vast numbers of people in
Latin America and the Caribbean.
The picture is complicated yet further by the effects of fuel price rises, which are raising the cost
of transport and a variety of public services. More expensive fuel, furthermore, has been one of the factors
14
Such as those that might be simulated using a computable general equilibrium model with a social accounting matrix and microsimulations
from household surveys that factored in an income shock because of higher food prices, or indeed the overall effects of higher prices on
national economies.
30
pushing up food prices. Here again, higher prices particularly penalize those who have the lowest incomes
and spend a substantial share of their earnings on public transport and basic household services.
If appropriate measures are to be taken against the food price surge of recent months, it is essential
to have a thorough understanding of the real effects of each different factor involved. Better knowledge
is needed not just of the role of the demand of emerging countries and the role of energy inputs in raising
production costs, but also of the impact (especially in developed countries) of subsidies for the production
and use of biofuels, and the part played by market structures in the production and commercialization of
farm products worldwide (Runge and Senauer, 2007).
Policy initiatives are needed in several areas. First, to encourage energy saving and greater energy
efficiency in general; in this context, the energy model of which biofuel production forms a part will
inevitably have to be reviewed. Second, to carry out a more thorough evaluation of the costs and benefits of
biofuel production; these include the cost in water, land and biodiversity, the energy balance, food security,
energy security versus any rural development benefits, lower emissions of vehicle pollutants, and currency
savings. Third, to promote research and development and innovation policies that can open the way to an
energy paradigm that provides an alternative to fossil energy without affecting food production, although
energy derived from biomass may play an important role. Fourth, to ensure that the range of biofuels and
bioenergies in general is not underpinned by incentives and subsidies that artificially increase the returns
on them by providing guaranteed markets and production or consumption subsidies, and that thereby also
increase the opportunity cost of producing food; this is an issue akin to the one that has dominated the Doha
Agenda over the last few years, but transferred to the sphere of biofuels. However, nothing should be done
to constrict the genuine comparative advantages of those countries that can develop biofuels because they
have the right conditions to produce them, such as crop diversity and the availability of land, water and solar
energy, and that take care to strike the right balance with the production of food so that their population has
adequate access to this (Rodríguez, 2008).
Consequently, argues ECLAC, the highest priority must be given to implementing and following
through on policies to mitigate these effects, in accordance with the position of each country as regards
factors such as its production structure (whether it is a net importer or exporter of food, for example), its
experience in handling different instruments and its fiscal situation. The policies to be implemented might
include measures to bring down food prices or moderate price increases in domestic markets, such as
lowering tariffs and consumption taxes. Other policies may set out to improve people’s incomes, especially
among the worst-off, by targeting new subsidies at particular sectors or increasing existing ones. Developed
countries and, to some extent, middle-income countries that are net food exporters also need to make
an exceptional contribution to programmes and organizations such as the United Nations World Food
Programme that can provide emergency aid to populations at risk. Because high food prices do not seem
to be a passing phenomenon, lastly, there is a need not just to maintain specific policies aimed at lowerincome sectors but also to introduce medium- and long-term measures to increase supply and productivity
in a sustainable fashion.
According to FAO, while trade and the market are vital and measures need to be tailored to each
country, there is a need for international disaster prevention mechanisms and for concerted action by a large
number of organizations and countries. Accordingly, the organization has invited the leaders of all countries
to a meeting in June where it will propose the creation of a kind of world food bank, i.e., an international
system of stocks and regulatory measures to ensure a minimum of global reserves; the morphology of the
mechanism to be proposed is now being designed. The intention is also to discuss agricultural measures
being used by countries to raise production and seek measures to calm the current political climate. The
starting point is that the main priority now is to increase production, and since it is not easy to increase
supply in the poorest countries where agricultural yields are very low, these require help to distribute seeds
31
and raise output and to improve growing systems and fertilizers. The idea is to use this dramatic situation to
create medium-term incentives for agricultural development around the world and to involve the advanced
economies; Africa has great untapped agricultural potential, and if low-income countries make progress
now, at a time when food prices are high, they will improve their quality of life (Sumpsi, 2008).
A whole host of crucial issues are now coming up in the debate about agriculture and food access:
how to raise agricultural productivity, how to reconcile this effort with environmental considerations to
safeguard health, how to increase international food reserves, how to multiply the yield of seeds and their
resistance to new climate conditions while continuing to discuss the implications of genetic manipulation,
how to increase agricultural research resources, what to decide about biofuels, how to reduce income
concentration so that food is shared out in a more balanced way, how to support small producers with
water, credit and advice so that they can increase yields, how to increase agriculture-specific development
assistance, how to limit the wastage of food that could be used for energy production. Multiple approaches
to an enormous task.
3. Lessons from the application of policies to combat hunger
and malnutrition
All the region’s countries carry out a wide range of interventions to reduce malnutrition, with programmes
usually being operated by health ministries or social security institutions.
Given the experience built up in different countries and the multiplicity of causes involved, it is
clear that comprehensive State policies with a long-term approach and stable financing are required to
eradicate hunger and combat malnutrition. The problem has three aspects to be addressed. First, there is a
need to address the structural causes with a view to improving the medium- and long-term food situation,
among other things, and to apply measures that encompass access to productive assets (especially land),
modernization of agricultural production and improvements to food distribution channels, plus others
designed to reduce socio-economic inequalities in the fields of employment, education and social protection
systems. There is likewise a need to act in the short and medium term to increase the purchasing power of
households so that their access to and use of foods can improve. Lastly, preventive or emergency measures
are required to forestall or cushion the consequences of critical food access situations.
The impact of nutrition programmes depends on the socio-economic context of families. Reversing
growth retardation is a complex process that requires a number of factors to be addressed in coordination
with one another. A poorly educated mother, a low income and a lack of health services are associated
with a higher risk of growth retardation in children. In countries that have succeeded in lowering poverty
or indigence indices or both by the greatest amounts, malnutrition rates have also fallen considerably.
Policies to reduce illiteracy, provide basic infrastructure and improve health services have contributed to
a considerable decline in the prevalence of growth retardation in children. The best nutrition indicators in
the region are found in Chile (a 1.3% chronic malnutrition rate among children under 6), which has had a
mother and infant food programme with wide coverage for over 50 years. The key factors in this success
are difficult to single out, since it is obviously due not just to the food programme but also to near-complete
health service coverage of the most vulnerable population, programme continuity and the emphasis put on
prevention, among other things. At the same time, the country has succeeded in achieving higher levels of
schooling and environmental improvements and in substantially reducing the poverty and indigence indices
in a context of economic expansion where the poorest families have shared in the general growth of per
capita earnings (Atalah and Pizarro, 2008; ECLAC, 2007b).
As long as the structural problems giving rise to them persist, there will always be a need
for temporary measures to deal with hunger and malnutrition and to enhance the capabilities and
32
socio-economic opportunities of the families affected, within the framework of an overall food and
nutritional security policy that takes account of the causes contributing to hunger and malnutrition in each
country, which include socio-economic, ethnic, cultural and territorial inequalities and the gender aspect.
The time required for an intervention to positively affect children’s growth is variable. In some
cases, even a long spell in the programme does not lead to significant reductions in growth retardation
(de Caballero and others, 2004). There are also instances where growth retardation has been reduced by
5.3% in two years, thanks to an excellent combination of cash transfers and health care, as in the case of
Nicaragua (IFPRI, 2002; Maluccio and Flores, 2004; Galván and others, 2008). In any event, the continuity
of programmes is essential. They are often interrupted, however, not necessarily because of poor results
but owing to changes of government or to administrative or financing problems that raise costs and make it
harder to achieve long-term goals.
Conditional transfer programmes that can influence food demand have to deal with a number of
challenges. One such challenge has to do with the impact that the quality of sectoral services has on the
stock of human capital. It is a cause for concern that, even if children’s health and nutrition are successfully
improved and school attendance increased, they will not necessarily be free of poverty in future unless other
conditions are also met. To make progress in this area, both the quality of health care and the quality and
scope of school provision are now coming under closer scrutiny. Since these depend on the social sectors
providing these services, the implication is that the quality of the health and education provision with which
monetary transfer programmes interact needs to be improved (Sojo, 2007). Concerning these interactions,
see box II.2.
Given the characteristics and consequences of child malnutrition, the priority must be to target
interventions on children under 3 and on expectant and nursing mothers, as these are passing through
critical stages of nutritional vulnerability whose consequences can be lifelong.
Programmes to combat hunger and malnutrition must not lose sight of the consequences in
terms of excess weight and obesity that they could lead to in some populations, as these have negative
repercussions for health and productivity and have increased in the region. This again highlights the need
for a comprehensive approach.
Against this background, a set of short- and medium-term policy guidelines is suggested:
(a) Promote exclusive breastfeeding up to the age of six months, providing suitable conditions for
working mothers.
(b) Maintain and improve programmes to fortify foods with micronutrients, which have proved
very cost-effective in closing health, learning and productivity gaps.
(c) Provide food supplements and encourage their consumption by expectant and nursing mothers
and by infants and preschool children.
(d) Promote and improve eating habits based on highly nutritional local and traditional food
products, taking account of cultural and ethnic diversities.
(e) Create cash and food transfer programmes for people living in extreme poverty, in return for
their participation in education and primary health-care services, community work, training,
literacy education, etc.
(f) Strengthen preventive measures aimed at the most vulnerable groups, particularly public
information programmes, education about food and nutrition, and the provision of information
about best practices in childcare, hygiene, parasite removal, healthy eating, and food handling
and storage.
33
Box II.2
SOCIAL HEALTH PROTECTION FOR MOTHERS, CHILDREN AND NEWBORN INFANTS:
LESSONS LEARNED FROM THE LATIN AMERICAN REGION
Bolivia’s Universal Maternal and Infant Insurance (SUMI), Chile’s Maternal and Infant Social Health Protection
Policy (PPSSMI), Brazil’s Family Health Programme (PSF) and Mexico’s Opportunities programme have all
improved equity in access to and use of health services. Meanwhile, Ecuador’s cost-free maternity and childhood
care law, the mother and child voucher system in Honduras and Peru’s comprehensive health insurance have had
mixed results and in some cases have made access to and use of health services more inequitable than before.
All seven plans seem to have succeeded in counteracting at least one of the social determinants adversely
affecting health or repressing the demand for health services. The amounts invested in implementing them, the
degree of coverage achieved, their continuity over time, success in strengthening women’s position in the family
and the explicit promotion of health rights appear to be crucial factors in the success of these programmes.
They have helped to extend coverage and increase access to technically appropriate interventions by
mitigating or removing at least one cause of health-care exclusion. Most of them reduce the financial barrier to
health-care access; analysis of Bolivia’s SUMI, Honduras’ BMI and Peru’s SIS, however, shows that in ethnically
diverse countries with geographically dispersed human settlements, merely removing financial obstacles does not
guarantee access to health care.
Brazil’s PSF and Chile’s PPSSMI have increased the coverage of technically appropriate health-care
interventions. Bolivia’s SUMI, Ecuador’s maternity law and Peru’s comprehensive health insurance, on the other
hand, have further overstrained these countries’ health systems by increasing the demand for services without first
proportionately expanding their supply, the resources available or the health-care infrastructure. In only two cases
—Bolivia’s SUMI and Chile’s PPSSMI— has the social health protection system attained coverage in excess of
60% of the target population.
Four of the seven —the SUMI, the maternity law, the mother and child voucher system and the maternal and
infant insurance— have suffered from underfunding that is threatening their sustainability.
In addition to continuity over time and investment in resources and infrastructure, it seems that institutional
capacity and the degree to which plan administration is decentralized are important factors in determining whether the
intended coverage is achieved. Experience shows that progress with maternal and infant health can only be achieved
by taking a comprehensive approach involving a combination of interventions that are designed to overcome the
social, financial, cultural and ethnic barriers to health-care access, and that are necessarily underpinned therefore by
a long-term political and social covenant.
Source: Group on PHC-based health systems for social protection, on the basis of Pan American Health Organization (PAHO), “Esquemas
de protección social en salud para la población materno-infantil: lecciones aprendidas de la región de América Latina”,
unpublished, 2007.
(g) Create or optimize food protection systems for emergencies arising because of natural disasters,
sudden or sustained rises in food prices, and social conflicts, ensuring that children and their
mothers are directly assisted.
(h) Increase infrastructure investment and improve the running of education and health services in
order to expand coverage and improve the quality of provision.
(i) Improve water and sanitation infrastructure in marginal areas to reduce the transmission
of diseases associated with malnutrition, irrigation infrastructure in dry areas to increase
agricultural productivity, and road infrastructure to facilitate trade in local produce and food
distribution in emergencies.
(j) Facilitate access to productive assets, including land, equipment and financing, for the
most vulnerable families. This should be supplemented by soil improvement programmes,
34
water resource management and food storage, as well as measures to improve productivity
and diversification, especially among subsistence farmers. Improve agricultural production
processes by investing in new technology and training.
(k) Promote hygiene, especially in food handling in commercial establishments and households,
along with effective sanitary control systems to protect children from diseases originating in
the different stages of food production and distribution.
(l) Press for the adoption of a fair international trading system for farm products, giving special
consideration to the adverse effects of subsidies and other protectionist mechanisms applied
by the developed countries. While they may give certain sectors of the population easier
access to food, these measures can affect the competitiveness of small farm producers and
microproducers, who are usually the most vulnerable, as well as local food security.
(m) Foster South-South cooperation so that experts and policymakers in the region have greater
opportunities to learn from each other’s experience. Countries dealing with severe problems
are often unaware of measures that have been tried successfully elsewhere, which means there
is a need to promote policies based on actual experience and to be aware of and reproduce the
best practices of successful programmes.
More attention also needs to be paid to the management quality of programmes to combat
malnutrition. Problems arising in the design and operating phases of programmes affect the planned
outcomes to a greater or lesser degree, examples being: time in programme that is less than the required
minimum, low acceptance of food supplements, and dilution within the family. For example, an evaluation of
Mexico’s Opportunities programme showed that just half of children aged from 6 to 23 months ate the food
provided for them once a week, and of these 50% consumed just half the recommended ration, indicating
that there are problems with product acceptability, distribution difficulties or both (Hoddinott and Skoufias,
2003; Behrman and Todd, 1999; Behrman and Hoddinott, 2000; Rivera and others, 2004). According to
recent evaluations, there have been positive results in terms of longitudinal growth and chronic malnutrition
(Leroy and others, 2008; Fernald and others, 2008). In the case of Nicaragua’s Social Protection Network,
malnutrition was reduced when implementation improved. When Honduras’ second Family Allowance
Programme ran into financing and implementation difficulties, on the other hand, its results were modest
(IFPRI, 2001 and 2003).
The importance of evaluation and its use in decision-making have yet to be properly recognized in
the region. Evaluations measuring processes, results and impacts are thin on the ground and few projects
have evaluation processes and financing in place, which makes it harder to systematize learning and identify
the best interventions. Mexico’s Oportunidades programme and Brazil’s Family Allowance (Bolsa Familia)
programme are positive exceptions here.
Given the scale of malnutrition in some countries and the high cost of policy implementation,
regional policies are another important area. One successful example is the Regional Initiative for the
Eradication of Chronic Child Undernutrition in Central America and the Dominican Republic. To speed the
pace of progress towards the eradication of chronic undernutrition, the member countries have reviewed,
linked and strengthened existing national programmes to coordinate the development of national plans
by means of short-, medium- and long-term action. This initiative has been energetically fostered by
governments and joined by a wide range of partners, including specialized United Nations agencies, nongovernmental organizations and other governments in the region such as those of Chile and Mexico, within
a framework of South-South cooperation.
35
Chapter III
THE HEALTH-RELATED MILLENNIUM DEVELOPMENT GOALS AND TARGETS:
COMPARISON OF PROGRESS INDICATORS IN THE REGION’S COUNTRIES
1. Goal 4: reduce the under-five mortality rate
Target 5 of Millennium Development Goal 4 is to reduce the under-five mortality rate (better known as child
mortality) by two thirds between 1990 and 2015. Almost 12 million children are born each year in Latin
America and the Caribbean, but it is calculated that some 400,000 of them die before their fifth birthday,
while 270,000 perish in their first year, 180,000 of these in their first month of life (PAHO, 2006).
The present analysis uses the two indicators proposed by the United Nations for following up this
goal, namely the infant mortality rate and the under-five mortality rate. However, it gives priority to the
first (the likelihood of dying between birth and the first birthday, expressed per 1,000 live births) because it
accounts for the bulk of childhood mortality and because there is a larger body of comparable information
for a greater number of countries. Given the weight of mortality in the first year of life as a proportion of all
childhood mortality (i.e., all deaths among children under 5 per 1,000 live births), the two indicators track
each other closely.1
Estimates for the Americas region show that meeting goal 4 will require a more rapid reduction in
under-five mortality, which fell by an average of about 2.4% a year during the 1990s. To bring mortality
down to a third of the 1990 rate by 2015, the pace of decline in under-five mortality will have to more than
double to 5.6% a year. If this goal were achieved, the number of such deaths would be 250,000 a year, i.e.,
less than half the figure calculated for 2000, and a third of the 1990 figure.
In the 1990-2007 period, i.e., two thirds of the way to the deadline set for meeting the Millennium
Development Goals, Latin America and the Caribbean have made substantial progress in terms of the health
of their populations, particularly children. In that population group, mortality fell substantially and life
expectancy at birth increased. In 2007, the region’s child mortality rate was the lowest in the developing
world and had been falling faster than in any other region, whence its relatively high global ranking
(see table III.1).
The regional averages for infant mortality mask large disparities between countries, however
(see figure III.1). Whereas levels in one group of five countries and territories were below 8.4, i.e., similar to
those in Europe, the indices of another 11 exceeded the regional average of 22 per 1,000. Haiti, the poorest
country in the western hemisphere, stands out with a rate of almost 50 deaths per 1,000 live births, indicative
of its general state of underdevelopment. Likewise, the inadequacy of the progress made by the great
majority of these countries towards the other Millennium Development Goals reveals how interconnected
the different facets of social development are.
1
The statistical annex includes estimates of childhood mortality rates for the region’s countries.
36
Table III.1
INFANT MORTALITY RATE PER 1,000 LIVE BIRTHS, WORLDWIDE AND BY CONTINENT, 1990-2007 a
1990
2007
Change between 1990 and 2007
(percentages)
World
63.4
49.9
-21.31
Africa
104.9
87.5
-16.56
Asia
61.6
43.7
-29.08
Europe
14.2
8.4
-40.35
Latin America and the Caribbean
42.4
22.0
-48.16
8.2
6.3
-23.78
31.1
26.1
-16.01
Geographical region
North America
Oceania
Source:
Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of tabulations from United
Nations, World Population Prospects. The 2006 Revision [online database] http://esa.un.org/unpp/.
a
Linear interpolation, calculated by the source, of the estimated probabilities of death before the first birthday in the fiveyear periods 1985-1990 and 1990-1995 (1990 data) and 2000-2005 and 2005-2010 (2007 data).
Figure III.1
LATIN AMERICA AND THE CARIBBEAN (35 COUNTRIES AND TERRITORIES): INFANT
MORTALITY PER 1,000 LIVE BIRTHS, 2007 a
Haiti
Bolivia
Guyana
Grenada
Paraguay
Guatemala
Dominican Republic
Honduras
Suriname
Brazil
Saint Vincent and the Grenadines
Peru
Nicaragua
El Salvador
Latin America and the Caribbean
Ecuador
Colombia
Panama
Venezuela (Bolivarian Rep. of)
Aruba
Mexico
Belize
Netherlands Antilles
Bahamas
Jamaica
Argentina
French Guiana
Uruguay
Saint Lucia
Trinidad and Tobago
Barbados
Costa Rica
United States Virgin Islands
Puerto Rico
Chile
Guadeloupe
Martinique
Cuba
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of tabulations from United Nations, World
Population Prospects. The 2006 Revision [online database] http://esa.un.org/unpp/.
a
Linear interpolation, calculated by the source, of the estimated probabilities of death before the first birthday in the five-year periods 20002005 and 2005-2010.
37
Target 5 of goal 4, meanwhile, is to reduce infant mortality by two thirds irrespective of the starting
level in each country. To be on track to meet this target, given that the period analysed (1990-2007) represents
about two thirds (68%) of the period running up to 2015, the countries ought to be at least two thirds of
the way there if a linear progression is assumed. In other words, infant mortality ought to have dropped by
45.3%, meaning that progress less than this can be considered inadequate.
Defined as the 35 countries and territories shown in figure III.2, the region as a whole exceeded
this figure: between 1990 and 2007, infant mortality fell by 48.2%. The decline was less than 45.3% in 23
of them, however, while in 14 rates fell by over 45%, the best performer being Cuba, which has already
reached the target.
Figure III.2
LATIN AMERICA AND THE CARIBBEAN (35 COUNTRIES AND TERRITORIES): PROGRESS IN
REDUCING INFANT MORTALITY, 1990-2007, AND FURTHER REDUCTION REQUIRED BY 2015 a
(Indicator 14: infant mortality rate)
Cuba
Peru
Nicaragua
Ecuador
Guadeloupe
Chile
El Salvador
Mexico
Brazil
Guatemala
Belize
Latin America and the Caribbean
Argentina
Haiti
Dominican Republic
United States Virgin Islands
Bolivia
Puerto Rico
Honduras
French Guiana
Bahamas
Colombia
Uruguay
Costa Rica
Jamaica
Panama
Guyana
Martinique
Barbados
Venezuela (Bolivarian Rep. of)
Saint Lucia
Paraguay
Saint Vincent and the Grenadines
Grenada
Suriname
Trinidad and Tobago
Netherlands Antilles
Aruba
Relative reduction 1990-2007
Distance remaining to the 2015 target
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of tabulations from United Nations, World
Population Prospects. The 2006 Revision [online database] http://esa.un.org/unpp/.
a
Calculations carried out by the source using data obtained by linear interpolation of the estimated probabilities of death before the first
birthday in the five-year periods 1985-1990 and 1990-1995 (1990 data) and 2000-2005 and 2005-2010 (2007 data).
38
While the progress made in reducing infant mortality, measured as a weighted regional
average, gives grounds for hoping that the target may be met, some of the poorest countries have
advanced less than they need to. Levels in Haiti, Bolivia and Guyana are estimated at over 40
per 1,000 in 2007.
The situation of the underperformers is heterogeneous. In those which had a rate of 16 per 1,000 or
less in 1990, i.e., Costa Rica and certain Caribbean countries (Martinique, Puerto Rico, Barbados, Trinidad
and Tobago and the United States Virgin Islands), the slow pace of progress can be attributed in part
to the difficulty of improving on their low starting rates of infant mortality. However, the situation in
Paraguay, Guyana and Suriname is disturbing since, setting out from intermediate or high levels of infant
mortality in 1990, they were unable to achieve a reduction of 45.3% by 2007.2 Concerning the case of
Ecuador, see box III.1.
Box III.1
THE CHALLENGE OF IMPROVING NEONATAL HEALTH IN ECUADOr
The under-five mortality rate has fallen in Latin America and the Caribbean, with reduced post-neonatal
(>28 days) mortality. In Ecuador, where there are 300,000 births a year, an under-five mortality rate of
53.5 per 1,000 live births and an infant mortality rate of 22 per 1,000 live births, the neonatal mortality
rate (<28 days) rose by 40% between 2000 and 2005, from 8.9 to 12.5 per 1,000 live births. The early
neonatal mortality rate (<8 days) rose by 42% over the same period, from 6.5 to 9.2 per 1,000 live births,
and neonatal mortality accounted for 49% of all infant mortality (<1 year) in 2000 but 60% in 2005, thus
increasing its share by 25%.
Between 22 February and 14 March 2007, Ecuador’s Ministry of Public Health and PAHO/WHO Ecuador
carried out inspections to evaluate implementation of the neonatal Integrated Management of Childhood Illnesses
(AIEPI) programme and perinatal/neonatal care in nine public maternity hospitals. The relevant recommendations
were made for improving maternal-perinatal/neonatal care and identifying the measures needed to attain
the fourth goal.
In terms of biostatistics, the study revealed that hospitals were failing to properly calculate and
record neonatal/perinatal and infant morbidity and mortality rates in accordance with the tenth International
Classification of Diseases (ICD-10). Levels of knowledge about preventing or treating the leading causes
of perinatal and neonatal mortality were very low, out of date and not evidence-based. There were no upto-date evidence-based standards or guidelines available at gynaeco-obstetric and neonatal facilities.
The neonatal AIEPI programme is still in the process of being rolled out nationwide. There are
high rates of Caesareans conducted by poorly trained personnel (general practitioners with 2 or 3 months’
training), partograms are prepared poorly or not at all, ineffective uteroinhibitors (Berotec) are used,
prenatal corticoids are underused or misused, antibiotics are misused in neonatal sepsis, and there is a lack
of training in neonatal resuscitation and in the basic handling of newborn children.
Another very important factor is the lack of proper management. Rates and precise causes of
perinatal-neonatal deaths are not recorded or understood, medical facilities are not properly organized to
give priority to pregnant women (who may spend hours waiting to be seen) and newborns, with the latter
receiving the poorest care (amounting in some cases to complete neglect), there is a lack of coordination
between gynaeco-obstetrics and neonatology/paediatrics departments (nursing, epidemiology) and an
2
Also, in small countries like these a small number of deaths can give rise to large variations in a year’s values that do not necessarily
represent a significant departure from the trend.
39
Box III.1 (concluded)
inappropriate distribution of human resources (priority is given not to maternal-perinatal/neonatal care
but to external consultations), medical facilities do not have neonatology nurses, and newborn children
are cared for by the least skilled staff (nursing assistants, interns, sometimes no-one at all). The study
also found that there was no joint analysis of levels and causes of perinatal/neonatal mortality by all those
involved (gynaecology/obstetrics, neonatology/paediatrics, nursing, epidemiology), or any consensus or
commitment among actors when it came to implementing solutions. Lastly, it was found that there was no
plan for reducing neonatal/perinatal mortality and no monitoring, evaluation or control at any level
Systematized solutions were devised for these problems, evidence-based perinatal intervention
guidelines for the reduction of neonatal mortality were drawn up in April 2007, and 1,750 posters on
neonatal resuscitation and other interventions were printed.
In 2008 the Ministry of Health launched the national campaign for the reduction of neonatal mortality,
with political support at the highest level of government and financial and administrative backing. With
the support of PAHO, a wide-ranging training process was begun in Quito, Guayaquil and Cuenca to
prepare 267 national and regional facilitators throughout the country and implement the national plan for
the reduction of neonatal mortality, involving application of the guidelines prepared, control of nosocomial
infections and maternal health.
All these interventions highlight the need to implement the neonatal AIEPI. Neonatal mortality
currently accounts for 60% of infant mortality in Ecuador; the interventions being implemented ought to
bring neonatal mortality down significantly, and with it infant and under-five mortality.
Source: Pan American Health Organization (PAHO), on the basis of official documents.
As can be deduced from the figure below, the positive correlation between the infant mortality
level in 1990 and its percentage reduction between 1990 and 2007 is virtually nil (see figure III.3). When
infant mortality is low, highly specialized and costly technical resources and staff need to be available
to treat the underlying diseases and pathologies, so that bringing the rate down further entails increasing
institutional, technical and financial exertions. This provides a measure of the importance attached to public
and health policies in the countries. Thus, Cuba, Chile and Guadeloupe have been able to reduce infant
mortality from what were already relatively low levels. The consistent public and institutional priority
given to the goal and a willingness to gradually adjust health programmes to emerging epidemiological
realities (which means ensuring universal coverage of primary care and of preventive and prophylactic
interventions and extending and improving protection and treatment for more complex pathologies) seem
to have been crucial factors in this success. When mortality levels are high, a wide spectrum of measures
can be used to bring them down, but countries that have not made progress must strive to identify the
reasons for this and act accordingly.
40
Figure III.3
LATIN AMERICA AND THE CARIBBEAN (35 COUNTRIES AND TERRITORIES): CORRELATION
BETWEEN THE LEVEL OF INFANT MORTALITY IN 1990 AND ITS PERCENTAGE REDUCTION
BETWEEN 1990 AND 2007 a
70
Cuba
Nicaragua
Reduction between 1990 and 2007 (percentages)
60
Guadeloupe
50
Peru
Ecuador
Chile
Mexico
El Salvador
Brazil
Guatemala
Belize
United States Virgin Islands
Latin America
Dominican Republic
Argentina
French
and the Caribbean
Puerto Rico
Guiana Bahamas
Costa Rica
Honduras
Colombia
Jamaica
Uruguay
Panama
Martinique
Saint Lucia
Guyana
Venezuela (Bolivarian Rep. of)
Barbados
Paraguay
Saint Vincent
and the Grenadines
Grenada
40
30
20
Trinidad and Tobago
10
Haiti
Bolivia
Suriname
Netherlands Antilles
Aruba
0
0
10
20
30
40
50
60
70
80
90
100
Infant mortality (rate per 1 000 live births)
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of tabulations from United Nations, World
Population Prospects. The 2006 Revision [online database] http://esa.un.org/unpp/.
a
Calculations carried out using data from the source, obtained by linear interpolation of the estimated probabilities of death before the first
birthday in the five-year periods 1985-1990 and 1990-1995 (1990 data) and 2000-2005 and 2005-2010 (2007 data).
The variety of situations notwithstanding, all the countries in the region will need to make further
efforts to deal with the main determinants of mortality and adopt appropriate and specific measures for
each circumstance.
Target 5 of goal 4 also includes the coverage of measles immunization among children aged from
12 to 23 months. With a rate of 92% in 2005, timely immunization against this disease is widely practised,
and this is reflected in the absence of recorded deaths from this cause in the region since 2000 (see the
PAHO site [online] www.paho.org). This shows the ability of the region to make major advances in health
matters and the need to reinforce the policies involved so that the achievements endure.
As ECLAC, PAHO and other agencies have often pointed out, the countries of Latin America
and the Caribbean are characterized by high levels of social inequality, and the region has the world’s
highest income concentration. Childhood mortality is linked to this, as historically the most excluded and
vulnerable groups are the ones that have been the most seriously affected.
The situation with children is not clear-cut. Although the averages show a decline in mortality
among all population groups, there are still divergent trends that reveal the effects of socio-economic
divides between different population groups defined by ethnic origin, area of residence, household income
and mother’s educational level.
Although infant mortality has been brought down sharply in the region, territorial factors are still
important: more urbanized regions have generally attained a higher level of socio-economic development
41
and there is better control of the main determinants of children’s health, essentially schooling (particularly
the mother’s), medical coverage and access to basic infrastructure services.
While it is a fact that infant mortality has also declined substantially in populations affected by
discrimination, there are still large differences between indigenous or African-descended people and the
rest of the population, and between city and countryside: the incidence of mortality is still higher among
indigenous and African-descended children, in both rural and urban areas (see table III.2 and figure III.4).
Table III.2
LATIN AMERICA (13 COUNTRIES): INFANT MORTALITY RATE PER 1,000 LIVE BIRTHS,
BY ETHNICITY AND PLACE OF RESIDENCE
(Censuses since 1990)
Country
Place of residence
Country total
Census
year
Indigenous
African
Urban
Other
Indigenous
African
Rural
Other
Indigenous
African
Other
1992
104.0
…
65.9
82.7
…
52.9
121.0
…
93.8
2001
77.7
…
50.5
67.8
…
48.1
87.8
…
57.1
1990
61.1
63.9
39.4
76.7
59.7
36.1
56.7
73.1
50.5
2000
39.7
40.2
26.7
37.2
37.6
24.7
41.8
48.1
35.0
Chile
2002
12.8
…
11.5
12.0
…
11.4
12.7
…
12.0
Colombia
2005
39.5
31.7
23.9
30.9
30.0
23.5
39.8
33.8
25.0
Costa Rica
2000
20.9
11.2
11.5
20.4
8.2
10.7
21.5
15.1
12.3
1990
101.8
…
53.3
61.5
…
39.6
108.0
…
69.4
2001
72.2
…
30.5
42.9
…
24.7
76.6
…
39.1
1994
61.1
…
49.7
56.9
…
41.0
62.1
…
55.2
2002
51.1
…
41.0
47.2
…
35.3
52.6
…
46.7
2001
43.5
31.9
34.5
27.1
30.1
25.1
45.2
33.7
41.8
1990
63.8
…
36.7
48.7
…
31.1
70.8
…
49.8
2000
42.7
…
26.2
35.4
…
23.7
47.1
…
33.3
2005
34.0
38.0
26.4
24.4
24.1
18.8
39.1
47.4
33.9
1990
72.2
…
21.6
39.9
…
17.7
75.3
…
26.0
2000
53.5
…
17.3
31.7
…
15.7
57.5
…
19.5
1992
96.2
…
45.8
90.8
…
45.9
96.5
…
45.8
2002
78.5
…
37.7
72.1
…
38.8
79.1
…
36.3
2001
44.4
…
19.6
31.9
…
19.1
58.1
…
22.6
Bolivia
Brazil
Ecuador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Paraguay
Venezuela
(Bol. Rep. of)
Source: Latin American and Caribbean Demographic Centre (CELADE) - Population Division of ECLAC, special processing of census
microdata.
Note:
To make the censuses comparable, two criteria were used to define the indigenous population. For Bolivia, Ecuador and Mexico, it was
defined as those speaking indigenous languages, since only the latest census included self-definition as a criterion. In all other cases, the
indigenous and African-descended populations were self-defined.
42
Figure III.4
INFANT MORTALITY BY COUNTRY AND INDIGENOUS PEOPLE/TERRITORY, 2000 CENSUS,
PER 1,000 LIVE BIRTHS
100
90
76
80
70
59
56
60
50
37
40
30
20 12 12
15
19
24
47
46
41
37
51 53
52
51
55
58
64
67 69
93
69
63
53
45
43
40
85
81
29
16
10
Panama
People/territory
Ecuador
Guatemala
Bolivia
Mbya
Ava-
Nivaclé
Pai
Western
Enhlet
Aymara
Quechua
Other
Guaraní
Mojeño
Chiquitano
Maya
Xinka
Sierra
Costa
Amazonia
Ngobe
Kuna
Bugle
Wounaan
Embera
Lenca
Honduras
Tolupán
Chortí
Misquito
Costa Rica
Garifuna
Bribri
Cabécar
Aimara
Chile
Quechua
Atacameño
Mapuche
0
Paraguay
Non-indigenous population
Source: Economic Commission for Latin America and the Caribbean (ECLAC), Social Panorama of Latin America, 2006 (LC/G.2326-P),
Santiago, Chile, 2007. United Nations publication, Sales No. E.06.II.G.133.
Mortality among indigenous and African-descended children varies to a notorious degree by
country, which indicates that national context is fundamental. It also differs between the different indigenous
peoples and African-descended groups. By way of example, the 2005 census in Nicaragua showed infant
mortality affecting these groups most, particularly in rural areas, but to varying degrees: mortality was
very high among the Mestizos of the Caribbean coast (40.2 per 1,000 live births), while the Creole infant
mortality rate was 18.8 per 1,000 (see table III.2). As figure III.2 shows, the Mbya and the Nivaclé of
Paraguay and the Quechua of Bolivia are particularly likely to die in childhood, with figures comparable to
the regional average of 40 years ago. Conversely, the indigenous children at lowest risk are the Mapuches
and Atacameños of Chile, who have rates of 11 and 12.5 per 1,000 live births, respectively, and live mainly
in urban areas.3 The conditions in which the Quechua and Aymara people live are very different in Bolivia
and Chile: a Quechua child is five times more likely, and an Aymara child four times more likely, to die
before its first birthday in Bolivia than in Chile. Consequently, mother and infant health programmes need
to reflect the heterogeneity of peoples, areas and local contexts, and policies have to take territorial factors
and cultural considerations into account, in both the countryside and cities.
3
One of the goals stated in the Programme of Action of the International Conference on Population and Development and reaffirmed in 2004
by all the countries of the region was to reduce the infant mortality rate to less than 50 per 1,000 live births by 2005. However, more than
half the indigenous peoples included in the study still record rates in excess of this figure (Del Popolo and Oyarce, 2005).
43
Again, there are still substantial differences in childhood mortality between different socioeconomic segments: the most disadvantaged groups systematically record higher mortality figures,4 as can
be deduced from the proxy value used for wealth in demographic and health surveys (see figure III.5).5
Figure III.5
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): INFANT MORTALITY RATE
BY WEALTH QUINTILE IN DEMOGRAPHIC AND HEALTH SURVEYS, RECENT YEAR
90
80
70
60
50
40
30
20
10
0
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
Bolivia (1998-2003)
Colombia (1995-2005)
Ecuador (1999-2004)
Haiti (1995-2006-2005-2006)
Honduras (1995-2006/2005-2006)
Peru (1994-2005/2004-2005)
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of information from the databases of the final
Demographic and Health Survey (DHS) reports [online] http://www.measuredhs.com and Centers for Disease Control and Prevention
(CDC), Reproductive Health Surveys.
As has been seen, the Americas region has made substantial progress in reducing infant mortality.
In many countries, however, high rates of neonatal mortality have not improved as expected. Between 1989
and 1998, for example, the mortality rate fell by 29% in Bolivia but neonatal mortality dropped by just 7%.
Neonatal mortality accounts for 60% of deaths among under-ones in the region, which shows that progress
in this area has been slow and that inequalities in access to prenatal care and health services generally,
including primary care, still persist.
4
5
The Latin American and Caribbean Regional Plan of Action on Population and Development (ECLAC, 1996), which is the regional
implementation instrument for the Programme of Action of the Cairo conference, lays down additional criteria concerning the need to
reduce inequality by specifying that differences in infant mortality by place of residence, geographical area and social group should be
reduced by 50%.
These surveys do not include income data. The wealth measurement, consequently, is a proxy value for well-being constructed using
information on certain physical household assets, the habitability of dwellings and access to certain services. It is not comparable, for
example, with measurements of income or unsatisfied basic needs obtained from household surveys that do include information on incomes.
On the numerous limitations of this proxy value for wealth, see Paraje (2008), section I.1.
44
Figure III.6 shows the leading causes of childhood mortality in the Americas around 2005. During
the perinatal period (which extends from five months before to one month after birth), the leading causes
of death are infections (32%), asphyxia (29%), premature delivery (24%), congenital malformations (10%)
and others (5%) (PAHO, 2004). Some causes are direct, while others may be contributing factors, such as
most cases of premature delivery and low birth weight.
Figure III.6
AMERICAS REGION: LEADING CAUSES OF UNDER-FIVE MORTALITY, AROUND 2005
Other (birth defects,
cardiovascular
diseases)
29%
Perinatal diseases
38%
Infections
32%
Asphyxia
29%
Congenital
defects
10%
Low birth
Accidents
Infections
weight
24%
6%
12%
Respiratory
ailments
12%
Malnutrition
3%
Source: Pan American Health Organization (PAHO), estimates of the Child and Adolescent Health Unit, 2005.
It has been shown that supplementation with iodine, vitamin A and zinc reduces infant mortality or
the prevalence of serious diseases, or both. Again, the risk of mortality due to neural tube defects is reduced
when mothers have adequate levels of folic acid in their diet. Interventions with micronutrients, especially
vitamin A, iron and zinc, have accordingly had a positive effect in reducing infant mortality (SCN, 2004).
A number of mortality risk factors in infancy (including the neonatal period) are directly related
to the mother’s sexual and reproductive health. Children who are high in the birth order, whose mother
is adolescent (particularly if she is under 18) or over 40, or who are born soon after the previous child,
are more likely to die (see table III.3). These risk factors are more frequent when fertility is high or
there is little access to family planning services. This being so, expanding the coverage of sexual and
reproductive health care, including contraception, contributes not only towards fulfilment of the agreements
laid down in the Plan of Action approved in Cairo, but also towards the Millennium Development Goals
(World Bank, 2003).
If the region is to meet the fourth Millennium Development Goal, it is essential for health-care
and community actors to give a prominent place to neonatal and child health (as part of an integrated care
strategy), putting greater emphasis on the promotion of effective policies and programmes, on interventions
based on proven data and on measures to strengthen systems of oversight that especially target poor and
deprived populations.
45
Table III.3
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): INFANT MORTALITY
BY BIRTH INTERVAL (LESS THAN 24 MONTHS), PARITY AND
AGE OF MOTHER, 2002-2006
Birth interval
Parity
Age of mother (years)
National
total
< 2 years
First
Secondthird
Fourthsixth
Seventh +
<20
40-49
(10 years
earlier)
Bolivia (2003)
115
55
60
77
90
79
74
68
Colombia (2005)
35
21
20
27
40
25
35
22
Dominican Republic (2002)
57
29
30
52
57
41
32
35
Guatemala (2002)
58
47
36
45
52
51
93
44
Haiti (2005/2006)
97
73
58
66
97
81
98
57
Honduras (2005)
43
28
26
28
42
35
59
29
Nicaragua (2001)
60
28
33
33
59
42
45
35
Peru (2004/2005)
63
20
35
33
40
42
25
30
Source:
Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of official publications in the countries [online]
http://www.measuredhs.com, and figures obtained by STATcompiler processing of data from the same site.
2. Goal 5: improve maternal health
The maternal mortality ratio is defined as the number of women dying each year from causes related to
pregnancy, childbirth and puerperium per 100,000 live births. Target 6 of goal 5 is to reduce this by three
quarters between 1990 and 2015.
When it comes to identifying trends in terms of progress towards this goal and target, the maternal
mortality indicator has to be used with care as there are a number of factors that affect its reliability,
chief among them being underdetection and under-recording of this cause of death. Under-recording is
widespread and especially affects poor women and vulnerable populations suffering from discrimination
because of race or ethnicity, or because of situations such as abortion, which in most Latin American and
Caribbean countries is concealed because it is illegal (Bergsj, 2001).
Maternal mortality and the morbidity associated with its determinants are serious public health
problems that expose some of the deepest inequalities in living conditions. They reflect the state of health
of women of childbearing age and the health services and quality of care available to them, such as
contraceptives, prenatal check-ups and obstetric emergency care, the absence of which leads to deaths
and health problems that could have been avoided by proper prenatal supervision and high-quality care
during childbirth, puerperium and any complications that might arise subsequently. Mortality apart, harm to
mothers’ health has many other consequences, among which the World Health Organization has highlighted
the high incidence of morbidity and disablement resulting from inadequate supervision and care during
pregnancy and childbirth, including infertility, sexually transmitted diseases and, at other stages of the life
cycle, genital prolapses and urinary incontinence.
Maternal mortality affects every stratum of society, but it is very strongly associated with poverty. It
is concentrated among women in low socio-economic groups, usually because of limited access to services,
shortcomings in health policies targeted on sexual and reproductive health, or the lack of guaranteed provision
of high-quality comprehensive health services for women (Ortiz, 2002). It is also strongly associated with
46
constraints on the enjoyment of women’s rights, making it a good indicator of gender inequalities and the
effective exercise of reproductive rights as well (UNFPA/CST, 2004). Denial of the right to decide freely
whether or not to have children, fear of violence because of gender inequalities, sociocultural pressure on the
issue of motherhood that affects even adolescents, the absence or failings of public sexual and reproductive
health information and provision services and a lack of sex education policies are causes associated with
maternal mortality that ought to be addressed openly.
Maternal mortality in Latin America and the Caribbean declined between 1997 and 2005. Whereas
in 1997 a mother was at 16 times greater risk of dying in the region than in Canada, by 2004 this relative
risk ratio had dropped to 14. This ratio and the absolute number of deaths have hardly changed in the last
decade, however, and this must be a cause for concern, as the region is not making clear progress towards
the target of reducing the incidence of maternal mortality by three quarters by 2015. Further efforts are
required for this.
Maternal mortality rates vary greatly between the region’s countries, and trends are divergent,
improving in some countries and worsening markedly in others. Levels in the group formed by Argentina,
Chile, Costa Rica, Cuba and Uruguay are below 50 deaths per 100,000 births. In the rest, ratios vary from
60 in the Bolivarian Republic of Venezuela to 630 in the extreme case of Haiti (see figure III.7).
Figure III.7
LATIN AMERICA AND THE CARIBBEAN: MATERNAL MORTALITY PER 100,000
LIVE BIRTHS, 2005
Chile (2005)
Argentina (2005)
Costa Rica (2006)
Cuba (2006)
Venezuela (Bol. Rep. of) (2005)
Mexico (2005)
Panama (2005)
El Salvador (2005)
Colombia (2005)
Brazil (2004)
Dominican Republic (2006)
Latin America and the Caribbean
Ecuador (2005)
Nicaragua (2005)
Jamaica (2001-2003)
Guatemala (2005)
Paraguay (2004)
Guyana (2005)
Peru (1994-2000)
Bolivia (1999-2003)
Haiti (2005-2006)
0
100
200
300
400
500
600
700
Source: Pan American Health Organization (PAHO), “Neonatal Health in the Context of Maternal, Newborn, and Child Health
for the Attainment of the Development Goals of the United Nations Millennium” (CD47/12), Washington, D.C., 2006.
47
Maternal deaths are due primarily to direct obstetric causes, such as haemorrhaging (20%),
toxaemia (22%), complications in puerperium (15%) and others (17%).6 Deaths related to complications
arising from unsafe abortions are believed to account for a large share; far higher at any rate than the
13% shown by official statistics, given that they go largely unrecorded. The other 13% are due to other
causes. Anaemia is a leading cause of maternal mortality, and deficiencies of vitamins and minerals (such
as vitamin A, iron, iodine, folic acid and calcium) are associated with complications in pregnancy (SCN,
2004).
One of the factors most closely and universally associated with lower maternal morbidity and
mortality is skilled care during pregnancy and childbirth, which helps forestall complications. Also
important are family planning services and prompt referral to services such as those that treat sexually
transmitted diseases.7
Skilled care during pregnancy and childbirth is one of the indicators accepted for verifying
that target 6 of the Millennium Development Goals, dealing with maternal mortality, is being met. By
comparison with Africa and Asia, where the coverage of care of this type in 2005 ranged from 45% to
75% and from 38% to 83%, respectively, it can be said that the relative position of Latin America and the
Caribbean is good, as 89% of births were attended by skilled personnel. However, this falls far short of
European and North American levels (99%).
By looking at the figures for skilled care during pregnancy and childbirth, it is possible to identify
situations and countries where substantial improvements are needed (see figures III.8a and III.8b). Of the
45 countries for which information is available (see the statistical annex), 34 have reached the threshold
of 90% of births attended by professionals that was set as a target for 2015 by the United Nations General
Assembly.8 As in the case of maternal mortality, however, Haiti, Guatemala, Bolivia and Peru are the
furthest from meeting it. Honduras, Nicaragua, Ecuador and El Salvador also have a great deal of ground
to make up.
Box III.2 identifies some policies implemented in Peru to deal with its deficiencies in this area.
6
7
8
According to an analysis of maternal deaths reported in 20 countries that PAHO carried out between 1995 and 2000. This drew on different
sources, chiefly vital statistics, epidemiological monitoring data and special national studies.
By skilled care is meant that provided by any health-care professional (doctors, nurses, gynaecologists, midwives, etc.) trained in the
disciplines needed to manage pregnancy and childbirth without complications and to provide care in the period immediately following
birth, and to identify, administer and refer cases to more specialized services in the event that the mother or newborn child suffers
complications.
Special session held in 1999 to follow up the International Conference on Population and Development, known as “ICPD+5”.
48
Figure III.8
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): SKILLED CARE BEFORE AND
DURING CHILDBIRTH, 2002-2006
(Percentages)
Figure III.8a
100
90
80
70
60
50
40
30
20
10
0
Bo
a(
livi
20
03
)
Co
lom
(
bia
20
05
)
Ec
ua
d
(2
or
El
00
lv
Sa
a
4)
ad
or
(2
2
00
/20
03
)a
iti
Ha
(20
05
)
Ho
nd
s
ura
(20
05
Nic
)
ara
a
gu
(20
01
)
Pa
rag
y
ua
(20
04
Pe
)
ru
0
(20
4/2
00
Do
5)
min
ica
e
nR
blic 2)
pu (200
At least 4 antenatal check-ups
Figure III.8b
100
90
80
70
60
50
40
30
20
10
0
a
livi
Bo 03)
(20
bia
lom 5)
Co (200
Doctor
la
ma )
ate 002
(2
Gu
iti
Ha 5)
0
(20
s
ura 5)
nd
Ho (200
Other health-care professional
a
gu
ara 1)
Nic (200
Midwife
n
ica
min 02)
Do c (20
li
ub
ep
ru
Pe 5)
00
2
/
4
0
(20
R
Other
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of demographic and health surveys (DHS); figures
obtained by STATcompiler processing of final reports and data from the reproductive health surveys of the Centers for Disease Control
and Prevention (CDC).
Note: a
Percentage of births in the five years prior to the survey concerned.
Five or more antenatal check-ups.
49
Box III.2
MATERNAL AND PERINATAL CARE IN PERU
Peru has one of Latin America’s highest rates of maternal mortality. Some 70% of maternal deaths take place
in indigenous rural communities. About 60% of deaths occur at the time of childbirth, the leading causes being
bleeding, toxaemia, infections, obstructed delivery and haemorrhages. All these factors are determined, of
course, by the woman’s previous condition.
One of the main reasons is lack of professional care during childbirth, due essentially to barriers of three
kinds: geographical, owing to the distance of health centres from people’s homes; financial, owing to poverty
and extreme poverty; and cultural factors, which discourage women from seeking professional care during
childbirth.
In view of this, three of the most important achievements in the last decade have been the implementation
of integral health insurance, homes for expectant mothers, and vertical childbirth with intercultural adaptation.
Integral health insurance (SIS) is a strategy to improve health-care access for the poor population. It was
created in 2002 under Ministry of Health Law 27657 of 20 January 2002, as a subsidy for poorer populations that
lack health insurance (under-eighteens, expectant women and targeted groups of adults). Its purpose is to lessen
constraints on health-care access, whether due to financial barriers or to cultural and geographical differences.
Some of its achievements are presented below:
• It financed approximately 79.1 million health-care interventions in just 60 months.
• Its focus is on free mother and child health care in deprived urban and rural areas.
• Over 1,206 million soles have been allocated for health-care provision right across the country.
• Free care has been provided to expectant mothers, and as of December 2006, 1.554.896 births had
been attended.
• Affiliates include over 2.7 million children, from newborns to 4-year-olds, and over 196,000
poor mothers.
• SIS serves 7.1 million children and young people of school age (5 to 17), even if they are not regular
students at educational establishments.
Homes for expectant mothers are establishments where women living a long way from health centres
can stay until they give birth. Expectant women do not give birth at these homes, but are looked after and
prepared for childbirth at a clinic or hospital. Efforts have been made to create warm environments similar to
their own homes, and to accommodate their eating habits. Women may also be accompanied by their husbands,
younger children or some relative. They have been in operation since 1999 and currently number about 100,
spread over 12 health regions, namely Cusco, Andahuaylas y Abancay (Apurímac), Loreto, Bagua (Amazonas),
Junín, Huancavelica, Huanuco, Ayacucho, Cajamarca, Junín, Ancash and Puno.
Vertical childbirth refers to the position adopted by the mother to give birth, which may be standing,
sitting or squatting, while health-care personnel take up position in front of or behind her. This position allows
the baby to orient itself mainly towards the birth canal, which facilitates the birth and reduces traumatisms for
the newborn child. This strategy has been institutionalized in Ministry of Health technical standard no. 33, called
the technical standard for attending vertical childbirth with intercultural adaptation, published on 2 August
2005.
These policies resulted in an average increase of 20% in the rate of institutional childbirth between the
1996 and 2004 National Demographic and Health Survey (ENDES). This increase has been most significant
in the countryside, where the rate of institutional childbirth tripled in the period from 15% to 45%. This has
contributed to progress towards the relevant Millennium goals.
Source: Pan American Health Organization (PAHO), on the basis of official documents.
50
However, a given level of assisted childbirth does not guarantee lower maternal mortality, as this
also depends on the effectiveness and quality of health care, as well as other socio-economic, cultural and
environmental factors. For example, while the coverage of professional care in childbirth is over 85% in
Guyana and Paraguay, the maternal mortality rate in the two countries is in excess of 150 per 100,000 live
births, with 161 and 154 deaths, respectively. In other words, elevated “skilled care” index values do not
always mean that this care is provided by properly trained personnel.
Inequalities within countries also need to be considered. The proportion of births attended by
skilled personnel is substantially lower in rural areas and those further from cities (see figure III.9). The
contrast may be as marked as in Haiti, where professional care is some four times as prevalent in urban
areas as in rural ones (UNFPA/CST, 2004). Socio-economic status is also decisive. When this indicator is
analysed by wealth quintile, for example, using CDC and DHS data, it transpires that in Peru just 28% of
births to women in the poorest quintile were attended by skilled personnel, while virtually all births in the
wealthiest households were.
Figure III.9
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): BIRTHS ATTENDED BY
SKILLED PERSONNEL, BY MOTHER’S AREA OF RESIDENCE, 2002-2006
(Percentages)
Bolivia 2003
Colombia 2005
Guatemala 2002
Haiti 2005
Honduras 2005
Nicaragua 2001
Peru 2004/2005
Dominican
Republic 2002
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Doctor
Other health-care professional
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of demographic and health surveys (DHS), figures
obtained by STATcompiler processing, and final reports and data from the reproductive health surveys of the Centers for Disease Control
and Prevention (CDC).
As already pointed out, lack of access to contraceptive methods is another key factor in maternal
mortality, as it gives rise to high-risk unwanted pregnancies. Contraceptive use by women of childbearing
age (15 to 49) is still low in some countries, and there are large differences between rural and urban areas
(see figures III.10 and III.11).
51
Figure III.10
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): CONTRACEPTIVE USE BY
WOMEN IN CONJUGAL RELATIONSHIPS, BY METHOD AND AREA OF RESIDENCE, 2002-2006
(Percentages)
100
90
80
70
60
50
40
30
20
10
0
a
livi
Bo
)
03
(20
bia
lom
Co
)
05
(20
u
Ec
4)
00
r (2
o
ad
or
ad
El
lv
Sa
4)
00
3/2
0
(20
02
(20
ate
Gu
Any method, urban
la
ma
)
iti
Ha
6)
00
5/2
0
(20
s
ura
)
05
(20
ara
nd
Ho
Any method, rural
a
gu
Nic
)
01
(20
y
ua
rag
Pa
)
04
(20
ru
Pe
(2
Modern method, urban
n lic
3)
ca
ini epub /200
R 002
(2
)
05
/20
4
00
m
Do
Modern method, rural
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of official publications in the countries [online]
http://www.measuredhs.com and figures obtained by STATcompiler processing of data from the same site.
Figure III.11
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): SATISFIED DEMAND
FOR CONTRACEPTION, 2002-2006
100
90
80
70
60
50
40
30
20
10
0
livi
Bo
)
03
20
a(
bi
lom
Co
)
05
20
a(
iti
Ha
(20
6)
00
/2
05
u
nd
Ho
)
05
20
(
ras
g
ara
Nic
)
01
20
(
ua
u
rag
Pa
)
04
20
(
ay
20
u(
Pe
5)
00
/2
04
n
ca
ini
m
Do
)
lic
ub 2002
(
p
Re
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of official publications in the countries [online]
http://www.measuredhs.com and figures obtained by STATcompiler processing of data from the same site.
52
Inequalities and difficulties in reproductive health service use and access, particularly in rural and
indigenous populations with their high maternal mortality rates, are very pronounced. This is connected
with the absence or high cost of emergency services and care, particularly when it comes to obstetric
emergencies (see table III.4). In the early part of the present decade, countries such as Honduras and El
Salvador did not have obstetric care centres equipped with the basic services recommended by the United
Nations, and Bolivia had attained a mere 11% of the recommended level. Access is also complicated by the
long distances that have to be travelled to reach health centres and by a general lack of information about
the services available. Thus, one way of contributing to progress towards the goal would be to take steps to
expand access and reduce inequalities.
Table III.4
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): EMERGENCY
OBSTETRIC CARE SERVICES AS PERCENTAGE OF THE MINIMUM RECOMMENDED
BY THE UNITED NATIONS, BY POPULATION SIZE
Number of centres surveyed
Basic facilities
Basic and comprehensive facilities
Bolivia, 2003
85
11
48
Honduras, 2003
27
0
33
El Salvador, 2003
33
0
43
123
53
86
31
48
58
Nicaragua, 1999/2000
Peru, 1999/2000 b
Source:
a
A. Paxton and others, “Global patterns in availability of emergency obstetric care”, International Journal of Gynecology
and Obstetrics, vol. 93, 2006.
The evaluation was carried out for 9 of the 17 Local Integral Health Care Systems (SILAIS).
a
b
The evaluation was carried out for 6 of the provinces in the Department of Ayacucho. The indicator is calculated by dividing
the number of health centres attending obstetric emergencies by population size/500,000. The United Nations recommends
a minimum of 4 centres with basic facilities and 1 centre with comprehensive facilities for every 500,000 inhabitants.
3. Target 8 of goal 6: to have halted by 2015 and begun to reverse
the incidence of malaria and other major diseases 9
(a) The struggle against malaria
One target in the Millennium Development Goals is to have halted and begun to reverse the incidence
of malaria by 2015. While some countries in the Americas region have made considerable progress with
this, for the target to be met there will be a need in all of them for sustained efforts, adequate financing,
greater collaboration between health programmes and other sectors, adequate recruitment and training of
health-care personnel and people from the community, the participation of different sectors of society in
disease control and prevention, and efforts to strengthen health systems and establish policies based on
documented evidence.
The incidence of malaria in Latin America and the Caribbean is much lower than in the world’s
worst-affected regions. In 21 of the 35 countries and territories that are members of PAHO/WHO, however,
9
HIV/AIDS is not analysed, for the reasons given earlier.
53
there are areas where malaria is actively transmitted, and 124 million people are estimated to be at risk (in
differing degrees) of contracting it. There were 919,877 cases in the region in 2006, which was 20% less
than in 2000. About 75% of all cases are caused by Plasmodium vivax, and most of the rest by Plasmodium
falciparum.10 That same year, 219 malaria-related deaths were notified, a drop of 37% from 2000.
The incidence of malaria fell between 2000 and 2006 in 14 of the 21 countries where the disease
is endemic. In four of them the decline was in excess of 75%, so that they met both the Roll Back Malaria
Initiative target and the Millennium target. Another four reported drops of 50% to 75%, while in a further
six the figure was less than 50%. In the same period, however, the number of cases was found to have risen
in the Bolivarian Republic of Venezuela, Colombia, Costa Rica, the Dominican Republic, French Guiana,
Haiti and Panama (see table III.5).
Table III.5
MALARIA INDICATORS IN ENDEMIC COUNTRIES OF THE REGION, 2006
Country
Argentina
Belize
Number of cases reported, Percentage change since
2006
2000
209
-53
Annual Parasitic Index
(API), 2006
Slide Positive Index
(SPI), 2006
0.09
3.29
844
-43
3.18
3.28
Bolivia
18 995
-40
13.29
9.11
Brazil
549 184
-10
23.27
15.67
Colombia
120 096
+12
10.52
26.61
Costa Rica
2 903
+55
1.82
11.85
Dominican Republic
3 525
+186
0.51
0.79
Ecuador
9 863
-91
1.29
3.10
49
-93
0.01
0.04
Guatemala
31 093
-42
7.97
18.40
Guyana
21 064
-12
30.14
10.39
4 074
+10
24.98
…
Haiti
32 739
+94
4.13
37.22
Honduras
11 561
-67
2.02
9.42
Mexico
2 514
-66
0.90
0.18
Nicaragua
3 114
-87
0.56
0.67
Panama
1 663
+61
0.52
0.78
823
-88
0.47
0.74
64 871
-5
3.06
…
3 631
-72
75.65
12.27
37 062
+25
5.02
7.73
El Salvador
French Guiana
Paraguay
Peru
Suriname
Venezuela (Bol. Rep. of)
Source: Pan American Health Organization (PAHO).
Note: 10
A negative value for the percentage change indicates a decline and a positive value an increase.
API below 1 means that the country can be deemed to be in the pre-elimination stage.
SPI below 5 in cases of fever indicates that the control programme is adequate.
The Bolivarian Republic of Venezuela, Brazil, Colombia, French Guiana, Guyana and Suriname also recorded cases of Plasmodium
malariae, representing less than 0.01% of all cases in the Americas region.
54
Meanwhile, nine countries where the disease is endemic reported a Slide Positive Index (SPI) of
less than 5, showing that it is well controlled in areas of malaria risk. Seven of them also declared an Annual
Parasitic Index (API) of less than 1/1,000 people in risk areas, a level at which a country is classified as
being in the pre-elimination stage. If endemic patterns, epidemiological trends and other aspects are also
considered, Argentina, El Salvador, Mexico and Paraguay can be considered to belong to this category and
to have good prospects of going on to eliminate the disease. Conversely, overall epidemiological trends in
the Dominican Republic and Haiti indicate that they are not moving in this direction. Given the incidence
of malaria on the island and the fact that it is the only one in the Caribbean where the disease is endemic,
and considering the risk of transmission to other islands, an effort at eradication is both practicable and
advisable. See box III.3 for the therapies being used to combat malaria.
Box III.3
IMPACT OF COMBINED MALARIA THERAPIES
Ever since the 1950s, there have been warnings that Plasmodium falciparum was becoming resistant to the
antimalarial drugs most commonly used as stand-alone therapies (monotherapy). Plasmodium falciparum is the
most pathogenic of the plasmodia and chiefly affects the countries sharing the Amazon forest in South America.
When resistance arises, treatment can be ineffective and the disease can progress to severe malaria and even
death.
In 1998, the Pan American Health Organization began working with experts from the countries to draw up
a protocol for dealing with cases of Plasmodium falciparum in the Americas on the basis of the WHO protocol.
The protocol was reviewed again by PAHO in 2000 and eventually updated in 2001 at a PAHO meeting on the
monitoring of antimalarial drug resistance.
As part of the Roll Back Malaria (RBM) alliance, PAHO has helped the Amazonian countries set up a
monitoring system that follows the protocol referred to. As part of this work, in March 2001 the countries agreed to
form the Amazon Network for the Surveillance of Antimalarial Drug Resistance and the Amazon Malaria Initiative
(RAVREDA-AMI), whose members are the Bolivarian Republic of Venezuela, Bolivia, Brazil, Colombia, Ecuador,
Guyana, Peru and Suriname.
One of the key aspects of the network is the use of evidence-based treatments. In Peru, before RAVREDAAMI started, studies had been carried out on the effectiveness of malaria treatment and the decision was taken, on
the basis of the results obtained, to change the system and start using combined therapies based on artemisinin.
Since 2002, all the other countries in the network have carried out effectiveness studies of the most commonly used
antimalarial drugs and they have all used the results of these for evidence-based decision-making.
One example of the impact of these changes can be seen in Guyana and Suriname, the countries with the
highest Plasmodium falciparum infection and mortality rates in the 1990s. In 2004, once again on the basis of the
findings of effectiveness studies, they changed their official treatment policy and began using combination therapy
based on artemisinin derivatives. Between 2004 and 2006, Suriname notified a 60% reduction in the number of
malaria cases, while Guyana recorded a 14% reduction. Similar trends can be seen in Bolivia, Ecuador and Peru,
countries that changed their policies and began using artemisinin-based combination therapies in 2004. Meanwhile,
Brazil and Colombia, which only switched their systems to the use of combination therapies in 2006, have yet to
report any reduction in Plasmodium falciparum infections.
Besides combination therapies, it is important to stress that the countries have made other investments, such
as in the prevention, monitoring, detection and containment of outbreaks and in the use of insecticide-impregnated
mosquito nets; they have expanded malaria diagnosis and treatment facilities, and they have worked to strengthen
health-care systems. All these efforts have been made possible by substantial financing from the countries’
own funds, supplemented by investments from other financing sources such as the Global Fund to Fight AIDS,
Tuberculosis and Malaria.
Source: Pan American Health Organization (PAHO).
55
In the countries and territories of the Americas that WHO deems transmission-free, an annual
average of 1,300 cases have been reported since 2000. These are “imported”, i.e., they concern travellers
from countries in the region and elsewhere in the world where malaria is endemic. In 2006 there were
outbreaks in Bahamas and Jamaica, two countries that are transmission-free, but national efforts carried
out with the collaboration of WHO and other international agencies brought them under control and the
situation is being actively monitored to prevent further outbreaks.
Following the main lines of the Regional Strategic Plan for Malaria in the Americas, 2006-2010,
which coincide with the working areas of the Global Malaria Control Strategy in the region, the strategy
has encompassed five components: prevention; surveillance and early detection and control of epidemics;
integrated management of vectors, diagnosis and treatment; an environment supportive of efforts to prevent
and control malaria; and efforts to strengthen the countries’ health systems and build capacities there.
(b) Controlling tuberculosis
The incidence of tuberculosis has also been falling since the 1980s (see figure III.12) and this trend is
expected to continue through to 2015. In 2006, the countries of Latin America and the Caribbean reported
209,000 new cases, 120,000 of which were of smear-positive pulmonary tuberculosis, a form that represents
a grave threat to the sufferer and the wider population owing to the high risk of death and contagion in the
community if it is left untreated. Some 80% of reported cases of smear-positive pulmonary tuberculosis
affected people aged between 15 and 54, with a preponderance of men over women (1.6 men per woman). It
affects people at the reproductive stage of life, with severe economic implications for families and society.
Figure III.12
AMERICAS REGION: INCIDENCE OF REPORTED TUBERCULOSIS, 1980-2005
70
Rate per 100 000 inhabitants
60
50
40
30
20
10
Directly observed treatment, short course (DOTS)
06
20
20
04
02
20
00
20
98
19
96
19
94
19
92
19
90
19
19
88
19
86
84
19
82
19
19
80
0
Year
Latin America and the Caribbean
The Americas
Source: World Health Organization (WHO), Global Tuberculosis Control, 2008. Surveillance, Planning, Financing, Washington, D.C., 2008.
56
The reduction in reported tuberculosis is put down to effective control measures in countries that
have successful, long-standing national tuberculosis control programmes. From 1996 to 2005, the decline
accelerated thanks to the successful application and extension of the directly observed treatment, short
course (DOTS) strategy, which improved control, especially in countries with limited financial resources
and high prevalence rates. As a result, by 2006 many countries were able to reach the international targets
of detecting 70% of existing cases of infectious tuberculosis and successfully treating 85% of these (see
figure III.12 and map III.1).
Alongside the progress with tuberculosis treatment and detection, the prevalence of the disease
and the mortality associated with it have also diminished. According to estimates by the World Health
Organization global tuberculosis monitoring and control programme, by 2006 the Americas region had
managed to halve the prevalence of the disease from its 1990 level (from 96 to 44 per 100,000 inhabitants)
and cut mortality by 44% (from 9 to 5 per 100,000 inhabitants), a position very close to the Millennium
target, which is to reduce tuberculosis prevalence and death rates by 50% from their 1990 levels.
The figures for the Latin American and Caribbean countries are very disparate, however. Those
with greater financial resources or successful control programmes (Argentina, Brazil, Chile, Costa Rica,
Cuba, Dominican Republic, Mexico, Nicaragua, Panama) reached the Millennium target before 2005, Peru
and Puerto Rico did so before 2006, and the remainder are expected to do so by 2015. To achieve this,
however, the countries that have a high prevalence or risk of tuberculosis, namely the Bolivarian Republic
of Venezuela, Belize, Bolivia, Colombia, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Paraguay and
Suriname, will have to take deliberate measures to control the disease and make a firm political commitment
in the form of sustainable financing provision. Because of the HIV/AIDS epidemic now ravaging Guyana,
the incidence, prevalence and mortality rate of tuberculosis have risen steadily, and it will probably be
the only country in the Americas region not to achieve this component of the 2015 Millennium targets
(see table III.6).
57
Map III.1
GEOGRAPHICAL COVERAGE OF THE DIRECTLY OBSERVED TREATMENT, SHORT COURSE
(DOTS) STRATEGY IN THE AMERICAS, 2006
58
Table III.6
LATIN AMERICA AND THE CARIBBEAN: PREVALENCE AND MORTALITY RATES
OF ALL FORMS OF TUBERCULOSIS, 1990 AND 2006
1990
2006
Country
Argentina
Belize
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Suriname
Uruguay
Venezuela (Bol. Rep. of)
AMR
Prevalence
Mortality
Prevalence
122
79
478
128
59
107
36
38
236
348
163
142
79
774
189
14
103
197
114
119
501
34
167
45
60
96
10
10
53
7
5
10
4
3
29
45
17
15
10
111
17
1
10
22
9
13
37
4
19
4
6
9
48
58
266
57
16
58
16
10
117
193
67
111
187
400
96
10
25
74
44
101
193
5
96
34
53
45
Mortality
5
6
30
4
1
6
1
1
15
26
9
14
29
58
11
1
2
7
4
12
16
1
13
3
6
4
Source: World Health Organization (WHO), Global Tuberculosis Control, 2008. Surveillance, Planning, Financing,
Washington, D.C., 2008.
Note:
Prevalence rate = cases per 100,000 inhabitants; mortality rate = deaths per 100,000 inhabitants.
Tuberculosis control in the Americas is based on application of the Stop TB Strategy, which involves a
comprehensive, patient-centred approach so that action is not limited to the diagnosis and treatment of detectable
tuberculosis but extends to the identification of individuals or groups who are at particular risk of illness or
death, such as those with TB and HIV coinfection, those suffering from multidrug-resistant TB, and vulnerable
and deprived populations generally. At the same time, other initiatives are being implemented to improve the
responsiveness of health services and bring all health-care providers on board with a view to creating an efficient
health system that respects basic rights and encourages the participation of sufferers and communities.
The regional Stop TB strategy and the Global Plan to Stop TB 2006-2015 are being implemented in
the Americas region through the Regional Tuberculosis Control Plan for 2006-2015. The two documents set out
the steps to be taken towards the tuberculosis-related Millennium targets and represent an appeal for political
commitment and for the mobilization of resources sufficient to eliminate tuberculosis as a public health problem
in the long term. El Salvador is an example of high-quality implementation of the Stop TB strategy. Since
implementation, tuberculosis detection and cure rates have both increased, coinfection with TB and HIV has
become less lethal, and multidrug resistance has fallen below 1% in both new and previously treated cases, and this
has helped to improve the quality and resolution capacity of the health system generally. This outcome confirms
the need to implement the strategy regionwide.
59
Annex
Table A-III.1
EVALUATION OF PROGRESS TOWARDS SELECTED HEALTH-RELATED MILLENNIUM
DEVELOPMENT GOALS
Indicator 13
Indicator 14
Indicator 15
Indicator 16
Indicador 17
Under-five mortality rate
per 1.000 live births
Infant mortality rate per
1.000 live births
Children immunized against
measles
Maternal mortality rate per
100.000 live births
Births attended by skilled medical
personnel
1990
level
Latin
America
and the
Caribbean
55.7
2007
level
27.5
Progress
1990
by 2007
level
(%)
-50.6
42.4
2007
level
22.0
Progress
1990 2000
by 2007
level onward
(%)
-48.2
76
92
-46.6
31
66
Progress
2000
level
2000
and
after
87
82.8
523
630
Progress
2000
level
-0.05
85
20.5
24
2000
and
after
Progress
Countries with medium-low and low human development
Haiti
133.5
73.0
-45.3
92.8
49.6
2006
112.9
2005/
2006
26
2005
8.3
Guatemala
85
39.9
-53.1
60.95
31.0
-49.2
68
95
2006
39.7
153
148.8
2005
-2.7
41
31
2004
-24.4
Nicaragua
75.8
26.6
-64.9
56.5
22.0
-61.1
82
98
2006
19.5
100
86.5
2005
-13.5
82
80
2005
-2.4
Honduras
66.8
42.4
-36.5
47.7
28.5
-40.1
90
91
2006
1.1
67
2005
Bolivia
113
62.1
-45.0
82.6
46.6
-43.6
53
88
2006
66.0
2006
230
230
1999/
2003
0.0
52
64
23.1
Countries with medium human development
El Salvador
64.1
29.6
-53.8
47.1
22.0
-53.3
98
98
2006
0.0
71.2
2005
44
2005
Ecuador
65.3
26.4
-59.6
49.85
21.5
-56.9
60
97
2006
61.7
90
85
2005
-5.6
69
80
2005
15.9
Dominican
Republic
70.7
33.6
-52.5
55.25
30.1
-45.5
96
99
2006
3.1
77
80
2006
3.9
96
96
2006
0.0
Paraguay
55.8
38.4
-31.2
44.8
32.4
-27.8
69
88
2006
27.5
152
153.5
2004
1.0
86
86
2004
0.0
Peru
85.7
30.2
-64.8
57.8
22.1
-61.7
64
99
2006
54.7
185
185
1994/
2000
0.0
59
71
2004
20.3
Countries with medium-high human development
Colombia
52.3
26.2
-49.9
31.45
19.2
-38.8
82
88
2006
7.3
105
72.7
2005
-30.8
86
97
2005
12.8
Brazil
59.6
29.5
-50.5
47.45
24.0
-49.5
78
99
2006
26.9
45
76.1
2004
69.1
97
97
2004
0.0
Venezuela
(Bolivarian
Rep. of)
30.3
22.2
-26.7
25
17.2
-31.2
61
95
2006
55.7
60
59.9
2005
-0.2
95
2008
Panama
35.8
24.3
-32.1
28.3
18.4
-34.8
73
94
2006
28.8
61
66
2005
8.2
90
91
2005
1.1
Countries with high human development
Mexico
Cuba
Costa Rica
Uruguay
Chile
Argentina
44.3
20.5
-53.7
36.3
17.1
-52.9
75
96
2006
28.0
79
63.4
2005
-19.7
85
94
2006
10.6
19
7.1
-62.6
15.6
5.2
-66.7
94
96
2006
2.1
34
49.4
2006
45.3
100
100
2006
0.0
18.6
11.1
-40.3
15.95
10.0
-37.6
90
90
2006
0.0
36
39.3
2006
9.2
96
94
2006
-2.1
25
16.2
-35.2
21.35
13.2
-38.0
97
94
2006
-3.1
11
100
2005
19.3
9.1
-52.8
16.25
7.3
-55.2
82
91
2006
11.0
19
19.8
2005
4.2
100
100
2005
0.0
30
22.5
-25.0
25.6
13.6
-47.1
93
97
2006
4.3
35
39.2
2005
12.0
98
99
2005
1.0
60
Indicator 13
Indicator 14
Indicator 15
Indicator 16
Indicador 17
Under-five mortality rate
per 1.000 live births
Infant mortality rate per
1.000 live births
Children immunized against
measles
Maternal mortality rate per
100.000 live births
Births attended by skilled medical
personnel
1990
level
2007
level
Progress
1990
by 2007
level
(%)
2007
level
Progress
1990 2000
by 2007
level onward
(%)
Progress
2000
level
2000
and
after
Progress
2000
level
2000
and
after
Progress
Caribbean countries
Anguilla
…
Antigua and
Barbuda
…
Netherlands
Antilles
17.0
16.05
14.8
-7.7
Aruba
20.2
16.85
17.2
2.0
89
93
2006
99
2006
93
2006
11.2
65
0
2006
0
2006
-100.0
100
2006
100
100
2006
0.0
99
96
2002
-3.0
99
2006
98
100
2005
2.0
100
91
2006
-9.0
Bahamas
17.2
22.85
14.0
-38.9
86
88
2006
2.3
Barbados
11.3
15.05
10.3
-31.4
87
93
2006
6.9
81
Belize
20.3
32.6
16.6
-49.0
86
99
2006
15.1
68
96
2005
100
2005
…
88
99
2006
12.5
0
2005
100
99
2005
-1.0
85
99
2006
16.5
0
2002
100
100
2005
0.0
92
2005
Bermuda
Dominica
Grenada
Guadeloupe
41.6
44.15
34.2
-22.6
6.9
-56.1
9.1
15.6
French
Guiana
15.2
22.45
13.5
-39.7
Guyana
58.1
64.8
43.6
-32.8
73
90
2006
Cayman
Islands
…
86
2006
Turks and
Caicos
Islands
…
99
2006
United
States Virgin
Islands
10.1
15.55
8.7
British Virgin
Islands
Jamaica
Martinique
17.2
21.85
13.7
-37.3
8.1
9.75
6.6
-31.9
Puerto Rico
Saint Vincent
and the
Grenadines
99
74
…
9.1
12.7
7.3
Saint Kitts
and Nevis
28.4
32.3
133
2005
161.2
2005
0
2006
-100.0
21.2
90
88
-44.2
…
Montserrat
23.3
0
2005
87
2006
99
2006
17.6
49
2004
94
2005
100
2006
100
2006
98
2004
0
2005
100
2006
95
2001
2003
89
2002
0
2004
100
2004
0
2006
100
2006
100
2005
-42.6
…
99
99
2006
0.0
0
2005
100
2005
23.6
-26.8
96
99
2006
3.1
0
2006
100
2005
4.4
13.6
Saint Lucia
16.3
18.45
…
82
94
2006
14.6
35
100
100
2005
0.0
Suriname
35.4
35.35
28.1
-20.5
65
83
2006
27.7
153
91
90
2004
-1.1
Trinidad and
Tobago
18.2
15.85
12.7
-20.1
70
89
2006
27.1
100
2003
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of official documents from the countries.
61
Chapter IV
CHRONIC CHILD UNDERNUTRITION, ITS DETERMINANTS AND ITS EFFECT
ON FULFILLING THE GOALS 1
Individual health is not an isolated phenomenon; its main determinants are social ones, in particular
poverty, malnutrition and poor employment conditions, but gender, ethnicity and race are also influential;
hence, the various aspects of the Millennium Development Goals are interrelated (PAHO, 2007b). Any
explanation of the determinants of health and of prevailing inequalities needs to recognize that advantages
and disadvantages in one dimension of life tend to be accompanied by advantages and disadvantages in
other areas, which are longitudinally structured throughout people’s lives. Disadvantages tend to cluster
and reinforce each other, and they may produce significant social gradients in individual health and
specific vulnerabilities among certain population groups, calling for analysis and action on many levels
(CSDH, 2007).
For the specific purpose of focusing the attention of governments, civil society, international
organizations and donors on feasible ways of promoting better social health conditions, particularly for
the most vulnerable, the World Health Organization formed the Commission on Social Determinants of
Health (CSDH) in 2005. This has a three-year mandate to promote equity as a shared objective among the
different sectors of Government to which different social actors contribute, and to lay foundations for a new
health agenda. The strategy supports changes in health policies in the various countries, through effective
and evidence-based models and practices that address the social determinants of health; it also supports the
formation of new action and research networks to confront them which involve simultaneous participation
by leading scientists, professionals, civil society organizations, civil servants and global initiatives.
The analysis that follows approaches this subject from the standpoint of the nutritional status of the
child population. As numerous studies show, eradicating extreme poverty and hunger, and reducing child
mortality are closely related to the nutritional status of children. Chapter II showed that malnutrition was
disproportionately prevalent in the lowest socio-economic strata: in policy terms, the glaring inequality that
exists in chronic undernutrition and its high prevalence among the poorest population groups requires it to
be tackled from the standpoint of its unequal distribution. Hence the importance of understanding not only
its causes, to be able to act on them, but also its socio-economic distribution through time, and to detect the
relevant socio-economic, environmental and biomedical variables that explain this.2
To that end, based on an analysis of demographic and health surveys in five Latin American and
two Caribbean countries in the 1990s and the first few years of the new century,3 this chapter describes the
1
2
3
This chapter is based on Paraje (2008), a consultancy paper to which the reader is referred for further details.
Given the sample quality required for the econometric analysis, it was impossible to analyse other dimensions of the Goals, such as infant
or maternal mortality. Therefore it was decided to focus on chronic child malnutrition.
The countries were chosen on the basis of the availability of relatively recent demographic and health surveys —better known as DHSs—
which made it possible to make a comparison: Bolivia (1994, 2003); Colombia (1995, 2005); Dominican Republic (1996, 2002); Haiti
(1994, 2005); Guatemala (1995, 1999); Nicaragua (1997, 2001) and Peru (1996, 2004). As can be seen, this includes a number of countries
that are behind schedule in terms of progress towards fulfilling the Millennium Development Goals. The sample includes children under
five years of age (59 months of life), except in Bolivia where it covers children under three (35 months of life). The explanatory variables
were chosen on the basis of theoretical-empirical evidence obtained from relevant studies and survey data. Estimates of the relation between
chronic child undernutrition and the set of explanatory variables are “reduced forms” which implicitly incorporate a certain number of
relations between malnutrition and variables that are not directly used.
62
general trends of chronic child undernutrition,4 analyses its level relative to the causes of its socio-economic
distribution, and reviews the changes that have occurred in this distribution. As findings are discussed for
seven countries, the intention is not to obtain universal conclusions for policies acting on the determinants
of malnutrition.
1. General trends in the levels of chronic undernutrition
in selected countries
Although levels of child undernutrition vary across the countries studied, its characterization is similar.
Table IV.1 shows its prevalence (i.e., the percentage of all children who are malnourished) in selected
categories. To avoid confusion in the subsequent causal analysis, it should be noted that the table does
not show causal relationships —or even a statistical relation— but percentages of chronic malnutrition
considering just one variable or category at a time.
In all cases, it is more prevalent among rural households than urban ones. Despite varying from one
country to another, it is not infrequent to find rural malnutrition rates that are twice as high as in urban areas
(e.g., Bolivia, Colombia, Haiti, Nicaragua) or even four times as high (e.g., Peru).
Moreover, in all cases it is more prevalent the lower the “wealth” quintile5 to which the household
belongs, and it becomes less frequent as the level of the mother’s or partner’s education rises.
In contrast, the relation between malnutrition and the mother’s employment status is less clear. In
some countries (Colombia, Dominican Republic, Guatemala and Nicaragua) the highest rates of chronic
undernutrition are found among children whose mothers do not have paid work. Elsewhere, however
(Bolivia, Haiti, Peru), this occurs among children whose mothers do unskilled work, possibly because the
low incomes earned in such jobs are insufficient to gain access to an appropriate nutritional intake, or else
the children do not receive adequate care.
In terms of biomedical variables, malnutrition is more prevalent among male children in nearly all
cases. Rates also tend to be higher among third or later children in birth order, and they are much higher
among children over one year old, possibly due to the benefits provided by maternal breast feeding of
children under one. Lastly, children born with professionally attended delivery suffer less malnutrition in
all cases.6
4
5
6
This measure of deprivation was chosen rather than others, such as acute malnutrition (low height/weight ratio), because it reflects more
faithfully past critical situations and continuous deprivations suffered by children, which can permanently impair their development.
It makes it possible to consider not only the person’s current situation, which may vary little after measurement, but also the genetic,
geographic, socio-economic and other long-term determinants of their health status (Larrea and Kawachi, 2005).
We underline again that DHSs do not provide any information on monetary expenditure and/or income indicating a household’s socioeconomic level. But they contain data on the use of certain physical assets, conditions of housing, and household access to certain services.
Not all countries collect the same information, but ideally it is possible to ask whether they possess the following items: (i) electricity;
(ii) radio; (iii) television; (iv) refrigerator; (v) telephone; (vi) cellular phone; (vii) computer; (viii) bicycle; (ix) motorcycle; (x) automobile;
(xi) separate room for cooking; and (xii) own farm land. In addition, the following items are considered among housing characteristics:
(i) number of persons per room; (ii) source of drinking water; (iii) type of sewerage services; (iv) flooring material; (v) materials used
for walls; and (vi) roofing material. Using this information and applying the Filmer and Pritchett (2001) methodology based on principal
components analysis, an index of material well-being or material wealth can be calculated and used to rank and classify households and
individuals by their socio-economic position. This is a rudimentary proxy value for wealth, which makes it possible to locate each household
in the socio-economic quadrant and to make a Oaxaca decomposition, as done by Paraje (2008), which will be described below. As this is a
proxy value with these limitations, the terms “wealth” or “wealth index” are used between inverted commas throughout this chapter.
Professional care at delivery is that provided by a doctor, nurse, professional midwife, auxiliary midwife or some other professional,
depending on each country’s definition.
63
Table IV.1
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): CHARACTERIZATION OF
CHRONIC UNDERNUTRITION BY CATEGORIES, 1994-2005
(Percentages)
Variables
National average
Bolivia
Colombia
Dominican
Republic
Guatemala
Haiti
Nicaragua
Peru
1994
2003
1995
2005
1996
2002
1996
2002
1994
2005
1997
2001
1996
2004
26.8
24.1
14.8
11.5
10.8
8.9
49.7
46.1
32.0
23.1
24.6
20.0
25.8
24.3
Regions
Region 0
31.7
29.4
16.4
12.2
6.5
8.7
33.5
27.8
17.0
15.9
14.9
7.5
10.6
8.0
Region 1
17.1
15.0
15.1
13.8
14.3
11.7
55.3
56.3
37.4
26.5
23.6
15.9
25.3
17.7
Region 2
28.2
25.4
13.5
10.6
6.8
7.5
44.0
49.4
34.5
27.2
31.7
27.4
34.4
36.2
Region 3
-
-
13.3
9.7
14.6
7.0
44.8
45.0
-
-
28.5
27.7
32.9
21.0
Region 4
-
-
16.6
11.3
18.4
12.8
45.8
45.6
-
-
-
-
-
-
Region 5
-
-
-
-
11.6
9.1
59.5
54.6
-
-
-
-
-
-
Region 6
-
-
-
-
20.4
10.5
69.7
69.0
-
-
-
-
-
-
Region 7
-
-
-
-
11.8
6.5
-
-
-
-
-
-
-
-
Rural
34.8
33.0
18.9
16.7
15.3
10.9
56.5
54.5
36.4
27.3
31.1
28.8
40.4
40.0
Urban
19.7
17.5
12.4
9.0
7.4
7.8
35.2
31.8
23.6
14.8
18.8
11.3
16.2
9.3
40.9
38.0
23.6
19.5
21.3
15.6
64.3
66.3
45.2
32.6
37.8
34.9
45.6
47.6
Area
Wealth
Quintile 1
Quintile 2
33.2
31.1
16.5
12.4
10.4
9.8
61.5
59.7
34.7
31.0
28.7
25.7
30.5
33.5
Quintile 3
23.4
18.5
13.2
9.8
7.9
7.6
53.4
53.7
37.8
25.4
22.2
15.9
18.8
14.4
Quintile 4
18.9
14.3
7.4
6.2
5.7
5.4
33.6
27.5
25.3
15.4
12.9
8.0
10.1
4.4
Quintile 5
7.1
7.1
6.0
2.8
2.5
2.9
11.9
7.6
11.2
4.6
8.5
4.5
5.1
4.8
43.2
38.5
25.6
26.7
23.4
14.9
63.3
63.8
39.0
33.5
37.4
35.7
50.8
54.3
30.0
30.2
18.6
15.0
13.8
12.0
46.2
43.1
28.4
22.1
26.1
20.7
32.7
39.1
15.0
13.3
7.5
8.0
6.7
7.0
14.2
12.7
16.1
8.7
11.3
8.2
12.7
13.7
6.8
9.6
6.8
3.9
1.6
3.2
8.1
1.7
0.0
2.6
5.2
4.3
4.9
3.4
Mother’s education
No education
Incomplete/complete
primary
Incomplete/complete
secondary
Incomplete/complete tertiary
Mother’s employment status
Not working
22.8
21.4
14.9
14.5
12.7
10.4
52.6
48.5
30.6
21.4
25.9
22.4
24.0
13.9
Skilled work
16.2
21.4
9.6
4.9
3.6
6.3
36.6
35.9
14.7
5.6
16.3
8.2
7.0
7.6
Unskilled work
31.8
26.4
15.8
11.6
10.0
7.0
43.9
42.3
34.6
25.7
24.5
19.3
29.3
32.1
38.5
31.7
19.4
16.3
21.4
13.6
61.8
59.9
36.9
33.4
34.4
30.2
49.4
45.3
31.9
32.5
17.7
14.8
15.3
12.0
52.3
51.4
35.8
27.0
25.9
22.1
37.1
39.7
22.4
16.3
8.7
7.8
7.2
6.9
18.1
17.3
16.0
11.2
15.8
9.7
17.5
19.6
9.1
10.5
6.7
3.9
2.1
2.8
13.4
4.2
16.1
5.8
10.3
4.4
8.6
7.1
Partner’s education
No education
Incomplete/complete
primary
Incomplete/complete
secondary
Incomplete/complete tertiary
Sex
Male
26.6
25.7
15.8
12.2
12.0
10.1
50.3
47.3
33.1
24.0
26.1
20.2
26.4
26.4
Female
26.9
22.4
13.7
10.8
9.4
7.6
49.0
45.1
30.9
22.2
23.2
19.9
25.1
22.2
64
Table IV.1 (concluded)
Variables
Bolivia
Colombia
Dominican
Republic
Guatemala
Haiti
Nicaragua
Peru
1994
2003
1995
2005
1996
2002
1996
2002
1994
2005
1997
2001
1996
2004
First child
18.9
17.0
10.7
7.8
6.0
6.5
39.8
36.7
29.7
17.3
17.6
14.9
15.9
16.5
Second child
19.7
22.9
13.3
10.9
10.2
8.0
39.6
35.4
26.5
18.6
20.9
15.8
21.3
17.5
Third child
24.4
21.9
16.3
11.7
10.5
8.7
47.2
44.2
30.5
21.6
23.5
17.4
22.3
21.7
Fourth or subsequent child
35.0
30.2
21.5
19.4
18.0
13.7
59.2
56.7
35.6
29.7
32.2
29.0
38.1
41.0
Under 12 months
11.0
9.5
6.0
6.0
6.3
5.3
22.5
21.1
10.0
11.2
9.1
6.3
10.2
7.1
12-24 months
38.1
32.5
16.8
16.6
14.8
11.6
57.2
53.1
31.5
30.3
29.7
21.9
31.5
29.0
Over 24 months
31.4
29.1
17.1
11.7
10.8
9.0
57.2
51.7
40.4
24.7
28.1
23.7
28.8
28.9
Without professional
attendance at delivery
37.0
36.8
26.7
19.5
24.6
18.3
62.0
60.2
36.5
30.1
34.2
35.4
42.0
45.2
With professional attendance
at delivery
16.4
17.1
12.6
10.7
10.2
8.6
46.8
43.6
26.8
17.6
19.8
18.4
14.0
15.5
Birth order
Age
Professional attendance
at childbirth
Source: Guillermo Paraje, “Evolución de la desnutrición crónica y sus distribución socioeconómica en siete países de América Latina y el
Caribe”, Políticas sociales series, No. 140 (LC/L.2878-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean
(ECLAC), 2008, on the basis of demographic and health surveys (DHSs).
Figure IV.1 shows the prevalence of chronic undernutrition according to the latest survey analysed,
along with the corresponding socio-economic distribution indicator. The horizontal axis shows national
average chronic undernutrition (a higher coefficient implies a greater incidence/depth of malnutrition),
whereas the vertical axis shows the socio-economic concentration index of that coefficient.7
The figure shows that while the prevalence of chronic undernutrition was relatively low in some
countries (e.g., the Dominican Republic in 2002), it was disproportionately concentrated among lowerincome households: of the seven countries reviewed, it is one of the three most unequal. Among the other
countries, Colombia and Nicaragua recorded an “average” incidence —less in the case of Colombia—
whereas Haiti, Bolivia, Peru and Guatemala, reported the highest levels. Nonetheless, this latter subgroup
display different characteristics, because in Haiti it is less concentrated than in Bolivia, Guatemala and,
above all, Peru, which is the most unequal of the seven countries reviewed.
7
The concentration index is calculated and interpreted similarly to the Gini coefficient and takes values in the range [0; 1]. If the variable
is concentrated among households in the highest socio-economic group, the coefficient will be closer to one in absolute terms, and vice
versa. It is also possible to estimate the relation between the variable in question and a number of explanatory variables, and to deduce how
the independent variable is affected by inequality in the socio-economic distribution of those explanatory variables. The index can also be
broken down in terms of the variables that determine the behaviour of the independent variable.
65
Figure IV.1
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): SOCIO-ECONOMIC
DISTRIBUTION OF UNDERNUTRITION, 1999-2005
Source: Guillermo Paraje, “Evolución de la desnutrición crónica y sus distribución socioeconómica en siete países de América Latina y el
Caribe”, Políticas sociales series, No. 140 (LC/L.2878-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean
(ECLAC), 2008, on the basis of demographic and health surveys (DHSs).
Figure IV.2 shows how chronic undernutrition and its distribution varied when the two surveys were
compared. In all of the countries analysed, the prevalence and depth of chronic malnutrition decreased, albeit
by varying amounts: the greatest reduction occurred in Haiti and Nicaragua, whereas Guatemala and Peru
were at the lowest point on the scale.8 It should also be noted that countries differ in the way the decrease
occurred. Whereas in Haiti this reflected a reduction in inequality, in Nicaragua it was closely related to an
increase in inequality, since malnutrition fell mostly among the relatively more affluent households.9
8
9
In statistical terms, changes in the national mean height/age coefficient were only significantly different from zero in Colombia, the
Dominican Republic, Haiti and Nicaragua (all at a level above 99%). In Bolivia, Guatemala and Peru differences between mean height/
age coefficients are statistically equal to zero; i.e., in these countries, chronic undernutrition did not vary during the period. A t-test for
differences in means was used to measure the statistical significance of the mean height/age coefficient and its concentration index. The key
assumption of this test is that the samples are independent. In the case of the DHSs, and given the difference between the samples in time,
this assumption seems safe.
Changes in the concentration index of the height/age coefficient were only significantly different from zero in the Dominican Republic and
Nicaragua (both at a level above 99%) and in Peru (at 95%).
66
Figure IV.2
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): CHANGES IN THE INCIDENCE
OF CHRONIC UNDERNUTRITION COMPARED TO CHANGES IN
THE INEQUALITY OF UNDERNUTRITION
-0.1
-0.0
Source: Guillermo Paraje, “Evolución de la desnutrición crónica y sus distribución socioeconómica en siete países de América Latina y el
Caribe”, Políticas sociales series, No. 140 (LC/L.2878-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean
(ECLAC), 2008, on the basis of demographic and health surveys (DHSs).
2. Determinants of chronic child malnutrition
As noted above, table IV.1 showed only the prevalence of malnutrition with respect to each variable or
category, and not its depth. Moreover, many of the variables considered in the table affect the prevalence
of chronic malnutrition simultaneously, since all of them affect its level. From the public policy standpoint,
however, it is useful to distinguish the effects exerted by each variable, to be able to act on the most
influential ones. For this purpose, a regression analysis was performed to measure the magnitude of the
effect of each variable on chronic undernutrition, while holding the influence of the others constant.
Table IV.2 summarizes the results of the linear regressions (ordinary least squares - OLS) for the seven
selected countries, with two observations per country.10
10
The annex in Paraje (2008) contains tables with the results for each country, showing not only the coefficient on each variable but also the
value of the t-statistic. The fit of the model used is relatively appropriate for this type of study, because the R2 values obtained range from
0.106 (Dominican Republic, 2002) to 0.383 (Peru, 2004). Moreover, in cases where this indicator is quite low, high values were obtained for
the F-statistic, which measures the statistical significance of all the coefficients jointly. The regressions were estimated using the HuberWhite/sandwich variance estimator, which makes it possible to obtain robust standard errors when a given group of observations may not
be independent. In the case of the DHSs, the group consists of the sample target cluster.
67
Table IV.2
LATIN AMERICA AND THE CARIBBEAN (7 COUNTRIES): DETERMINANTS
OF CHRONIC CHILD MALNUTRITION, 1994-2005
(Linear regression coefficients)
Bolivia
1994
Colombia
2003
Dominican Republic
2005
1995
1996
2.152 **
2002
1.808 **
Guatemala
1996
2002
Constant
1.427 **
1.904 **
1.712 **
1.490 **
Region 1
-0.416 **
-0.376 **
-0.394 **
-0.245 **
0.024
-0.003
-0.223 *
-0.225
Region 2
-0.070
-0.146 **
-0.291 **
-0.326 **
-0.071
-0.018
-0.201 *
-0.231
Region 3
-
-
-0.326 **
-0.351 **
0.077
-0.068
-0.215 **
-0.259
Region 4
-
-
-0.387 **
-0.322 **
0.157 *
Region 5
-
-
-
-
-0.012
Region 6
-
-
-
-
Region 7
-
-
-
Urban
0.115
0.067
0.184 **
Wealth
-23266.5 **
0.004
2.238 **
2.463 **
0.064
0.020
-0.046
0.326 **
0.129
0.101
-0.019
0.474 **
0.154
-
-0.038
-0.105
-
-
0.008 **
0.018
0.029
-0.021
0.058
-0.239 ** -18277.3 **
-0.149 ** -18535.8 ** -15324.7 ** -35418.1 **
Mother’s education
-0.017
-0.057 **
-0.070 **
-0.038
-0.024
-0.002
-0.058 **
Mother’s education
squared
0.000
0.003 **
0.002 *
0.001
0.000
-0.001
0.002 *
-47508.0 **
-0.073 **
0.002
Mother: skilled work
(ref. not working)
-0.106
-0.017
-0.052
-0.145 **
-0.080
-0.064
-0.038
0.298
Mother: unskilled work
(ref. not working)
-0.018
0.003
0.047
-0.074 *
-0.047
-0.059
-0.043
0.046
Partner’s education
-0.007
-0.012 *
-0.012 *
-0.007 *
-0.011 *
-0.008 *
-0.014 *
-0.015
Sex of child: female
-0.069
-0.068 *
-0.086 **
-0.071 **
-0.145 **
-0.107 **
-0.035
-0.048
Second child
-0.028
0.033
0.031
0.081 **
0.112 **
0.081 **
0.002
0.051
Third child
0.118
0.043
0.058
0.088 **
0.097 *
0.132 **
0.051
0.139
Fourth or subsequent
child
0.139 *
0.025
0.028
0.171 **
0.145 **
0.113 **
0.145 **
0.176
Age in months
0.125 **
0.107 **
0.025 **
0.025 **
0.020 **
0.016 **
0.083 **
0.072 **
-0.003 **
-0.002 **
0.000 **
0.000 **
0.000 **
0.000 **
-0.001 **
-0.001 **
0.000 **
0.000 **
-
-
0.000 **
0.000 **
0.000 **
0.000 **
-0.186 **
-0.111 **
-0.040
-0.005
-0.093
0.053
-0.042
0.117
Age in months squared
Birth weight (g)
Professional attendance
at childbirth
*
*
N
2864
5054
4333
10161
3317
8128
7943
2947
R
0.255
0.265
0.127
0.126
0.184
0.106
0.334
0.358
46.80 **
74.94 **
24.41 **
48.06 **
25.29 **
26.81 **
96.84 **
54.19 **
2
F-test
68
Table IV.2 (concluded)
Haiti
1994
Nicaragua
2005
Peru
2001
1997
1996
2004
Constant
1.186 **
1.704 **
1.913 **
1.800 **
1.730 **
2.216 **
Region 1
0.064
0.022
0.008
0.103 *
0.245 **
0.097
Region 2
0.032
-0.051
0.082
0.189 **
0.240 **
0.165
Region 3
-
-
-0.096
0.098
0.249 **
-0.060
Region 4
-
-
-
-
-
-
Region 5
-
-
-
-
-
-
Region 6
-
-
-
-
-
-
Region 7
-
-
-
-
-
-
Urban
0.219
0.114
-0.019
0.011
0.037
Wealth
-42213.0 **
-27494.9 **
-21167.0 **
-19077.4 **
-0.041 **
-0.051 **
-0.035 **
-0.252 **
0.214 **
Mother’s education
-0.065
-0.029
Mother’s education
squared
0.002
0.001
0.000
Mother: skilled work
(ref. not working)
0.284
0.055
0.047
Mother: unskilled work
(ref. not working)
0.013
-0.007
Partner’s education
0.005
Sex of child: female
Second child
Third child
Fourth or subsequent
child
Age in months
Age in months squared
-0.034
0.000
0.000
-0.050
0.038
0.124
0.045
-0.020
0.089 **
0.176 **
-0.018
0.000
-0.004
-0.014 **
-0.004
-0.184
-0.143 *
-0.113 **
-0.057
-0.061 **
-0.139 **
-0.012
-0.047
0.065
0.045
0.059 *
-0.041
-0.155 *
0.075
0.062
0.092 **
-0.008
0.068
0.133 **
0.138 **
0.177 **
0.143 *
0.053 **
0.037 **
0.044 **
0.036 **
0.045 **
0.042 **
-0.001 **
-0.001 **
-0.001 **
0.000 **
-0.001 **
-0.001 **
0.000 **
0.044
-0.018
0.002 *
-0.323 **
Birth weight (g)
0.000
0.000 **
0.000 **
Professional attendance
at childbirth
0.003
-0.161 **
-0.120 **
N
2693
2371
6443
5633
14468
2237
R
0.208
0.137
0.177
0.231
0.282
0.383
21.40 **
19.57 **
50.00 **
56.14 **
2
F-test
-0.074
0.000
-0.210 **
123.82 **
0.000 **
-0.143
37.18 **
Source: Guillermo Paraje, “Evolución de la desnutrición crónica y sus distribución socioeconómica en siete países de América Latina y el
Caribe”, Políticas sociales series, No. 140 (LC/L.2878-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean
(ECLAC), 2008, on the basis of demographic and health surveys (DHSs).
Note:
*
The dependent variable is the negative value of the height/age ratio for children under 60 months old.
Different from zero at the 95% significance level.
** Different from zero at the 99% significance level.
69
A number of general trends should be noted. Firstly, in all cases, socio-economic conditions
—captured by the “wealth” index— significantly affect chronic malnutrition (i.e., under equal conditions,
less “wealth” is associated with higher malnutrition levels). This result, which is frequent in studies on this
subject, reveals the clear and predictable relation between long-term nutritional status and the household’s
capacity to ensure a stable supply of food.11 Some of the components of this particular “wealth” index, such
as the existence of secure sources of water and sewage disposal, could have a major influence on child
malnutrition, as noted in several studies (Smith, Ruel and Ndiaye, 2005).
Secondly, age and age-squared are highly significant in all cases. As the child grows older, the
incidence of chronic malnutrition rises, albeit at declining rates.12 As noted in table IV.1, chronic malnutrition
generally increases rapidly during the first year of life, which suggests a negative relation between maternal
breast feeding and the level of malnutrition. Nonetheless, in most of the cases reviewed, the effects of age
on malnutrition diminish through time.
In most countries, chronic malnutrition levels apparently do not vary between urban or rural
sectors.13 Only in three cases (Colombia, 1995 and 2005; Nicaragua, 1997) does living in urban areas have
positive consequences for chronic malnutrition. In other words, while malnutrition is more frequent in rural
zones (see table IV.1), this is due to the specific characteristics of the area, such as the level of “wealth”
and the mother’s education. This would suggest that geographically selective policies should target other
aspects such as income levels or the mother’s education.
Regional effects are also likely to mitigate the effect of this variable. Although these are not always
significant, in some countries they are highly relevant, albeit with differing signs. In Bolivia, for example,
the Llano region had significantly lower levels of malnutrition than La Paz or el Valle in the two years
compared (1994 and 2003). In Colombia, all regions reported lower levels than those of the Bogotá area.
In Peru, in 1996 the figures for Lima were significantly lower than in the rest of the country, although these
differences had disappeared by 2004.14
The influence of the mother’s education is not uniform: while higher levels always have a positive
influence on reducing chronic malnutrition, the coefficient is not significant in seven cases.15 There is also
evidence of a nonlinear effect; i.e., as the mother’s education increases, malnutrition declines, but at a
decreasing rate, significantly in four cases. The partner’s education also has an effect but, apart from the
Dominican Republic in 2002, this is much less than that of the mother’s education, which would suggest
that it is the mother who has the greatest influence on children’s nutritional status.
Generally speaking, chronic malnutrition affects boys more than girls, and the effect is significant
in most cases.16 Birth order also tends to affect chronic malnutrition: the higher in the order, the greater the
malnutrition, although there are sharp differences between countries.
For example, Wagstaff, van Doorslaer and Watanabe (2003); Valdivia (2004); Smith, Ruel and Ndiaye (2005); Harttgen and Misselhorn
(2006); van de Poel and others (2006); van de Poel, O’Donnel and van Doorslaer (2007).
12
This result is consistent with those obtained by Valdivia (2004), Larrea and Karachi (2005) and by Harttgen and Misselhorn (2006),
although not with those reported by Wagstaff, van Doorslaer and Watanabe (2003).
13
This agrees with the findings of Smith, Ruel and Ndiaye (2005) and van de Poel, O’Donnel and van Doorslaer (2007). Table IV.1 shows
that chronic undernutrition is greater in the rural sector in all cases. This result is compatible with that obtained in the regression analysis:
geographic area per se does not greatly affect chronic malnutrition, but it is other variables such as wealth and educational factors which are
distributed differently by geographic area. The regression analysis thus shows that the higher prevalence of chronic malnutrition in rural
areas is due to the fact that average socio-economic conditions, measured mainly by wealth and the mother’s education, are inferior.
14
Variables that were not considered, such as race, or, more generally, culture, probably act through this variable in countries such as Bolivia
or Peru, where there are major cultural/ethnic differences between the Andean zone and other regions.
15
The effects of the mother’s education on malnutrition are not equal to the value of the coefficient associated with it, but are more than
double the coefficient associated with the mother’s education squared, the latter multiplied by the mean of mothers’ education (if the effect
is measured for the average group).
16
This is consistent with the findings reported by Marcoux (2002).
11
70
Lastly, professional care at childbirth, which is used as a proxy for the household’s access to
health care, is negatively related to chronic malnutrition, but in many cases the relation is not significant.17
Nonetheless, this is important when health-care coverage is low, but its effect tends to fade as coverage
improves.18 In Bolivia, for example, the service covered 49.5% of all cases in 1994 and 65.1% in 2003.
Here the coefficient is significant and negative, although its value decreases considerably. Nicaragua is an
illustrative and notable case, where the coefficient loses statistical significance when coverage expands
from 66.7% in 1997 to 90.6% in 2001.
3. The causes of inequality in chronic child malnutrition
Table IV.3 shows the proportion in which each variable contributes to the distribution of chronic child
malnutrition, for each country and year.19
As shown in table IV.3, the most important variable in explaining the inequality of chronic
malnutrition is “wealth”, which accounts for between 41% in Peru (1996) and 97% in Haiti (1994). In all
cases, these high percentages were the consequence of the high level of the “wealth-elasticity” of malnutrition
and, in particular, high “wealth” concentration levels.20 This again reveals the widely recognized glaring
socio-economic inequality that characterizes Latin American and Caribbean countries (ECLAC, 2007a;
PAHO, 2007b; De Ferranti and others, 2004). It also quantifies the social determinants of malnutrition,
and, hence, infant mortality, which are broader and transcend sector-level health or nutrition policies, for
example. Thus, reducing the incidence of chronic malnutrition in the poorest households firstly requires
improving their living conditions and socio-economic environment; and this means applying a wide range
of policies including housing, employment and income policies, along with macroeconomic policies to
assure these households at least a setting of economic stability.21
Some of the elements used to construct the “wealth” index, such as the availability of adequate
drinking water and sanitation services in the home, may affect chronic child undernutrition directly
(Wagstaff, van Doorslaer and Watanabe, 2003; Smith, Ruel and Ndiaye, 2005).22 The mere fact of improving
these services could thus produce a significant reduction in the incidence of undernutrition, aside from its
effects on “wealth”.
Unlike the causes of infant mortality, according to Harttgen and Misselhorn (2006), variables measuring access to the health infrastructure
are relatively unimportant in explaining child malnutrition.
18
This can be seen from data on the means of each variable in the annex of Paraje (2008), tables A.3, A.6, A.9, A.12, A.15, A.18 and A.21.
19
Three elements affect a factor’s potential contribution to the chronic undernutrition concentration index. The first of these is the importance
of that factor, under equal conditions, on its level if it has a high coefficient in the explanatory linear regressions, it contributes more to the
inequality of undernutrition. Secondly, the mean of this variable is important: the higher the mean, the greater will be its contribution to the
inequality of malnutrition. Both elements —the regression coefficient and the variable’s mean— make it possible to estimate the elasticity
of each variable with respect to chronic malnutrition, i.e., how much a 1% increase in each variable affects its prevalence (Paraje, 2008,
section 2). The third element is the socio-economic distribution of each variable, i.e., its socio-economic concentration index. If a variable
has a significant influence on undernutrition (i.e., a high elasticity with respect to it) and it is relatively concentrated in a specific group (e.g.,
among poor households) this does more to explain the relative concentration of the result.
20
Both the “wealth elasticities” and their concentration indices (which in this case are the same as the Gini coefficients) for each country are
shown in Paraje (2008), tables A.3, A.6, A.9, A.12, A.15, A.18 and A.21.
21
The volatility of growth has clearly negative effects on household poverty (Sauma, 2007 and Sánchez, 2007).
22
For information on housing and sanitation deficiencies, see the UBN measurements contained in section 1 of chapter II of this report.
17
71
Table IV.3
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): TREND OF THE
DETERMINANTS OF INEQUALITY IN CHRONIC CHILD MALNUTRITION, 1994-2005
(Percentages)
Bolivia
Colombia
Dominican Republic
Guatemala
1994
2003
1995
2005
1996
2002
1996
2002
Region 1
6.1
6.2
-18.8
-9.3
0.3
0.0
-3.0
-2.6
Region 2
-0.5
-0.4
-1.7
-1.6
0.3
-0.1
-0.8
-1.8
Region 3
-
-
4.2
-2.1
0.8
-0.7
-1.4
-1.3
Region 4
-
-
-3.0
-0.5
1.6
0.1
-0.4
-0.1
Region 5
-
-
-
-
0.0
-0.2
1.0
0.7
Region 6
-
-
-
-
1.8
-0.4
7.0
2.3
Region 7
-
-
-
-
-0.3
-0.8
-
-
Urban
-11.8
-7.2
-27.9
-1.2
-1.6
-2.4
1.1
-2.7
Wealth
64.7
68.1
84.8
70.8
58.6
61.6
68.1
82.4
Mother’s education
14.2
46.1
76.7
41.0
21.5
2.4
27.3
29.1
Mother’s education squared
0.6
-31.9
-37.6
-17.3
-6.6
17.9
-10.8
-9.2
Mother: skilled work
(ref. not working)
2.1
0.3
1.4
4.1
1.7
1.9
0.4
-2.3
-0.6
0.0
-0.3
0.3
0.5
1.1
0.5
-0.7
Partner’s education
5.6
8.8
14.3
7.6
10.1
9.5
7.4
6.9
Sex of child: female
0.1
-0.1
-0.5
0.0
0.0
0.6
-0.1
-0.2
Second child
0.4
-0.5
-0.5
-1.4
-1.3
-1.4
0.0
-0.5
-1.1
0.0
0.1
0.1
-0.4
-0.6
-0.1
-0.6
6.1
1.0
1.6
8.8
5.3
5.5
4.2
4.5
-10.7
2.8
-0.8
-3.7
-1.5
-3.7
-2.2
-3.4
Age in months squared
8.3
-3.0
0.0
2.1
1.1
3.7
1.6
2.6
Birth weight (g)
1.9
0.8
-
-
4.2
4.1
0.3
0.7
Professional attendance at
childbirth
15.8
8.2
2.5
0.2
1.1
-0.5
1.1
-2.6
Residual
-1.1
0.8
5.5
2.0
2.8
2.7
-1.2
-1.1
Total
100
100
100
100
100
100
100
100
Mother: unskilled work
(ref. not working)
Third child
Fourth or subsequent child
Age in months
72
Table IV.3 (concluded)
Haiti
Nicaragua
Peru
1994
2005
1997
2001
1996
2004
Region 1
2,8
1,0
-0,1
-1,5
-1,0
-1,1
Region 2
0,7
-1,5
3,5
6,1
8,4
4,6
Region 3
-
-
-2,2
2,9
2,4
-0,9
Region 4
-
-
-
-
-
-
Region 5
-
-
-
-
-
-
Region 6
-
-
-
-
-
-
Region 7
-
-
-
-
-
-
Urban
-18,4
-11,7
-20,2
1,7
-0,8
-2,6
Wealth
97,2
77,9
76,9
51,9
40,9
60,9
Mother’s education
34,2
24,4
29,2
37,2
21,1
19,5
Mother’s education squared
-11,1
-12,4
-2,7
-13,7
-0,8
-1,3
-1,3
-1,0
-0,8
0,9
-0,5
-2,1
0,1
-0,2
-0,8
0,3
0,9
4,6
Partner’s education
-2,9
15,8
-0,1
3,2
7,3
1,7
Sex of child: female
-1,1
-0,2
0,0
0,0
0,1
0,2
0,1
0,8
-0,8
-0,5
-0,7
0,3
Third child
-0,2
0,5
-0,3
-0,2
-0,3
0,0
Fourth or subsequent child
-0,5
3,7
4,8
4,7
5,6
4,1
Age in months
-3,1
-5,1
-0,7
4,6
-4,4
4,0
0,4
3,4
0,5
-2,5
3,1
-3,8
Birth weight (g)
-0,1
-6,0
4,1
3,6
4,3
3,5
Professional attendance at
childbirth
-0,1
9,4
8,0
1,5
14,4
7,0
Residual
3,4
1,4
1,7
-0,2
-0,1
1,4
Total
100
100
100
100
100
100
Mother: skilled work
(ref. not working)
Mother: unskilled work
(ref. not working)
Second child
Age in months squared
Source: Guillermo Paraje, “Evolución de la desnutrición crónica y sus distribución socioeconómica en siete
países de América Latina y el Caribe”, Políticas sociales series, No. 140 (LC/L.2878-P), Santiago, Chile,
Economic Commission for Latin America and the Caribbean (ECLAC), 2008, on the basis of demographic
and health surveys (DHSs).
Note: The dependent variable is the chronic child malnutrition concentration index (equation (2) of section 2.2).
Secondly, the mother’s and partner’s education levels explain the inequalities seen. In all cases,
apart from the Dominican Republic in 2002, the mother’s education has a major influence, albeit mitigated
by the non-linear relation that exists between this variable and child undernutrition, as noted above. The fact
that education is relatively concentrated among the “wealthier” households helps to explain the inequality of
73
malnutrition; but its influence is reduced because of the non-linear effect of the mother’s education, which
tends to fade as the level of schooling rises. The mother’s and partner’s education, and the corresponding
non-linear effect, jointly explain between 20% (Bolivia, 1994; Haiti, 1994) and 53% (Colombia, 1995) of
the inequality in chronic undernutrition.23
Moreover, while certain biomedical variables (sex, age, birth order, birth weight) are important
in explaining the level of malnutrition —as would be expected— they are not themselves significant
in explaining inequality in the distribution of chronic child malnutrition. The sex of the children, for
example, does not follow a defined socio-economic distribution pattern (poor households do not have more
or fewer girls, for example) and therefore cannot explain this inequality. Taken individually, the other
variables have some effect on the inequality of malnutrition, especially those indicating birth order, but
jointly they never account for more than 10% of that inequality; the highest value being 9.7% in the case
of Nicaragua, 2001.
Geographic/regional variables also do not display a defined pattern, but vary from one country to
another. Whereas in the Dominican Republic neither regional variables nor those distinguishing between
urban and rural areas help to explain inequality in the distribution of chronic malnutrition (e.g., malnourished
children are not concentrated in a specific region/area when other variables are taken into account), in
Colombia they have a considerable influence. For example, chronic undernutrition in Region 1 (Atlantic) is
far less than in the benchmark region (Bogotá), and a large proportion of poor households are concentrated
there. Taken together, these two factors mean that, under equal conditions, the lower level in the Atlantic
region tends to reduce the inequality of chronic undernutrition nationally.
Lastly, professional care at childbirth, which proxies for the household’s access to the health
system, also varies considerably between countries. As one would expect, in those that have broad
coverage (Colombia, the Dominican Republic, Guatemala and Nicaragua, 2001) the effect is small, for
socio-economic inequalities in its distribution tend to disappear, so its power to explain malnutrition also
fades.24 Nonetheless, when coverage is relatively low (Bolivia, Peru, Nicaragua, 1997), it has more effect
on chronic malnutrition and exceptionally reaches high levels. The highest (16%) was recorded in Bolivia,
1994, when coverage was just 49.5%.
4. Determinants of changes in the inequality of chronic
child malnutrition
Apart from statically considering the determinants of inequality in the distribution, it is important to analyse
how variations in those factors affect trends in the inequality of undernutrition. A consideration of past
changes may shed light on the effects that public policies may have on such factors as inequality in the
distribution of malnutrition and, often, its level.
Table IV.4 provides information on this through a Oaxaca decomposition of changes in the inequality
of chronic malnutrition.25 Holding other factors constant, it shows the contribution of each of the variables
analysed to the increase/decrease in the inequality of chronic malnutrition in the years studied.
In the case of Colombia (1995), for example, this would mean that if all mothers had received the same level of schooling (equal to the
national average in 1995), under equal conditions, the inequality of chronic malnutrition would have been 52% less than it actually was
24
This probably does not mean the disappearance of socio-economic differences in professional care at childbirth, since these are most likely
to be manifested in terms of quality rather than coverage. Unfortunately, the information provided by DHSs does not make it possible to
measure this dimension.
25
Here the contents of equation (3) from section 2.2 are applied. In Paraje (2008), tables A.4, A.7, A.10, A.13, A.16, A.19 and A.22 show each
of the terms needed to make this decomposition for each of the countries considered.
23
74
Table IV.4
LATIN AMERICA AND THE CARIBBEAN (SELECTED COUNTRIES): BREAKDOWN OF
VARIATIONS IN THE INEQUALITY OF CHRONIC CHILD MALNUTRITION, 1994-2005
(Percentages)
Bolivia
Colombia
Dominican
Republic
Guatemala
Haiti
Nicaragua
Peru
Region 1
7.5%
81.3%
1.6%
-0.9%
18.2%
-5.3%
-1.5%
Region 2
0.9%
-1.2%
1.5%
-6.5%
18.8%
12.6%
-14.5%
Region 3
-
-62.2%
5.7%
-0.9%
-
16.1%
-17.3%
Region 4
-
23.8%
6.8%
1.2%
-
-
-
Region 5
-
-
0.6%
-0.6%
-
-
-
Region 6
-
-
9.5%
-19.3%
-
-
-
Region 7
-
-
1.5%
-
-
-
Urban
79.3%
255.0%
1.1%
-20.1%
-73.4%
57.8%
-11.7%
Wealth
132.0%
-64.1%
48.6%
147.9%
254.7%
-12.1%
161.0%
Mother’s education
647.3%
-301.3%
85.8%
37.3%
114.0%
57.8%
11.4%
-644.2%
177.2%
-89.0%
-1.8%
-0.7%
-42.0%
-3.6%
-33.7%
30.7%
1.1%
-14.7%
-4.1%
5.2%
-10.1%
Mother: unskilled work
(ref. not working)
12.9%
6.3%
-1.3%
-6.0%
3.4%
3.1%
23.4%
Partner’s education
70.2%
-56.1%
12.1%
4.6%
-155.5%
11.7%
-26.5%
Sex of child: female
-2.8%
4.9%
-1.8%
-0.6%
-8.6%
-0.2%
0.7%
-16.2%
-9.7%
-1.2%
-2.5%
-5.3%
0.4%
5.0%
20.5%
-0.4%
0.4%
-2.7%
-5.4%
-0.1%
1.4%
Fourth or subsequent child
-95.2%
77.4%
4.7%
5.9%
-34.9%
4.5%
-3.4%
Age in months
256.6%
-31.0%
5.8%
-8.9%
13.4%
18.3%
45.6%
-215.9%
22.0%
-7.8%
7.1%
-24.4%
-10.0%
-38.4%
-19.6%
-
4.6%
2.1%
48.4%
2.4%
-0.6%
-135.5%
-21.8%
6.2%
-19.8%
-78.1%
-15.3%
-29.7%
Residual
36.0%
-30.9%
3.4%
-0.9%
19.7%
-4.8%
8.8%
Change in inequality
100%
100%
100%
100%
100%
100%
100%
Change in concentration index
-0.008
-0.013
0.053**
-0.031
0.017
-0.059**
-0.040*
Mother’s education squared
Mother: skilled work
(ref. not working)
Second child
Third child
Age in months squared
Birth weight (g)
Professional attendance at
childbirth
Source: Guillermo Paraje, “Evolución de la desnutrición crónica y sus distribución socioeconómica en siete países de América Latina y el
Caribe”, Políticas sociales series, No. 140 (LC/L.2878-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean
(ECLAC), 2008, on the basis of demographic and health surveys (DHSs).
Note: This breakdown corresponds to equation (3) of section 2.2.
* Different from zero at a 95% significance level 95%.
** Different from zero at a 99% significance level 99%.
75
The bottom row of the table shows how the chronic undernutrition concentration index has varied;
a negative figure means inequality has increased (i.e., it has become increasingly concentrated among the
poorest groups), while a positive change indicates the opposite. Variations in inequality have only been
significant in the Dominican Republic, Nicaragua and Peru; in other cases, the measurement is useful not in
terms of its magnitude but in analysing its direction.
As shown in figure IV.2 and table IV.4, in this period inequality decreased in two of the seven
countries: Dominican Republic and Haiti. However the change was only significant in the first case —which
in itself merits analysis. The most influential variable in this reduction was “wealth”, which accounted for
half of the recorded decrease in the inequality of chronic malnutrition. Two elements were crucial to this. An
improvement in the distribution of physical assets, measured by the variation of the “wealth” concentration
index, was easily the most important factor. Between 1996 and 2002, the distribution of the “wealth” index
improved significantly in both countries (Paraje, 2008, table A.10 of the annex). As “wealth” tends to reduce
malnutrition, less concentration tends to improve the situation of the most deprived, which has a favourable
impact on chronic undernutrition among their children and thus reduces the inequality of undernutrition.26
The socio-economic improvement among the poorest households did not have major repercussions
on chronic malnutrition because the “wealth” elasticity increased in this period, i.e., a 1% increase in
“wealth” caused chronic malnutrition to fall in both years, but its effect was greater in 2002 than in 1996.
Despite these socio-economic improvements and given the magnitude of the concentration of wealth and
the increasing importance of “wealth” in explaining malnutrition, this tended to favour wealthy households,
thereby widening the malnutrition gap between them and poorer households. Nonetheless, as this effect was
not so strong as the one described in the previous paragraph, the change in “wealth” had levelling effects.
Changes in education were large when considered individually, although their influence was not
very important overall. These variables explain 12% of the reduction in inequality. The average number of
years’ schooling received by the mother and partner increased, which favoured the poor by reducing the
concentration of inequality. Moreover, in both cases, and as a result of the increase in educational levels, the
education-elasticity of undernutrition decreased; and this also helped to close the undernutrition gap between
poor households and rich ones, which continue to enjoy a relatively higher level of education. Nonetheless,
these important changes were mitigated because, although the increase in the mother’s schooling occurred
at all education levels, it was greater at the secondary and tertiary levels and thus had less of an effect on
malnutrition (Paraje, 2008, table A.10 of the annex).
There were statistically significant changes in just two of the countries in which the socio-economic
inequality of chronic undernutrition increased: Nicaragua, the country in which inequality increased
most, and Peru. The case of Nicaragua has a number of interesting features: e.g., it is the only country
where chronic undernutrition did not become more unequal as a result of the “wealth” effect: in fact, the
“wealth” elasticity of malnutrition declined. The other element that favoured the poor was professional
care at childbirth. During this period, the coverage of this health service increased significantly (in 1997
only 67% of deliveries were professionally attended, whereas in 2001 around 91%) mainly among the
poorest households.
Although “wealth” and professional care at childbirth had levelling effects, other variables were
more influential and clearly increased the inequality of chronic undernutrition in both countries. The main
variables were educational and geographic. The first explains just over one quarter of the increase in the
Given the shortcomings of the “wealth” index (noted in section 1.1), care is needed when working with the trend of this index through
time, and when drawing conclusions from it. Nonetheless, there are other elements that may be linked to the trend of “wealth “ (or more
generally, the households’ socio-economic position), such as the distribution of education variables (maternal and partner), which display a
similar behaviour pattern to the “wealth” index (rising average and less concentration). These factors indicate an improvement in the socioeconomic situation of lower-income groups.
26
76
inequality of malnutrition; and, in the case of both the mother’s and her partner’s education, this reflected
an increase in the education-elasticity of undernutrition (Paraje, 2008, table A.18 of the annex) and to its
greater concentration among the wealthiest households.27
The regional variables (regions and urban/rural area) also increased the inequality of chronic
malnutrition, with greater regional or area elasticity contributing to this effect in all cases. In the latter, for
example, “wealthy” households became relatively more concentrated in urban, i.e., in these households the
quality of life tended to diverge from that of rural areas.
5. Conclusions
In general, the numerous causes that determine the level of chronic child malnutrition in a country form
a complex web of reciprocal relations. From the public policy standpoint, this stems from isolated health
policies which individually can only partially reduce the problem; they need to be applied comprehensively
in areas such as education, housing and income, and in a stable macroeconomic environment that promotes
economic growth and a better distribution of the fruits of development. When the socio-economic distribution
of undernutrition is so unequal, reducing it has strong socio-economic determinants in terms of basic
social infrastructure.
The socio-economic situation of families not only determines the level of chronic malnutrition among
their children, but also its causes; the more concentrated this “wealth”, the more this form of deprivation will
be concentrated among “poor” households. As noted in the Dominican Republic, the lesser concentration of
“wealth” has significantly reduced the concentration of chronic child malnutrition, and particularly its levels.
The “wealth” indicator used does not measure family incomes/expenditure, but housing conditions,
possession of assets, and available services. Some of these elements, such as better access to drinking water
and adequate sanitation, could directly influence malnutrition and its distribution.28 The corresponding policies
could certainly also have a redistributive effect depending on how progressive the tax structure is. Similarly,
policies that improve the housing situation of less privileged groups can also help to reduce malnutrition.
The parents’ education level, and in particularly the mother’s, has a decisive influence on the level
and distribution of chronic malnutrition. Nonetheless, for education improvements to have their full effects,
they must be biased in favour the poorest households. Despite some progress, countries such as Bolivia,
Colombia, Guatemala, Haiti and Nicaragua are still far from achieving universal primary school enrolment.
Geographic, cultural, ethnic and idiosyncratic factors, some of which were measured directly and
others indirectly, have an explanatory role, but apparently based on their link with the distribution of socioeconomic variables such as “wealth” and the mother’s education, which sector policies need to consider
comprehensively.
It is highly likely that the greater concentration of education in wealthy households has caused an increase in the education-elasticity of
undernutrition. This greater concentration tends to “separate” “poor” households from “wealthy” ones, thus widening the differences
between them and increasing the explanatory power of education.
28
On this latter aspect, chapter II made a detailed analysis of unsatisfied basic needs (see table II.1).
27
77
Chapter V
OUT-OF-POCKET HEALTH EXPENDITURE: EVIDENCE OF PRONOUNCED
INEQUALITIES
Health goods and services are funded in three main ways, which vary from one country to another according
to the structure of each health system: general and specific taxes, social security contributions collected
through payroll deductions, other taxes or contributions, and outlays made by households in respect of
direct payments and private insurance premiums. While social protection and security funding systems play
a key role in the population’s health, it should be remembered that the region’s labour markets have not
displayed a capacity for inclusion either in terms of quality job creation or in terms of contributory social
protection (ECLAC, 2006 and 2007a).
Household income and expenditure surveys make it possible to quantify and analyse the amounts
households spend on health. In relation to the Millennium Development Goals in the health sector, however,
this source does not allow for breakdowns that would establish links between the indicators used to measure
the goals and the direct household spending on health care. Examples of the latter include expenses arising
from episodes of illness which could be related to indicators such as maternal or child mortality and could
give rise to catastrophic expenses, or information on households that lack access to services and are unable
to pay health-care expenses out of their own pocket, even when affected by patterns of disease related
to the indicators.
Nonetheless, household health expenses provide interesting pointers to the provision of health services
and highlight the need to move towards equity in their financing and supply, which is why this perspective has
been included in this document.1
As will be seen below, although indirectly related to the Millennium targets and relevant indicators in
the health sector, a worrying feature in Latin America and the Caribbean is the number of poor households that
lack health-care coverage and seem unable to finance their health expenses. As will be noted, while catastrophic
expenditure relates more to large health-care outlays than to lack of payment capacity, the latter is another
basic constraint. This is important because the presence of children under five involves clearly higher health
expenditure, albeit mitigated, for instance, by the existence of specific health care programs targeting this age
group. In keeping with the unequal distribution of income or the high levels of inequality in chronic malnutrition
reviewed in the previous chapter, Latin America and the Caribbean also displays extreme inequity in out-ofpocket expenditure on health-care as a proportion of household incomes.2
In addition to the prices charged by private suppliers, or the co-payments involved in public
or private insurance schemes, family outlays on health care could well reflect the availability of public
resources and services, through which it is possible to indirectly assess equity in health-service access.
The proportion of the family budget assigned to health care, and its relative composition, together with
comparisons between income groups, provide important information on household expenditure alternatives
1
2
Albeit not systematically, out-of-pocket health expenses have also been studied in other analyses of progress towards achieving the
Millennium Development Goals in the health sector. For example, Wagstaff and Claeson (2004, p. 72 and 73) provide specific information
on cases of disease that involve out-of-pocket expenses and argue that these constitute access barriers to health goods and services for the
poor, and undermine progress towards achieving the Goals.
Household spending on health has increased significantly, and it is now recommended that poverty measurements in the region take
this variable into acount. Two corrections to the standard measurements of poverty have been proposed: (a) subtracting out-of-pocket
household expenditures on health from total household income in order to better reflect the income available for spending on “food and
other necessities”; and (b) adding to the non-food basket the item “necessary spending”, which is to cover a certain minimum level of health
spending (Rio Group, 2006, pages 67-73).
78
(PAHO, 2007b, pp.336-342; Suárez, Gordillo and Vane, 2007). An analysis will be made of the inability of
families to pay out-of-pocket expenses on health goods and services under certain circumstances, no matter how
necessary and appropriate those expenditures may be (Perticara, 2008a and 2008b).
To review these aspects of health-care access, a group of 12 countries has been analysed which have
specific characteristics in the regional context in terms of their public health achievements and health systems
(Perticara, 2008a and 2008b), namely Argentina, Bolivia, Brazil, Chile, Colombia, Dominican Republic,
Ecuador, Honduras, Mexico, Nicaragua, Peru and Uruguay. An econometric model is developed to make a more
in-depth analysis of the characteristics of households that face the highest out-of-pocket medical expenses, and
those that seem unable to pay them in seven of those countries (Perticara, 2008a).3
Some surveys are nationally representative, while others are only urban; some are limited to the national
capital, or to state capitals; some are from the 1990s and others from the current decade. An important variable,
insurance policies, was considered only in some cases. All of this restricts substantially the comparison between
countries (see table V.1).
Table V.1
LATIN AMERICA (SELECTED COUNTRIES): COVERAGE AND PERIODS FOR UNDERTAKING
INCOME AND EXPENDITURE SURVEYS
Country
Name
Coverage
Period
Argentina
National expenditure and income household survey
urban
February 1996-March 1997
Bolivia
Continuous household survey
national
November 2003-November 2004
Brazil
Family budget survey
national
July 2002-June 2003
Chile
Family budget survey
Greater Santiago
August 1996-July 1997
Colombia
National expenditure and income
household surveys
23 departmental
capitals
March 1994-February 1995
Dominican
Republic
National expenditure and income household surveys
national
October 1997-October 1998
Ecuador
National income and expenditure urban household survey
urban
February 2003-January 2004
Honduras
Living conditions survey
national
July-December 2004
Mexico
National income and expenditure
national
Third-quarter 2004
Nicaragua
National living standard measurement household survey
national
April-July 2001
Peru
National household survey
national
May 2003-April 2004
Uruguay
Income and expenditure household survey
Montevideo and
other urban areas
June 1994-May 1995
Source: Economic Commission for Latin America and the Caribbean (ECLAC).
3
With the aim of enriching this interagency document, the consultancy performed by Marcela Perticara (2008a) analyses Argentina, Brazil,
Chile, Colombia, Ecuador, Mexico, and Uruguay. For a broader treatment of the arguments, explanation of the methodology used and a full
bibliography, see the text. This study reproduces its arguments partially, either literally or with minor modifications of form. At the outset
of the study, ECLAC was reviewing certain categories of expenditure from surveys that could not be included. Nonetheless, following this
review, several variables were processed later from the following income and expenditure surveys: Bolivia, 2003-2004; Peru, 2003-2004;
Dominican Republic, 1997-1998; Honduras, 2004; and Nicaragua 2001 (Perticara, 2008b). This chapter combines the findings of both texts,
and the reader is referred to the first of them for a more detailed treatment of the issues.
79
1. Brief definition of certain concepts
Household spending on health services as a percentage of total domestic consumption represents the costs
of health-care services paid for directly by families (also referred to as out-of-pocket expenses), or indirect
expenses relating to prepaid medical care plans, private medical insurance, and contributions to public
insurance (PAHO, 2007b). Households make these direct payments on a fragmented basis, generally to the
service provider. As they depend on each household’s payment capacity they do not have any solidarity or risk
diversification rationale (Sojo, 2003). Direct out-of-pocket expenses are considered one of the most inefficient
and unfair methods of financing health care, and can lead to family impoverishment.
Out-of-pocket health expenditure encompasses direct net outlays by households on health-related
expenses, such as hospitalization, outpatient procedures and medicines, i.e., having deducted the reimbursements
received from the health system or insurance system to which the person is affiliated. The burden of out-ofpocket expenditure expresses the magnitude of such expenses in relation to the household’s payment capacity,
defined as the total income of the household minus its subsistence expenses.4
Subsistence needs refer to food expenditure incurred by each household, including the consumption
of food but excluding luxury goods. The level of subsistence expenditure (i.e., the amount the household
needs to feed its members adequately) needs to be estimated for each country. Following Xu (2005), a
poverty line or relative subsistence line is defined, which is estimated as the average per capita expenditure
on food made by a family located between percentiles 45 and 55 of the distribution of the ratio between
food and total expenditure. This subsistence line thus reflects expenditure by a “typical” family, i.e.,
one located in the middle of the distribution.5 In order to ensure that the findings of this analysis can be
related to previous studies, the poverty line traditionally used in research in this area will be employed
in this chapter.
It should be noted that this poverty line is not comparable with the poverty or indigence lines used
generally in Latin America and the Caribbean to analyse household surveys, as was done to measure indigence
in chapter II of this volume. Indigence thresholds are established on a normative basis in each country according
to the value of a basic subsistence food basket. In other words, extreme poverty lines are equal to the cost of
that basket, per person per month in the national currency. Poverty lines, in contrast, are calculated on the basis
of a consumption basket that includes other basic items apart from food. To highlight the specific nature of
the poverty line proposed by Xu which is used here and is not comparable with others, the terms “poverty” or
“impoverishment” will be used between inverted commas throughout this chapter.
Another aspect of out-of-pocket health expenditure is catastrophic expenditure: when the magnitude
of the burden of out-of-pocket expenses exceeds a certain threshold of the family’s expenditure capacity,
these are considered catastrophic. Generally speaking, this threshold is set at 40% of payment capacity, and
expenses in this category can impoverish a family (Xu, Evans, and Aguilar, 2003). Constraints on social
protection in the health sector may lead to serious acute or chronic disease events, (e.g., hypertension,
kidney transplant, HIV/AIDS), or to small-scale but recurrent events (recurrent bronchitis in breastfeeding children) which can result in high out-of-pocket expenses; consequently, both are potentially
catastrophic. Catastrophic expenses do not necessarily relate to high-cost diseases; their relative incidence
depends not only on health status but also on the characteristics of insurance. Incidence should be less,
for example, in countries that offer a package of explicit guarantees that are universal and demandable, or
where the State provides universal free coverage to the entire population. Nonetheless, studies are not yet
4
5
This has also been referred to as effective income not destined for subsistence.
Xu (2005) suggests defining the “typical” family as one located in the centre of the distribution of the ratio between expenditure on food
and total expenditure, for the level of food expenditure of a family that spends 100% of its expenditure on food will be low because it is a
low-income family, whereas one that spends 5% on food is highly likely to be in the high-income bracket.
80
conclusive in identifying the key elements of a health insurance system that protects households against
catastrophic expenses or, on the contrary, encourages households to incur expenditures of that magnitude
(Perticara, 2008a).6
It should be added that the nature of what is catastrophic depends not only on the size of the outlay
but also on the time for which such expenses have to be incurred, or on their specific or repetitive nature. The
periodicity of expenditure, for example, should be related to the type of disease: such is the case of chronic
illnesses, which are of high incidence also in low-income population groups. Seen in this way, measurement
through income or expenditure surveys can not fully reflect the incidence of catastrophic expenditure or the
“impoverishment” suffered by households for this cause (Knaul and others, 2003), and the analysis of this
chapter is subject to that underestimate.
Studies on out-of-pocket health expenses have tended to ignore a key aspect that emerges in the region,
namely repressed health expenditure. Clearly, a lack of household health expenditure may occur for widely
varying reasons, both positive and negative: good health-care coverage through public or private systems, the
absence of disease events in the period, the precarious nature of household incomes and lack of access to credit
that prevents them from incurring expenses during disease episodes, even when lacking adequate coverage.
Nonetheless, if a household has limited expenditure possibilities for the latter reason, the amount of its real
health expenditure needs is not observed, and the reasons could depend on the same set of determinants of
out-of-pocket health expenses, which will be analysed in depth in this chapter.
2. The burden of out-of-pocket health expenditure and “impoverishment”
The significance of out-of-pocket health expenditure varies considerably from one country to another (see
tables V.2a and V.2b). In some cases the burden is not that high. The smallest amount is recorded in Bolivia, at
4%, whereas in Brazil, Chile, Colombia, Mexico, Uruguay the burden reaches roughly 5%, in the Dominican
Republic 6%, and in Ecuador 7.4%. The highest levels are in Argentina with 8%, Peru, with almost 9%, and
Nicaragua, with 10%. Among the countries studied, Honduras easily registers the highest burden, at roughly
16% (see figure V.1).
6
Perticara (2008a) discusses a number of possible links between the characteristics of out-of-pocket health expenses and those of health
systems in the seven countries analysed.
81
Table V.2a
LATIN AMERICA (SELECTED COUNTRIES): OUT-OF-POCKET HEALTH
EXPENDITURE INDICATORS
(Percentages)
Argentina Bolivia Brazil Chile Colombia Ecuador Honduras Mexico Nicaragua
Peru
Dominican
Uruguay
Republic
Total per capita income (as a proportion of total average income)
Expenditure capacity/total
per capita income
Total expenditure/
expenditure capacity
Health expenditure/total
expenditure
73.9
108.8
56.4
86.6
78.6
73.3
80.7
82.1
80.9
138.7 113.2 109.3
128.0
83.0
150.2
113.9
54.7
…
65.2
79.8
179.0 139.6
365.4
109.5
8.5
3.2
5.4
6.0
3.8
5.2
13.5
4.8
5.9
6.6
3.3
10.4
Cost of medical coverage/
health expenditure
27.7
…
27.4
9.6
8.3
0.5
…
1.4
…
…
…
57.2
Out-of-pocket health
expenditure/total health
expenditure
72.3
100.0
72.6
90.4
91.7
99.5
99.7
98.6
100.0 100.0
97.1
42.8
8.1
3.9
4.9
5.5
5.3
7.4
16.2
5.3
10.1
8.8
5.8
5.2
0.8
…
…
…
80.7
Out-of-pocket health
expenditure/payment
capacity
Distribution of households by coverage
Percentage of households
with out-of-pocket health
insurance expenditure
27.5
…
23.1
22.2
8.0
0.5
Percentage of households
with zero out-of-pocket
health expenditure
50.1
43.9
19.9
37.1
23.9
5.8
20.6
23.6
23.2
13.6
52.0
26.9
Out-of-pocket health
expenditure/payment
capacity, households with
positive expenditure
…
7.0
…
…
…
…
20.4
…
13.1
10.2
10.9
…
Percentage of households
with zero out-of-pocket
health expenditure, but
with expenses on medical
insurance
10.3
…
1.8
6.4
1.0
0.0
…
0.1
…
…
…
18.4
Percentage of households
whose burden of out-ofpocket expenses reaches
a level of 40%
5.6
0.9
0.5
2.1
0.6
1.6
13.3
1.9
5.3
2.4
0.4
0.5
Poverty rate
13.8
13.0
4.4
11.1
7.7
7.4
20.3
3.9
23.2
10.7
59.6
3.8
Poverty rate in households
with zero out-of-pocket
health expenses
21.6
18.7
11.1
22.4
8.0
27.4
27.2
6.6
27.4
23.2
67.6
9.5
Percentage of households
“impoverished” after
meeting out-of-pocket
health expenses
1.9
0.6
0.6
0.9
1.0
1.1
4.8
0.5
2.5
1.4
1.3
0.3
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series,
No. 141 (LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted by selected countries.
Note:
See table V.1 for the periods in which the surveys were undertaken.
Three dots (...) indicate that data are not available or are not separately reported.
82
Table V.2b
LATIN AMERICA (SELECTED COUNTRIES): OUT-OF-POCKET HEALTH EXPENDITURE
INDICATORS, BY HOUSEHOLDS WITH AND WITHOUT MEDICAL INSURANCE
Argentina
Brazil
Ecuador
Mexico
Peru
Uruguay
Households
Households
Households
Households
Households
Households
Without
With
Without
With
Without
With
Without
With
Without
With
Without
With
insurance insurance insurance insurance insurance insurance insurance insurance insurance insurance insurance insurance
Total per capita income
(as a proportion of total
average income)
0.56
1.21
0.61
1.98
0.68
1.95
0.74
1.34
0.58
1.90
0.44
1.02
Expenditure capacity/total
per capita income
50.2
80.0
78.0
95.0
71.6
92.6
75.3
91.6
…
…
60.2
80.4
181.9
98.1
128.6
101.7
98.4
62.5
128.7
88.9
159.8
118.3
157.6
108.8
Health expenditure/
total expenditure
4.4
9.7
3.9
6.8
5.0
5.1
5.0
2.7
5.0
7.3
2.7
10.6
Cost of medical coverage/
health expenditure
1.7
32.9
3.9
46.9
0.0
1.9
1.6
1.9
…
…
1.0
57.0
98.3
67.1
96.1
53.1
100.0
98.1
98.4
98.1
100.0
100.0
99.0
43.0
5.5
9.1
4.9
4.5
7.5
7.0
5.9
2.4
7.0
9.1
3.1
5.3
24.1
59.1
72.4
6.4
55.8
8.3
56.9
3.1
30.3
13.2
1.7
91.7
Total expenditure/
expenditure capacity
Out-of-pocket health
expenditure/total health
expenditure
Out-of-pocket health
expenditure/payment capacity
Distribution of households
by coverage
Percentage of households with out-of-pocket health insurance expenditure
Percentage of households
with zero out-of-pocket
health expenditure
62.7
45.3
24.3
14.7
7.7
7.8
23.7
38.8
25.4
11.6
52.1
26.1
Out-of-pocket health
expenditure/payment
capacity, households with
positive expenditure
…
…
…
…
…
…
…
…
9.4
10.3
…
…
Percentage of households
with zero out-of-pocket
health expenditure, but
with expenses on medical
insurance
0.6
15.2
0.2
11.3
0.0
0.0
0.2
0.0
…
…
0.0
18.4
Percentage of households
whose burden of out-ofpocket expenses reaches a
level of 40%
3.4
6.5
0.6
0.3
1.8
1.6
2.0
0.3
2.7
2.2
0.0
0.5
Poverty rate
30.9
6.5
6.0
0.1
12.2
1.9
6.3
0.0
15.5
7.4
122.4
1.6
Poverty rate in households
with zero out-of-pocket health
expenditure
39.6
11.2
12.5
0.7
35.3
2.9
10.8
0.0
28.8
3.1
14.4
9.3
Percentage of households that
become “impoverished” after
meeting out-of-pocket health
expenses
1.6
2.0
0.8
0.0
1.8
0.1
0.9
0.0
1.5
0.5
0.0
0.3
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted by selected countries.
Note:
See table V.1 for the periods in which the surveys were conducted. “With insurance” refers to households in which all of its members
have some type of medical insurance; “Without insurance” refers to households in which none of the members have any type
of insurance.
Three dots (...) indicate that data are not available or are not separately reported.
83
Figure V.1
LATIN AMERICA (SELECTED COUNTRIES): INCIDENCE OF OUT-OF-POCKET HEALTH
EXPENDITURE ON HOUSEHOLD PAYMENT CAPACITY
(Percentages)
Total households
Insured and uninsured households
18.0
16.0
14.0
12
10
8
6
4
2
Uruguay
Peru
Dominican
Republic
Nicaragua
Mexico
Honduras
Ecuador
Colombia
Chile
Brazil
Bolivia
Argentina
0
Percentage of impoverished households after making out-of-pocket expenditures
Households without insurance
Argentina
Brazil
Ecuador
Households with insurance
Mexico
Peru
Uruguay
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted in selected countries.
Note:
See table V.1 for the periods in which the surveys were conducted.
In terms of the “impoverishment” caused by the magnitude of the expenditure, the percentage
of households is very low in Brazil, Mexico, and Uruguay; in Bolivia it amounts to just 0.6%; in Chile,
Colombia and Mexico it approaches 1%; in Peru and the Dominican Republic it is around 1.5%; while
Argentina records the highest value at 1.9%. Nonetheless, rates in Nicaragua are higher (2.5%) and levels
in Honduras are also very substantial (almost 5%) (see figure V.2 ).
84
Figure V.2
LATIN AMERICA (SELECTED COUNTRIES): HOUSEHOLDS THAT BECOME IMPOVERISHED
AFTER ABSORBING OUT-OF-POCKET HEALTH EXPENSES
(Percentages)
Total households
Insured and uninsured households
6
2,5
5
2,0
4
1,5
3
2
1,0
1
0,5
Uruguay
Peru
Dominican
Republic
Nicaragua
Mexico
Honduras
Ecuador
Chile
Colombia
Brazil
Bolivia
Argentina
0
Percentage of impoverished households after making out-of-pocket health expenditures
0,0
Households without insurance
Argentina
Brazil
Ecuador
Households with insurance
Mexico
Peru
Uruguay
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted in selected countries.
Note:
See table V.1 for the periods in which the surveys were conducted.
In other words, in several countries the proportion of households that become impoverished when
facing health expenses is not that high. Nonetheless, the negative effects are severe in Honduras: the
percentage of households that have become impoverished is almost five times that of the country with the
lowest figure. It is also worth repeating that both income and health expenditure are measured for the month
in which the survey is conducted, so they do not reflect the permanent burden or average out-of-pocket
health expenditure. Thus, as will be seen below, families may have unusually high or low health expenses
in that particular month owing to fortuitous or more structural events.
Private health insurance policies and prepayment plans are important private health expenditure
mechanisms and pose a major public policy challenge in terms of regulations to ensure the effective
functioning of the corresponding markets, and to address inequalities in access to health systems. Apparently,
the size of private health insurance markets and prepayment plans are determined by the public health
system, the scope of population coverage, the services covered by social health insurance, and policies that
regulate the functioning of the markets in question (PAHO, 2007a).
A number of findings show how the burden of out-of-pocket health expenditure can reflect not
only the coverage of public health systems and prices on the corresponding markets, but also insurance
systems. In Argentina and Uruguay the State provides medical services directly to the lowest-income
groups, and the coverage provided by the social security system is relatively broad. But in these countries,
it is precisely households with full coverage that bear the heaviest burden of out-of-pocket health expenses7
and face higher rates of “impoverishment”, when the cost of their medical coverage is certainly not less. In
7
This is also true if the average burden of out-of-pocket expenditure is calculated only considering households that report this type
of expenditure.
85
Argentina, for example, households with full coverage spend one third of their monthly health expenditure
on medical insurance, while in Uruguay the equivalent figure is 57%. In contrast, in Ecuador and Mexico,
although health insurance coverage is less, the burden of out-of-pocket health expenses is not particularly
high, and outlays for medical coverage are small. In Brazil, only a small proportion of households contract
health insurance policies to complement the Single Health System (SUS), but some of those households pay
considerable sums out of their own pocket for this purpose (Perticara, 2008a).8
3. Catastrophic health expenditure and medication expenses
Honduras reports the largest proportion of households incurring catastrophic expenses, at 13.3%, followed
by Nicaragua, at 5.3%. Using other definitions of the limit of payment capacity (30% or 20%), Honduras
still has the highest incidence of catastrophic expenses (see figure V.3 and table V.2). In Argentina, about
3% of households incur such expenses, followed by Peru, with 2.4%, and by Chile, Mexico and Ecuador
with roughly 2% (see figure V.3 and table V.2). Using other thresholds (30% or 20%), the incidence of
catastrophic expenses is also high in Argentina, which is affected by the expenditure of households that
have insurance coverage (see figure V.4).
Figure V.3
LATIN AMERICA (SELECTED COUNTRIES): CUMULATIVE DISTRIBUTION OF HOUSEHOLDS
BY BURDEN OF OUT-OF-POCKET HEALTH EXPENDITURE
(Percentages)
Up to 10%
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Honduras
Mexico
Nicaragua
Peru
Dominican Republic
Uruguay
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted in selected countries.
Note: 8
See the periods in which the surveys undertaken in table V.1.
According to ECLAC (2006), based on Medici (2001), in this country over 50% of total health expenditure (which includes insurance
payments) is made by households because, although 40% of the population uses the SUS exclusively, 44% complement it with private
insurance policies.
86
Figure V.4
ARGENTINA: CUMULATIVE DISTRIBUTION OF HOUSEHOLDS, BY BURDEN OF OUT-OF-POCKET
HEALTH EXPENDITURE ON PAYMENT CAPACITY, WHETHER OR NOT AFFILIATED
TO MEDICAL INSURANCE
(Percentages)
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No.141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted in Argentina (1996 and 1997).
Having said that, which groups face catastrophic expenses? Low-income households with relatively
high health expenses, or high-income households that face very expensive health events?
Table V.3 shows the percentage distribution of households for different expenditure levels in 12
countries. It also shows average per capita income, out-of-pocket health expenditure and expenditure on
medical insurance among households facing different levels of this burden. Catastrophic expenditure seems
to be more closely associated with high out-of-pocket expenses than with a lack of payment capacity. In
Brazil, Chile, Colombia and Mexico, a household with a high burden can pay over 10 times what an average
household spends. In Bolivia, a high burden household (40% or more) may spend 16 times more than an
average household. In the Dominican Republic, in contrast, the high burden is more indicative of low
payment capacity than high levels of out-of-pocket health expenses.
87
Table V.3
LATIN AMERICA (SELECTED COUNTRIES): STRUCTURE AND LEVEL OF EXPENDITURE
BY BURDEN OF OUT-OF-POCKET HEALTH EXPENSES
(Percentages)
In percentages of the average
Distribution of the percentage of out-of-pocket health expenditure
Per capita Out-of-pocket health
General
Laboratory
Specialties
Hospitalization
income expenditure (OPHE) consultations a
expenses
Medications
Medical insurance
expenditure as a
percentage of total
expenditure
Argentina
Without OPHE
87
Less than 10%
127
66
11.1
35.9
0.0
1.5
51.5
4.9
6.5
10%-19%
109
216
5.7
26.4
0.0
4.3
63.7
6.7
5.4
20% -29%
99
326
6.1
20.9
0.0
6.1
66.9
30%-39%
102
414
4.7
21.6
0.0
8.2
65.6
4.1
40% or more
76
572
2.6
15.6
0.0
11.2
70.6
3.3
Without OPHE
91
Less than 10%
110
95
10.8
17.6
6.7
3.5
61.5
10%-19%
97
309
6.1
16.7
6.0
24.4
46.8
0.0
20%-29%
101
600
3.2
9.8
4.5
61.4
21.1
0.0
Bolivia
0.0
0.0
30%-39%
70
668
2.7
8.5
3.3
59.7
25.8
0.0
40% or more
77
1725
0.6
3.3
0.5
80.7
14.9
0.0
Without OPHE
69
Less than 10%
115
86
31.3
3.3
1.8
63.6
4.5
10%-19%
73
228
32.4
4.9
6.8
55.9
4.5
20%-29%
73
337
29.7
6.9
9.0
54.4
3.1
30%-39%
78
476
27.5
6.0
18.7
47.8
4.3
40% or more
90
1318
14.9
3.0
60.0
22.1
2.6
Brazilb
1.7
Chile
Without OPHE
81
Less than 10%
111
60
27.7
15.0
5.3
2.4
49.6
1.1
1.9
10%-19%
116
247
23.4
23.1
8.8
6.3
38.3
1.5
20%-29%
107
375
20.3
27.4
9.5
9.5
33.3
1.9
30%-39%
100
599
16.3
27.8
7.1
27.1
21.8
0.8
40% or more
107
1126
10.0
22.7
4.6
49.2
13.5
1.3
Colombia
Without OPHE
86
Less than 10%
112
74
14.5
20.7
6.2
10.4
48.2
1.0
10%-19%
69
223
15.4
12.5
12.9
13.6
45.7
0.6
20%-29%
61
330
16.5
9.0
14.4
12.5
47.6
0.2
1.2
30%-39%
65
554
7.9
8.3
32.0
15.8
35.9
0.1
40% or more
71
1050
5.3
11.9
27.2
36.9
18.7
0.2
Without OPHE
95
Less than 10%
104
64
12.3
27.6
10.1
9.5
40.5
0.1
89
188
6.9
19.9
8.1
23.5
41.6
0.0
Ecuador
10%-19%
0.0
20%-29%
92
287
4.7
13.6
6.4
35.5
39.9
0.1
30%-39%
83
342
4.1
12.9
6.1
40.5
36.4
0.0
40% or more
79
411
2.7
9.3
6.2
41.7
40.1
0.0
88
Table V.3 (concluded)
In percentages of the average
Distribution of the percentage of out-of-pocket health expenditure
Laboratory
Per capita Out-of-pocket health
General
Specialties
Hospitalization
expenses
income expenditure (OPHE) consultationsa
Medications
Medical insurance
expenditure as a
percentage of total
expenditure
Honduras
Without OPHE
120
Less than 10%
109
25
68.6
31.4
10%-19%
105
92
76.4
23.6
20%-29%
89
135
77.4
22.6
30%-39%
79
193
82.0
18.0
40% or more
59
374
87.9
12.1
Mexico
Without OPHE
90
Less than 10%
104
53
18.2
27.2
6.1
1.8
46.6
0.2
83
192
12.6
24.2
7.4
6.8
48.8
0.0
10%-19%
0.1
20%-29%
78
349
9.7
13.8
7.4
16.3
52.7
0.1
30%-39%
140
606
5.6
11.5
4.2
24.4
54.2
0.1
40% or more
184
1707
5.3
8.0
3.0
13.0
70.6
0.1
Nicaragua
Without OPHE
104
Less than 10%
121
46
29.6
70.4
10%-19%
80
140
36.1
63.9
20%-29%
65
202
30.4
69.6
30%-39%
58
280
34.0
66.0
40% or more
48
594
45.2
54.8
Peru
Without OPHE
83
Less than 10%
115
54
21.0
25.8
5.1
7.4
40.7
0.0
88
160
17.3
16.5
10.6
13.2
42.4
0.0
10%-19%
0.0
20%-29%
67
255
13.7
12.1
14.9
16.7
42.6
0.0
30%-39%
82
356
11.9
11.2
22.3
15.5
39.0
0.0
40% or more
52
505
8.7
5.1
29.6
22.5
34.1
0.0
Dominican Republic
Without OPHE
89
Less than 10%
123
186
18.1
33.8
17.5
7.5
23.1
0.5
1.2
10%-19%
101
200
14.2
21.5
28.3
6.1
29.9
0.9
20%-29%
72
166
13.5
14.0
38.6
5.0
28.8
0.1
30%-39%
74
185
9.9
12.5
41.9
8.6
27.2
0.7
40% or more
80
217
8.2
18.6
30.2
6.8
36.2
0.0
Uruguay
Without OPHE
71
Less than 10%
114
78
15.3
25.7
0.3
32.6
26.1
13.2
10%-19%
106
284
22.7
33.3
0.1
15.9
27.9
14.3
20%-29%
92
401
31.0
29.0
0.1
15.6
24.4
13.7
30% or more
75
561
22.6
26.6
0.2
24.8
25.9
12.5
14.0
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted in selected countries.
Note:
See table V.1 for the periods in which the surveys were conducted.
In Honduras and Nicaragua, out-of-pocket expenses on general consultations exclude medications; it was impossible to obtain a breakdown of
the different items of health expenditure; and medication expenses could only be identified in medical expenses.
a
b
The database for Brazil does not allow general consultations to be separated from specialist ones.
89
Table V.3 shows that catastrophic expenditure is associated more with hospitalization and medication
expenses than with general and professional consultations. In all countries apart from Uruguay, the share of
hospitalization expenses in total expenditure rises as the relevant burden increases. For example, in Brazil
and Mexico, a household facing a burden of 40% or more may spend up to 60% or more on hospitalization
expenses. In contrast, in Uruguay, the latter are also very high in households with a low burden, i.e.,
less than 10%.
Medication expenses account for a high proportion of out-of-pocket health expenditure in all
countries (see figure V.5). They are relatively low in Honduras (just under 18%) and in Uruguay, where
they vary around 25%, followed by Peru (40%) and Bolivia (over 40%). In Argentina, Brazil and Mexico,
however, medicines absorb over 50% of total expenditure and in Nicaragua 60%.
Figure V.5
LATIN AMERICA (SELECTED COUNTRIES): OUT-OF-POCKET EXPENDITURE ON MEDICINES
(Percentages)
70
60
50
40
30
20
10
Uruguay
Dominican Rep.
Peru
Nicaragua
Mexico
Honduras
Ecuador
Colombia
Chile
Brazil
Bolivia
Argentina
0
Health spending on medication
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú y
República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished.
Note:
See table V.1 for the periods in which the surveys were conducted.
90
In Argentina and Mexico, expenditure on medications by households facing catastrophic expenses
accounts for over 70% of total out-of-pocket health expenditure. In contrast, in Brazil, Chile and Colombia,
medicines absorb a smaller proportion of total out-of-pocket expenditure among households with catastrophic
expenses (see table V.3).9
4. Inequality and repressed health expenditure
As noted above, studies have traditionally ignored a key issue, namely the underlying reasons for a lack of
out-of-pocket health expenses. Yet, except for Ecuador, a large percentage of households in the countries
studied do not declare such expenses.
In the Dominican Republic, 52% of households do not declare out-of-pocket health expenses; the
equivalent figure in Argentina is 50%, followed by Bolivia at almost 44%. In Chile, 37% of households
report zero out-of-pocket expenses, while the proportion ranges between 20% and 30% in Brazil, Colombia,
Mexico, Nicaragua and Uruguay. Although in Peru the figure is lower (13.6%), it is higher in households
lacking medical coverage (25.4%).
Argentina is clearly a special case; although families tend to incur in high out-of-pocket health
expenses averaging 16% of their payment capacity, over half of all households do not declare any out-ofpocket spending (see table V.2).
The underlying reasons for a lack of health expenditure cannot be determined a priori. Presumably,
the “constraint” factor could be less in countries that have public health systems or collective insurance
schemes (e.g., Argentina, Uruguay and Mexico),10 and households with zero expenditure would not incur
out-of-pocket expenses for the positive reasons mentioned above. But, in this regard, in three countries that
have information on medical insurance policies,11 the proportion of households with zero expenditure is
relatively high among those lacking medical coverage. Thus, in Argentina, 62.7% of households without
coverage reported zero expenditure, compared to 45.3% for households with full coverage. In Brazil and
Uruguay, the proportion is also higher in the group without any insurance.
In Argentina, Bolivia, Brazil, Chile, Dominican Republic, Mexico, Peru and Uruguay, the proportion
of households reporting zero health expenditure is substantially higher among low-income sectors (see
table V.4). Moreover, a high proportion of households not declaring out-of-pocket health expenses are
concentrated in the initial income quintiles (see table V.4). There are several reasons for this: firstly, in
all countries the lowest-income population enjoys some level of coverage from social health insurance
schemes, which usually do not require co-payments; otherwise they have cost-free access to a certain
level of primary care. On the other hand, low-income households may face serious problems in paying
for health services, no matter how much they need them, because “poverty” is also relatively high among
households not declaring health expenses (see table V.2). So, while catastrophic expense is associated
more with high out-of-pocket expenses than with low payment capacity, the constraint facing those with
low payment capacity is basically expressed as an inability to make such expenditures, even without
insurance coverage.
In some cases the data on medication expenses may be somewhat vague, because the family’s statement may depend on how hospitals
cover or invoice medicines supplied during hospitalization episodes. In Chile, for example, the cost of medications in outpatient care is only
covered by public and private systems for the pathologies covered by the System of Universal Access with Explicit Guarantees (AUGE).
Nonetheless, all health plans cover medicines in cases of hospitalization to a greater or lesser extent in all countries (from 70% to 90%, with
or without limit). In Argentina, the insurance provided by “obras sociales” and private insurance policies usually cover medications to the
extent of 50% to 70%, but medications and disposable material during hospitalization are only partially covered.
10
See Perticara (2008a), annex I.
11
The exceptions are Ecuador and Mexico.
9
91
Table V.4
LATIN AMERICA (SELECTED COUNTRIES): PROPORTION OF HOUSEHOLDS DECLARING ZERO
OUT-OF-POCKET HEALTH EXPENSES BY PER CAPITA INCOME QUINTILES
(Percentages)
Argentina Bolivia
Brazil
Chile Colombia Ecuador Honduras Mexico Nicaragua
Peru
Dominican
Uruguay
Republic
Percentage of households declaring zero out-of-pocket expenditure
Quintile I
66
50
30
49
19
8
18
28
20
20
60
44
Quintile II
52
51
22
42
17
5
19
25
28
15
48
34
Quintile III
49
45
20
36
18
5
20
22
20
11
47
23
Quintile IV
44
37
15
33
16
5
22
23
24
10
42
19
Quintile V
39
37
12
23
15
6
24
19
24
12
39
15
Quintile I
26
23
30
27
23
29
18
24
18
30
26
33
Quintile II
21
23
22
23
20
17
19
21
24
22
20
25
Quintile III
20
20
20
20
21
18
20
19
17
16
20
17
Quintile IV
18
17
16
18
19
17
21
20
21
14
18
14
Quintile V
16
17
12
13
17
19
23
16
21
18
17
11
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United
Nations publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras,
Nicaragua, Perú y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean
(ECLAC), 2008, unpublished.
The situation is different in Honduras, however, where the proportion of households with zero
expenditure is greater in the higher quintiles; and in Nicaragua where the second quintile and the two
wealthiest quintiles contain larger proportions of households with zero expenses.
5. Variables explaining the different incidence
of out-of-pocket expenses 12
In view of the foregoing analysis, the following econometric exercise relates the distribution of out-ofpocket health expenses, or the burden of this expense, in Argentina, Brazil, Chile, Colombia, Ecuador,
Mexico and Uruguay to variables such as the age of the head of household, his or her educational level,
the household’s health coverage, geographic area, income level, the employment status of the head of
household and the presence of young children and older adults.
In five of the seven countries (the exceptions are Chile and Uruguay) this burden declines with
income. The negative income effect is quantitatively more important in Argentina, Brazil and Colombia,
less important in Mexico, and very low in Ecuador. In Uruguay, the burden initially rises with the income
level— in second-decile households it is 10% higher than those of the first decile —but it remains relatively
12
For the reasons outlined earlier on, only seven countries were included in the analysis performed with linear econometric models, selection
control and quantile regressions as explained in annex III of Perticara (2008a). The results should not be interpreted causally, as some the
explicative variables considered are potentially endogenous. Althoug the econometric models used do not have a theorical framework that
defines the explicative variables to be included, those used are in keeping with the suggestions made in related studies (Prah Ruger and Kim,
2007; Xu, 2005; and others, 2003b). For further details, see the full analysis in Perticara (2008a).
92
constant until the fifth decile before starting to fall at the higher income levels: in the wealthiest decile it is
25% lower than in the poorest. In Chile, the burden grows with the income level up to the eighth decile and
then falls for the wealthiest deciles (see figure V.6).
Figure V.6
LATIN AMERICA (SELECTED COUNTRIES): BURDEN OF OUT-OF-POCKET HEALTH EXPENSES
BY INCOME LEVELS
(Predictions of the linear model by family per capita income deciles, first decile = 1)
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
1
Argentina
2
3
Brazil
4
Chile
5
6
Colombia
7
Ecuador
8
9
Mexico
10
Uruguay
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted in selected countries.
Note:
See table V.1 for the period in which the surveys were conducted.
The household’s age structure also affects the incidence of out-of-pocket expenses (Perticara,
2008a). In Chile and Mexico, young children under five years of age give rise to clearly higher burdens
(14% and 17%, respectively). In contrast, Argentine households with young children have an out-of-pocket
expense that is 9% lower, possibly reflecting the fact that most social institutions have mother-child plans
involving preferential or zero co-payments for regular services and medications for expectant mothers
and young children.
Persons over 65 years of age also generate higher out-of-pocket expenses in all countries. Among
families in Argentina, Brazil, Chile, Ecuador and Uruguay, where there is at least one older adult other
than the head of the household, the burden of this category of expenditure is 45%-55% greater than in
families without older adults. In Colombia and Mexico, households with older adults face a burden that is
30% higher. If the older adult is also the head of the household, in Argentina, Brazil, Chile, Ecuador and
Mexico the burden is greater still: the incidence of out-of-pocket health expenses in households headed
by an individual of over 65 years of age is 45%-60% greater than when the older adults are not heads of
household. In other words, households whose heads are older than 65 generate a high out-of-pocket health
expense burden. Countries in which this is substantially higher are Argentina, Chile and Ecuador (80%),
followed by Brazil and Mexico (60%).
93
Catastrophic expenses, meanwhile, are clearly associated with hospitalization episodes, and their
effects can be used to classify the seven countries in three groups. Chile and Mexico make up the first
group: when households face hospitalization, the burden of out-of-pocket health expenses can increase by
five- and sevenfold, respectively. The middle group consists of Argentina, Brazil, Colombia and Ecuador,
where expenditure doubles or triples. Lastly, in Uruguay it increases by just 28%. In Brazil and Mexico,
when urban or rural residency is taken into account, in the latter case the burden is 20%-30% higher.
With regard to insurance, the burden of these expenses among Argentine households in which
only some members have medical insurance is 15% less than in those with no coverage. In Mexico, having
some type of medical coverage substantially reduces expenses; those incurred by families in which some
or all of their members have medical insurance are 25% or 10% lower than those that have no insurance. In
Chilean and Colombian households it is lower among those with insurance.13 In Brazil, on the other hand,
insured households have a burden that is 14% greater. In the other countries this variable displays negative
coefficients which are not statistically significant.
Lastly, the burden is clearly higher in cases where the head of household is unemployed: 35%
in Argentina and 15%-20% in Brazil, Chile, Mexico and Uruguay. In terms of the factors that affect the
likelihood of a household having out-of-pocket expenses (see Perticara, 2008a, table A.6), the higher the
income the higher the probability of outlays, even taking account of the cost of medical coverage. The
highest income elasticity is in Uruguay, where a 1% increase in income is associated with a 14 point rise
in the probability of incurring expenses, whereas in Ecuador this variable does not have a statistically
significant effect.
In Argentina, Brazil and Ecuador, households with partial medical insurance are more likely to incur
out-of-pocket health expenses. The marginal effects range from 5% and 3.6% in Argentina and Ecuador,
respectively, to 12% in Brazil. Argentine households whose members are all insured also report higher
expenses than those without any type of insurance. In contrast, the expenses of Mexican households in
this situation are 20% lower than those lacking insurance. In all countries, apart from Mexico, households
without medical coverage do not seem more likely to incur out-of-pocket expenses.
6. The unequal distribution of out-of-pocket health expenditure
Different household characteristics give rise to different distributions of the burden of out-of-pocket
expenses, which are analysed in terms of seven variables: income, age of the head of household, presence
of small children, presence of older adults, zone of residence, employment status of the head of household
and the occurrence of hospitalization events.
Irrespective of household characteristics, the highest incidence of out-of-pocket expenses occurs in
Argentina. In all countries, three characteristics substantially increase the burden of such expenses: head of
household of 65 years old, hospitalization events and the presence of an older adult. When the older adult
is not the head of the household, the effect on expenditure is less than when the older adult is the head,
possibly because the ratio between out-of-pocket expenditure and payment capacity is even higher in the
second case, as it undermines income generation capacity and at the same time increases out-of-pocket
health expenses.14
As explained in section 1, expenditures on health insurance do not constitute out-of-pocket health expenditures, but a form of indirect health
spending.
14
The numerator of the indicator increases, at the same time as the denominator decreases.
13
94
Hospitalization episodes give rise to particularly high ratios between expenditure and payment
capacity in Argentina, Chile and Mexico: expenses can be between two and 12 times higher than in
households not affected by this type of situation.
The burden is particularly unequal in Chile (see Perticara 2008a, table A.15). For example, the ratio
between expense and payment capacity in the most vulnerable 5% of households (percentile 95) is 200
times higher than in the wealthiest 5% (percentile 5). In Mexico, the ratio is 127 to 1, and in Colombia 114
to 1. In Uruguay, the incidence of out-of-pocket expenses is less, even for households facing hospitalization
episodes, and the dispersion of the burden is also very low (see figure V.7).
Figure V.7
LATIN AMERICA (SELECTED COUNTRIES): PERCENTILES OF THE BURDEN
OF OUT-OF-POCKET EXPENSES
(Predictions for the baseline category, regressions by quintiles, in percentages)
Percentiles 5-50
Percentiles 50-95
0.07
0.45
0.40
0.06
0.35
0.05
0.30
0.04
0.25
0.03
0.20
0.15
0.02
0.10
0.01
0.05
0.00
0.00
P5
Argentina
Ecuador
P 10
P 25
Brazil
Chile
Mexico
P 50
Colombia
Uruguay
P 50
Argentina
Ecuador
P 75
P 90
Brazil
Chile
Mexico
P 95
Colombia
Uruguay
Source: M. Perticara, “Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos”, Políticas sociales series, No. 141
(LC/L.2879-P), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008. United Nations
publication, Sales No. S.08.II.G.18; and “Un análisis descriptivo de gastos de bolsillo en salud en Bolivia, Honduras, Nicaragua, Perú
y República Dominicana”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC), 2008, unpublished,
on the basis of income and expenditure surveys conducted in selected countries.
Note:
See table V.1 for the periods in which the surveys were conducted. The baseline category consists of households with no medical coverage
of any kind (when the information is available), whose heads of household are younger than 30, lack education and are employed, in
urban zones, without children under five, without older adults, with average incomes, which do not experience hospitalization events,
and in which the household does not have medical insurance expenses.
According to the linear model, the presence of small children raised the level of average expenditure.
Percentile analysis shows that, on average, households with small children spend more in relation to
their payment capacity for outpatient services, medical appointments, and low-cost medicines but do not
necessarily face catastrophic events.
By zone of residence, the mean burden in rural households is higher in Mexico and Brazil. In
Brazil, geographic zone has a slightly larger impact on the first percentiles, from 5% to 10%; in contrast, in
Mexico the difference between rural and urban households increases in the higher percentiles and reaches
30% in percentile 90-95 (Perticara, 2008a).
95
Chapter VI
FINANCING OF THE MILLENNIUM DEVELOPMENT GOALS ON HEALTH
IN LATIN AMERICA AND THE CARIBBEAN
This chapter firstly analyses general trends in non-contributory social public expenditure on health in the
region as an overall financial framework that conditions progress towards the Millennium Development
Goals on health.1 The advances and constraints affecting such expenditure broadly reflect the resource
endowment available in the health sector at the different levels of government and the relative priority given
to it. Regional trends are illustrative since those of individual countries vary, reflecting different volumes
of spending and government levels that are not necessarily comparable. As low-income population groups
often depend on the public sector as the only provider of health coverage, it is relevant to analyse noncontributory public health expenditure.
Secondly, to backstop arguments contained in this report, the funding that would be needed to
implement a spectrum of preventive and curative health interventions to reach some of the Millennium
Development Goals on health in Latin America and the Caribbean is taken into account. The results were
obtained from a costs projection model. Detailed calculations using this model cover a group of 10 countries
in the region, each of which displays very different health indicators and progress through time. The results
are then extrapolated for the region as a whole.
1. Trends in public expenditure on health
Owing to high unemployment rates and the size of the informal sector, the region has not succeeded in
turning its labour markets into universal, dynamic gateways to social protection (ILO, 2005); therefore
employment and social protection based exclusively on contributory systems have lost their capacity for
social integration and safeguarding against risks. Although the situation is particularly complex in the
rural and informal sectors of the various economies, formal urban and high-productivity jobs do not fully
guarantee contributory social protection either. Moreover, given the lack of public policies on society’s care
needs, the sex-gender system which tends to delegate unpaid domestic chores to women (children, older
adults and the sick) makes it hard for women to enter the labour market, often rendering them dependent
on their spouses to gain access to contributory social protection services. Hence the solidarity financing of
social protection needs to be addressed comprehensively, i.e., both within and outside the labour market,
and additional mechanisms need to be put in place (ECLAC, 2006 and 2007a).
Tax policy can affect a country’s income distribution in two ways. First and foremost, public
expenditure on human capital can improve the primary income distribution, i.e., income obtained from the
labour market before deducting taxes and transfers. Secondly, progressive taxes can alter the secondary
income distribution, particularly through taxes on income and assets. Given that both the level of the tax
burden and the composition of the main taxes generally have distributive effects, it is notable that the tax
1
See details of the sources and levels of government considered in analysing social spending on health in the table is contained in the
statistical appendix to this chapter and in ECLAC (2007a), chapter II. Given their aggregation, the figures do not cover resources of
programmes related to the Millennium Development Goals which are executed in other unidentified government levels. Note also that
official information on social spending by functions includes the primary function of each organization, for which reason health expenses
made through programs dependent on social security institutions are generally not included in the health function.
96
burden is low in the region, except in Brazil (Serra and Afonso, 2007), and personal income tax has played
only a small role. While efforts have been made to strengthen value-added tax (VAT), in contrast income
taxes in general, and personal income taxes in particular, have been weakened (Gómez Sabaini, 2006).
Although public social spending on health is clearly not free from tax constraints, efforts made by
the region’s countries to increase it have generated a relatively sustained expansion; since 1990, it has risen
by just over one third, from US$ 104 to US$ 141 per capita at 2000 prices (see figure VI.1).
450
400
Regional average
346
2004-2005: US$ 141
350
2002-2003: US$ 127
300
2000-2001: US$ 130
1998-1999: US$ 126
220
200
181 179
150
Regional average
1990-1991: US$ 104
156 152
107
100
98
81
77
50
50
39
36
36
36
33
28
18
1990-1991
1998-1999
2000-2001
2002-2003
Ecuador
Nicaragua
El Salvador
Honduras
Bolivia
Peru
Colombia
Dominican
Republic
Venezuela
(Bol. Rep. of)
Jamaica
Panama
Uruguay
Mexico
Chile
Brazil
Cuba
Costa Rica
Trinidad and
Tobago
0
15
15
Guatemala
199
Paraguay
250
Argentina
Per capita public social spending in health (in 2 000 dollars)
Figure VI.1
LATIN AMERICA AND THE CARIBBEAN (21 COUNTRIES): PER CAPITA NON-CONTRIBUTORY
PUBLIC EXPENDITURE ON HEALTH, 1990-1991 TO 2004-2005
(In dollars at 2000 prices) a
2004-2005
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of the Commission’s social expenditure database.
a
Owing to changes in the base year for GDP (1997), information in dollars has only been available since 2000. The regional average does not
include Cuba.
Nonetheless, the level and trend of this category vary significantly from one country to another. In
2004 and 2005, seven countries — including large ones such as Argentina, Brazil and Mexico — were above
the regional average. Secondly, in some cases public health budgets increased exceptionally, doubling and
even tripling in 15 years (Chile, Colombia, Dominican Republic, Panama, Paraguay and Peru).2 Changes
have also occurred in the mode of expenditure execution, which could be related to decentralization
processes. In Ecuador, Mexico, Uruguay and the Bolivarian Republic of Venezuela, the central government
budget in this area either decreased or remained constant during the period.
With regard to the macroeconomic priority of these expenses, their relation to the trend of GDP
in a setting of slow but sustained economic growth shows that the efforts being made to increase health
spending are insufficient at the regional level. In the periods 1990-1991 and 2004-2005, this expenditure
grew only very slightly as a percentage of GDP, or else decreased, in eight out of 21 countries: Argentina,
Costa Rica, Ecuador, Guatemala, Mexico, the Bolivarian Republic of Venezuela, Trinidad and Tobago and
Uruguay (see figure VI.2).
2
With the exception of Colombia, the figures refer to central government or to budgetary central government.
97
7
Regional average
2004-2005: 3.4%
2002-2003: 3.3%
2000-2001: 3.3%
1998-1999: 3.2%
6.0
4.4
3.5
Regional average
1990-1991: 3.1%
3.5 3.3
3
2.8 2.8
2.5
2.3 2.3
2
2.2
1.7
1.6
1.6
1.5
1990-1991
1998-1999
2000-2001
1.4 1.2
Dominican
Republic
El Salvador
Peru
Uruguay
2002-2003
Venezuela
(Bol. Rep. of)
Panama
Trinidad and
Tobago
Colombia
Mexico
Jamaica
Chile
Nicaragua
Honduras
Bolivia
Argentina
Brazil
0
Costa Rica
1
1.1
1.0
Guatemala
4.6
4
Paraguay
5.0
5
Ecuador
6
Cuba
Total social spending (percentages of GDP)
Figure VI.2
LATIN AMERICA AND THE CARIBBEAN (21 COUNTRIES): NON-CONTRIBUTORY PUBLIC
EXPENDITURE ON HEALTH AS A PERCENTAGE OF GDP, 1990-1991 TO 2004-2005
2004-2005
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of the Commission’s social expenditure database.
Although public social spending in the region has increased significantly, rising from 12.9% to
15.9% of GDP between 1990-1991 and 2004-2005, the health sector has grown relatively more slowly,
expanding by just 0.3% of regional GDP (see figure VI.3).
Figure VI.3
LATIN AMERICA AND THE CARIBBEAN (21 COUNTRIES): TREND OF NON-CONTRIBUTORY
PUBLIC SOCIAL SPENDING AS A PERCENTAGE OF GDP BY SECTORS, 1990-1991 TO 2004-2005
(Percentages)
3.0
{
18
15.9
14
12.9
12
10
1.71
{
8
6.97
1.0
3.29
4.29
3.06
5.26
- 0.07
3.39
{
4
0.33
{
6
{
Percentages of GDP
16
2
0
1.28
Total social spending
1990-1991
Education expenditure
1992-1993
1994-1995
Health expenditure
1996-1997
1998-1999
Expenditure on retirement
pensions, work programs
and welfare assistance
2000-2001
1.21
Expenditure on housing
and other items
2002-2003
2004-2005
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of the Commission’s social expenditure database.
a
Weighted average of the countries.
This suggests a lower fiscal priority given to public spending on health as compared to other social
sectors such as education, social assistance and, particularly, social security (see figure VI.3). In the course
of a decade and a half, this category grew moderately, from 11.1% to 13.0% of the total public expenditure
98
budget in the region’s countries. Nonetheless, its weight among the social sectors declined slightly, slipping
from 23.7% of public social spending in 2004-2005 to 21.4% in early 1990.
It is therefore unsurprising that health expenditure at the levels of government analysed behaves
in a highly procyclical pattern. In the periods 1994-1998 and 2001-2003, it was highly sensitive to the
economic crises occurring in a number of countries. As can be seen, the business cycle has a somewhat
lagged effect. In general, adjustments occur in the following year: rather than causing major adjustments
in current expenditure execution, they seem to have a greater effect on the subsequent annual public health
budget (see figure VI.4).
Figure VI.4
LATIN AMERICA (20 COUNTRIES): ANNUAL VARIATION OF GDP AND NON-CONTRIBUTORY
PUBLIC EXPENDITURE ON HEALTH, 1991-2006
(Percentages)
15
Annual variation
10
5
0
-5
-10
-15
1991
1992
1993
1994
1995
Annual variation in GDP
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Annual variation in public expenditure on health
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of the Commission’s social expenditure database.
The findings of national studies show that the poorest sectors of the population have also been
favoured in countries with the highest public expenditure on health. This expenditure is slightly progressive,
i.e., with respect to primary income from the labour market, it favours the lower-income sectors. Lowerincome sectors benefit more from primary and outpatient care, which suggests greater coverage and often
cost-free access to this type of service. In contrast, hospital services are more regressive, since the higherincome groups tend to use them more. The higher costs of the infrastructure, equipment and specialized
staff required, cause them to be located preferentially in areas of heavier population concentration, or
else the services they provide depend on co-payments in certain countries (see figure VI.5).
99
Figure VI.5
LATIN AMERICA AND THE CARIBBEAN (16 COUNTRIES): a DISTRIBUTION OF NONCONTRIBUTORY PUBLIC EXPENDITURE ON HEALTH AND PRIMARY AND HOSPITAL
HEALTH CARE b BY PRIMARY INCOME QUINTILES, 1997-2004
(Percentages)
Cumulative percentage of expenditure
100
Primary
care
90
80
70
Health
expenditure
60
50
Hospital
care
40
30
20
Primary income
10
0
0
20
40
60
80
100
Cumulative percentage of the population
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of national studies.
Average weighted by the percentage of health expenditure in each country’s primary income.
Simple average of four countries.
a
b
This greatly restricts timely access to these services for the poorest population groups living
far from the main urban centres; and it thus becomes harder to make headway in improving minimal
health conditions among the Latin American and Caribbean population, as envisaged in the Millennium
Development Goals. Moving towards these goals necessarily requires both a larger volume of resources
and greater efforts to include poor population groups. The second section of this chapter will give details
of measures needed to provide certain services of proven efficiency to bring down childhood mortality
rates, improve maternal health, and combat malaria and tuberculosis.
2. Estimation of the costs of attaining selected Millennium
Development Goals on health in the region
Several years ago the WHO Commission on Macroeconomics and Health (CMH) attempted to cost the
Millennium Development Goals targets on health for a group of 83 developing countries (six of which
from the Latin American and Caribbean region) in order to estimate the scale of the additional financing
needed to expand coverage and improve the quality of the priority services required to achieve the Goals
in this domain (Sachs, 2001). That study is thus a key reference when addressing this subject. Apart from
the CMH, other authors have also calculated the costs of attaining the Millennium Development Goals.
Devarajan, Miller and Swanson (2002), for example, estimated that the additional funding required to
achieve the three Millennium Development Goals on health for 2002 varied between US$ 25 billion and
US$ 30 billion per year —a figure very close to that estimated by the CMH of US$ 22 billion for 2007,
although the two studies used different methods.
100
To flesh out the arguments of this report, a model was developed to project the costs of achieving the
Millennium Development Goals in health,3 which was used to calculate the funding needed to implement
a set of preventive and curative health measures that would make it possible to fulfil the aforementioned
goals in Latin America and the Caribbean. These were selected on the basis of evidence on their specific
effects (Bitrán, 2008).4 5
Given the scale of the effort and access to information, the following Millennium Development Goals
on health are analysed: reducing the childhood mortality rate, improving maternal health and combating
malaria and tuberculosis, in accordance with sector interventions in this area. Thus, no calculation is made
of the costs of actions in the domain of the health determinants, which have been analysed throughout
this report.
The model and results of the CMH estimation were closely analysed, as were other international
studies on the feasibility of achieving the Millennium Development Goals on health,6 7 including the
UNICEF and the World Bank’s Marginal Budgeting for Bottlenecks Model (MBB).
Ten of the region’s countries displaying very different health indicators and degrees of progress were
chosen. On average they are less poor than the six included in the CMH study. Listed in ascending order of
per capita GDP in dollars at 2006 prices, they are Haiti, Bolivia, Dominican Republic, Honduras, Nicaragua,
Ecuador, Jamaica, Guatemala, El Salvador and Peru. The work entailed obtaining information on economic
and social development, health status, health financing, coverage levels of health interventions linked to the
Millennium Development Goals, the cost of the corresponding interventions and cost-effectiveness. Based
on these costs projections, an extrapolation for the region as a whole was done.
The model makes it possible to estimate the disability-adjusted life years (DALY) 8 which are
lost in the countries as a result of disability, death or both.9 Together with data on the cost-effectiveness
of each of the health interventions considered, these results were used to obtain projections of the
additional interventions needed to achieve the Millennium Development Goals. Based on data for current
coverage, population and unit costs, the interventions needed to cover the increase in population are
quantified, and the resulting coverage is calculated, in order to measure the additional production of
5
3
4
6
7
8
9
This study will soon be published by ECLAC as part of the Políticas sociales series.
On the effectiveness of the interventions, see Escobar (2008).
To be consistent with the rest of the report, target 7 of Goal 6 (To have halted and started to reduce the propagation of HIV/AIDS by 2015),
was excluded, since it is the subject of another United Nations study to be presented shortly at the respective international conference to be
held this year.
The key models are: the model for costing the Millennium targets on health in Guatemala (PHRplus Project); UNICEF/World Bank,
Marginal Budgeting for Bottlenecks (UNICEF/World Bank, 2007a); Child Health Cost Estimation Tool of WHO; Reproductive Health
Costing Model of the United Nations Population Fund (UNFPA); Integrated Health Care Technology Package (IHTP) of WHO and
the Medical Research Council (MRC); Strategies to Prevent Mother to Child Transmission of HIV (PMTCT) and HIV/AIDS Resource
Allocation and the GOALS Model of the Constella Group; Planning, Costing and Budgeting Framework and CORE Plus of Management
Sciences for Health; Comprehensive multi-year planning of WHO; Integrated Health Model of the United Nations Development Programme
(UNDP); Planning and Budgeting tool for Tuberculosis Control, Resources Needs and Malaria Cost Estimation Tool of WHO. Many of them
were available in Excel, and are not necessarily linked to documents, and manuals are provided in some cases. Consequently, bibliographic
references are not available for all of them. For a full bibliography, see Bitrán and others (2008).
The results of a comparative study on the financing of the Goals on health, education and sanitation in the region’s countries, using a
computable general equilibrium model, will soon be published. This study considers three options for financing investment related to the
Goals: the fiscal, external-aid and other domains (Vos, Sánchez and Kaldewei, 2008). This was a joint project of the World Bank, UNDP
and the Department of Economic and Social Affairs of the United Nations. The Social Development Unit of the ECLAC subregional
headquarters in Mexico, and ECLAC headquarters in Santiago participated in several national studies, and the unit also supported the
methodological discussion. Other calculations of the costs of achieving the Millennium Development Goals have been made using general
equilibrium models, such as those made for Peru by Castro and others (2006) and by Yamanda and Castro (2007), which analysed several
Millennium Development Goals other than those relating to health, and incorporate the effects of interventions made in several social
sectors such as the health benefits of greater school enrolment.
The report, which will be published in the ECLAC Políticas sociales series will include a CD containing the model and the figures in which
it was based.
The term is a classic concept that was originally coined by the World Bank (1993).
101
interventions needed to achieve the chosen targets. Diagram VI.1 shows the input and output parameters
of the model and describes the formulas used with the parameters. Two types of costs are estimated, both
separately and jointly:
• Those facing countries to be able to maintain current coverage levels of interventions
relating to the chosen targets Millennium Development Goals, taking account of natural
population growth;
• The additional cost of increasing that coverage when necessary to be able to achieve the
aforementioned targets by 2015.
Diagram VI.1
DESCRIPTION OF THE COSTS PROJECTION MODEL TO ACHIEVE HEALTH-RELATED
millennium development goals IN THE REGION, AND related FORMULAS
Model inputs
Model outputs
Formula
Desired mortality
rate reduction
Population
DALYs to avoid
DALYs to avoid = (reduction in mortality rate) x (population)/(DALYs resulting from death)
DALYs lost as result
of premature death
Cost effectiveness
of interventions
(dollars per DALY)
Additional cost
of avoiding
DALYs (in dollars)
Additional cost = (DALY to avoid) x (cost-effectiveness)
Current coverage
(percentages
of the population)
Cost of maintaining
current coverage
(in dollars)
Maintenance cost = (coverage) x (population) x (unit cost)
Unit costs of
interventions
(dollars per unit)
Production
(units of each
health intervention)
Production = (cost of maintenance + additional cost)/(unit cost)
Population
Coverage achieved
(population
percentages)
Coverage = (production)/(population)
Population
Unit costs of
interventions
(dollars per unit)
Source: R. Bitrán, “Estimación del costo de alcanzar las objetivos del Milenio en salud en algunos países de América Latina y el Caribe. Primer
informe”, January 2008, unpublished.
102
Inputs included various parameters that characterize the situation of each country, resulting in
estimates of the costs of achieving the Millennium Development Goals in the health domain mentioned
above, both individually and as a group. To make the calculations through time, projections are made of
the trend of the economy, health expenditure, health status and other variables. Parameters are defined
such as annual growth of per capita GDP, using the historical average of the last 20 years in each country,
the gross and net population growth rate (using data from the Latin American and Caribbean Demographic
Centre (CELADE)-Population Division of ECLAC), and total health expenditure as a proportion of GDP
for the period considered, which runs from 2007 to 2050, taking 2006 as the base year.10 In relation to
the unit costs of health interventions, data are incorporated from cost studies performed in various Latin
American countries. Cost-effectiveness ratios were obtained from publications on the subject, mainly
the multinational study entitled Prioridades para el control de enfermedades en países en desarrollo
[priorities for disease control in developing countries].
As shown in table VI.1, the model is broken down for each Millennium Development Goals and
for each health intervention by country; and the results are then extrapolated to the region as a whole. The
extrapolation based on the average of the 10 countries of the sample to Latin America and the Caribbean
as a whole uses per capita cost values. The per capita expenditure needed by the countries in the sample
is expanded to the region’s population to determine the expenditure needed to achieve its Millennium
Development Goals. The extrapolation is considered valid given the diversity of the countries included
in the sample, and considering certain parameters, e.g., the fact that the per capita GDP of the countries
of the sample is practically the same as that of Latin American and Caribbean as a whole. All monetary
values in the study are expressed in 2006 dollars.
Table VI.1
LATIN AMERICA AND THE CARIBBEAN (EXTRAPOLATION): MAIN RESULTS
OF THE COSTS PROJECTION OF SELECTED HEALTH INTERVENTIONS
TO ACHIEVE SELECTED millennium development goals
(Millions of dollars at 2006 prices)
Year
Expenditure to maintain current coverage
Additional expenditure to increase coverage
Total expenditure to attain the Millennium Development Goals
Per capita expenditure in Latin America and the Caribbean (in dollars)
2007
2015
2 036
2 328
53
1 277
2 089
3 605
3.76
6.48
Source: R. Bitrán and others, “Estimación del costo de alcanzar los objetivos del Milenio en salud en América
Latina y el Caribe”, Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC),
March 2008, unpublished.
10
The model assumes that the percentage of GDP allocated to health by each country in 2006 remains constant in future years. This does
not restrict the calculation of health expenditure, because these are estimated independently and then compared with the result if the
aforementioned percentage were applied to GDP.
103
Lastly, the results were compared with the earlier estimates made by CMH. That calculation was
taken as a reference since, following adjustments and despite their clear differences, both the method
applied and the interventions used by the Commission and this model are comparable.11 It was not
compared with Devarajan and others (2002), despite the fact that, as noted above, the results are similar
to those of the CMH because that study presents them in different ways for the different regions, thus
complicating the comparison.
As can be seen, most expenditure in the various countries is used to maintain current coverage
levels in the different health interventions. Only a relatively small proportion is explained by an increase in
coverage to levels that would make it possible to achieve the Millennium Development Goals. Nonetheless,
expenditure to maintain current coverage is increasing over time, as a result of natural population growth.
The estimated total expenditure of the region to maintain current coverage of the health interventions
used by the model amounts to US$ 2,036 million in 2007 and US$ 2,328 million in 2015. The additional
expenditure needed to achieve the selected targets, in a scenario where additional resources are provided
uniformly to all interventions, is US$ 53 million in 2007 and US$ 1,277 million in 2015 (see table VI.1).12
The results obtained are consistent and compatible with the expenditure levels that the countries of the
sample currently apply to the selected interventions, and with current progress in achieving the Millennium
Development Goals. Table VI.2 shows the cost of achieving each of the aforementioned goals.
Table VI.2
LATIN AMERICA AND THE CARIBBEAN (EXTRAPOLATION): COSTS PROJECTION
OF SELECTED HEALTH INTERVENTIONS TO ACHIEVE THE CHOSEN
millennium development goals
(Millions of dollars at 2006 prices)
Year
Maternal mortality
Infant mortality
Tuberculosis
Malaria
Total
2007
2015
1 374
1 644
465
1 360
56
309
194
292
2 089
3 605
Source: R. Bitrán and others, “Estimación del costo de alcanzar los objetivos del Milenio en salud en
América Latina y el Caribe”, Santiago, Chile, Economic Commission for Latin America and the
Caribbean (ECLAC), March 2008, unpublished.
Table VI.3, below, gives details of the results obtained by each country in the sample and for the
extrapolation to the region.
A direct comparison cannot be made given the methodological differences between the two estimations. On the adjustments needed for the
comparison, see Bitrán and others (2008). See the results of the comparison in table A-VI-5.
12
All monetary values used in this study are expressed in 2006 dollars.
11
104
Table VI.3
LATIN AMERICA AND THE CARIBBEAN (10 COUNTRIES) AND EXTRAPOLATION FOR THE
REGION: TOTAL EXPENDITURE REQUIRED TO INCREASE THE CURRENT COVERAGE
OF SELECTED HEALTH INTERVENTIONS TO A LEVEL THAT PERMITS
THE ACHIEVEMENT OF SELECTED millennium development goals
(Millions of dollars at 2006 prices)
Countries
Year
2007
2015
Bolivia
41.05
62.77
Ecuador
49.29
76.85
El Salvador
21.54
33.57
Guatemala
50.11
128.38
Haiti
25.39
71.85
Honduras
25.62
55.52
Jamaica
10.09
12.54
Nicaragua
28.80
46.98
Peru
97.69
127.13
Dominican Republic
44.54
64.56
394.14
680.16
2 088.93
3 604.90
3.76
6.48
Total 10 countries
Total Latin America and the Caribbean
Per capita Latin America and the Caribbean (in dollars)
Source: R. Bitrán and others, “Estimación del costo de alcanzar los objetivos del Milenio en salud en
América Latina y el Caribe”, Santiago, Chile, Economic Commission for Latin America and the
Caribbean (ECLAC), March 2008, unpublished.
105
Statistical appendix
Table A-VI.1
LATIN AMERICA AND THE CARIBBEAN (21 COUNTRIES): PUBLIC SOCIAL SPENDING
AS A PERCENTAGE OF GROSS DOMESTIC PRODUCT
(Percentages)
Country
Period
1990-1991
1992-1993
1994-1995
1996-1997
1998-1999
2000-2001
2002-2003
2004-2005
19.3
20.1
21.1
19.9
20.9
21.8
19.5
19.4
…
…
12.4
14.6
16.2
18.0
19.4
18.6
Brazil
18.1
17.6
20.4
19.4
21.6
21.1
21.8
22.0
Chile
12.7
12.8
12.4
12.8
14.2
15.1
14.7
13.1
Colombia
6.6
7.9
11.5
15.2
13.7
13.2
13.7
13.4
Costa Rica
15.6
15.2
15.8
16.8
16.4
18.0
18.6
17.5
Cuba
27.6
32.8
28.5
25.0
24.3
22.2
24.7
28.7
7.4
8.0
6.1
5.6
4.9
4.9
5.5
6.3
…
4.1
4.8
5.2
5.4
6.1
5.6
0.0
Guatemala
3.3
4.1
4.1
4.3
5.9
6.1
6.5
6.3
Honduras
7.5
7.6
6.6
6.6
7.4
10.0
11.3
11.6
Jamaica c
8.4
8.0
8.2
9.0
…
9.5
9.5
9.9
Mexico
6.5
8.1
8.9
8.5
9.2
9.7
10.2
10.2
Nicaragua
6.6
6.5
7.2
6.5
7.6
8.1
9.3
10.8
Panama
7.5
9.3
8.3
8.8
9.7
9.5
8.3
8.0
Paraguay
3.2
6.6
7.8
8.7
9.1
8.0
9.1
7.9
Peru
3.9
5.1
6.5
6.9
7.4
8.3
9.5
8.9
Dominican Republic
4.3
5.9
6.7
6.9
7.1
7.7
7.6
7.1
Trinidad and Tobago e
6.9
7.3
6.6
6.4
…
9.1
9.7
9.4
16.8
18.9
20.2
21.3
22.0
22.2
20.8
17.7
Venezuela (Bol. Rep. of)
8.8
9.2
7.8
8.6
8.8
11.6
11.7
11.7
Latin America and
the Caribbean f
9.7
10.8
11.1
11.3
11.8
12.4
12.7
12.6
Latin America and
the Caribbean g
12.9
13.5
14.9
14.6
15.5
15.7
15.8
15.9
Argentina
Bolivia a
Ecuador
El Salvador
b
d
Uruguay
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of information from the Commission’s social
expenditure database.
The figure reported for the biennium 1994-1995 corresponds to 1995.
b
The figure reported for the biennium 1992-1993 corresponds to 1993.
c
The figures reported for the biennium 1996-1997 correspond to 1996; those of 2004-2005 correspond to 2004.
a
Figures prior to 2000 correspond to the budgetary central government.
e
The figure reported for the biennium 1996-1997 corresponds to 1996.
f
Simple average of the countries. Includes estimates in years and countries where information is lacking.
g
Weighted average of the countries. Includes estimates in years and countries where information is lacking.
d
106
Table A-VI.2
LATIN AMERICA AND THE CARIBBEAN (21 COUNTRIES): NON-CONTRIBUTORY PER CAPITA
PUBLIC SOCIAL SPENDING ON HEALTH
(In dollars at 2000 prices)
Country
Period
1990-1991
1992-1993
1994-1995
1996-1997
1998-1999
2000-2001
2002-2003
2004-2005
264
321
363
356
393
378
295
347
…
…
30
33
33
36
37
36
Brazil
119
87
150
138
137
150
160
180
Chile
62
82
97
113
130
144
153
156
Colombia
18
23
60
69
75
61
57
50
Costa Rica
153
154
168
171
189
210
236
220
…
…
…
…
…
135
141
182
18
21
11
12
10
10
15
19
…
22
26
27
31
28
32
33
Guatemala
12
13
12
11
16
16
16
15
Honduras
26
27
24
22
22
32
38
37
63
70
65
68
…
64
72
81
147
172
118
111
129
132
135
153
Nicaragua
19
17
18
18
20
23
26
28
Panama
49
66
63
67
79
90
79
98
Paraguay
4
16
18
20
20
16
17
16
15
15
25
29
31
32
34
37
17
24
25
30
36
50
44
40
115
119
99
101
…
136
170
199
142
160
196
151
169
153
105
107
Venezuela, (Bol. Rep. of)
79
89
56
59
70
71
66
77
Latin America and the
Caribbean g
68
77
81
80
88
91
89
96
Latin America and the
Caribbean h
105
105
122
117
125
129
127
141
Argentina
Bolivia
a
Cuba b
Ecuador
El Salvador
Jamaica
c
d
Mexico
Peru
e
Dominican Republic
Trinidad and Tobago
f
Uruguay
Source:
Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of information from the Commission’s social
expenditure database.
The figure reported for the biennium 1994-1995 corresponds to 1995.
b
Owing to variations in the GDP base, information on dollars has only been available since 2000 (see box II .6).
c
The figure reported for the biennium 1992-1993 corresponds to 1993.
d
The figures reported for the biennium 1996-1997 correspond to 1996; and the figures shown for 2004-2005 correspond to 2004.
e
f
The figure reported for the biennium 1996-1997 corresponds to 1996.
g
Simple average of the countries. Includes estimates for years and countries where information is lacking, and does not include Cuba.
h
Weighted average of the countries. Includes estimates for years and countries where information is lacking, and does not include Cuba.
a
Figures prior to 2000 correspond to the budgetary central government.
107
Table A-VI.3
LATIN AMERICA AND THE CARIBBEAN (21 COUNTRIES): NON-CONTRIBUTORY SOCIAL PUBLIC
EXPENDITURE IN HEALTH AS A PERCENTAGE OF GROSS DOMESTIC PRODUCT
(Percentages)
Country
Period
1990-1991
1992-1993
1994-1995
1996-1997
1998-1999
2000-2001
2002-2003
2004-2005
Argentina
4.3
4.6
4.9
4.6
4.9
5.0
4.4
4.4
Bolivia
…
…
3.1
3.3
3.3
3.6
3.7
3.5
Brazil
3.6
2.6
4.2
3.8
3.8
4.1
4.3
4.6
Chile
2.0
2.2
2.4
2.4
2.7
2.9
3.0
2.8
Colombia
1.0
1.2
2.9
3.2
3.7
3.0
2.8
2.3
Costa Rica
4.9
4.5
4.7
4.7
4.8
5.2
5.7
5.0
Cuba
5.0
6.6
5.6
5.3
5.8
5.2
5.3
6.0
Ecuador
1.4
1.6
0.8
0.9
0.7
0.8
1.1
1.2
El Salvador b
…
1.2
1.3
1.4
1.5
1.3
1.5
1.5
Guatemala
0.9
1.0
0.9
0.8
1.1
1.1
1.0
1.0
Honduras
2.9
2.8
2.6
2.3
2.4
3.3
3.8
3.5
2.2
2.4
2.2
2.3
…
2.2
2.5
2.8
Mexico
2.9
3.4
2.3
2.2
2.3
2.3
2.3
2.5
Nicaragua
2.8
2.5
2.8
2.5
2.7
2.9
3.3
3.3
Panama
1.6
1.9
1.8
1.9
2.0
2.3
2.0
2.3
Paraguay
0.3
1.1
1.2
1.3
1.4
1.2
1.3
1.1
Peru d
0.9
0.9
1.3
1.4
1.5
1.5
1.6
1.6
Dominican Republic
1.0
1.3
1.2
1.4
1.5
1.8
1.6
1.4
Trinidad and Tobago e
2.6
2.8
2.2
2.0
…
2.1
2.3
2.2
Uruguay
2.9
3.0
3.4
2.5
2.7
2.6
2.0
1.7
Venezuela (Bol. Rep. of)
1.6
1.7
1.1
1.1
1.4
1.5
1.6
1.6
Latin America and
the Caribbean f
2.3
2.6
2.6
2.4
2.6
2.7
2.7
2.7
Latin America and
the Caribbean g
3.1
3.0
3.3
3.0
3.2
3.3
3.3
3.4
a
Jamaica
c
Source: Economic Commission for Latin American and Caribbean (ECLAC), on the basis of information from the Commission’s social
expenditure database.
a
The figure reported for the biennium 1994-1995 corresponds to 1995.
b
The figure reported for the biennium 1992-1993 corresponds to 1993.
The figures reported for the biennium 1996-1997 correspond to 1996; and the figures shown for 2004-2005, to 2004.
d
Figures prior to 2000 correspond to the budgetary central government.
e
The figure reported for the biennium 1996-1997 corresponds to 1996.
f
Simple average of the countries. Includes estimates in years and countries where information is lacking.
g
Weighted average of the countries Includes estimates in years and countries where information is lacking.
c
108
Table A-VI.4
LATIN AMERICA AND THE CARIBBEAN (18 COUNTRIES): HEALTH EXPENDITURE,
BREAKDOWN BY PRIMARY INCOME QUINTILE
(Percentages)
Income quintile
Total
Gini
Quintile I Quintile II Quintile III Quintile IV Quintile V
Latin America
Health
24
22
20
18
17
100
-0.067
Argentina 2003
Health
20
21
19
21
19
100
-0.010
35
27
18
13
7
100
-0.277
8
17
21
27
28
100
0.202
7
16
20
27
30
100
0.228
9
19
22
29
20
100
0.134
11
15
14
25
35
100
0.232
4
11
13
27
45
100
0.389
18
20
14
22
26
100
0.075
Public health care
Health insurance expenditure
Social works - health care
Ins.Nac.de Jubilados y Pensionados health care
Bolivia 2002
Health
Health savings institutes (Cajas de salud)
Insurance policies and others
Brazil 1997
Health
16
20
22
23
19
100
0.036
Chile 2006
Health subsidies
55
33
18
3
-10
100
-0.633
Colombia 2003
Health
34
29
19
12
5
100
-0.295
41
32
16
8
3
100
-0.395
28
27
22
16
8
100
-0.203
Contributory health regime
18
50
91
121
-180
100
…
Costa Rica 2004
Health
25
24
24
17
10
100
-0.150
Ecuador 1999
Health and nutrition (Ministry of Health)
19
23
23
24
11
100
-0.060
El Salvador 2002
Health
Subsidised regime
Supply subsidies
Guatemala 2000
26
23
21
18
12
100
-0.132
Primary care
29
23
21
17
10
100
-0.176
Hospital care
20
23
22
19
16
100
-0.048
Total health
17
18
23
25
17
100
0.028
Hospitals
13
16
21
29
22
100
0.119
Health centres
20
23
28
20
9
100
-0.100
Health posts
40
22
27
6
5
100
-0.344
Community centres
39
20
23
8
10
100
-0.280
21
22
23
20
14
100
-0.066
Honduras 2004
Health
Mexico 2002
Health
15
18
21
23
22
100
0.078
Primary care
16
18
21
23
22
100
0.061
Maternal care
10
19
23
31
18
100
0.107
3
15
32
21
30
100
0.236
Hospitals
Nicaragua 2005
Health
21
22
22
20
16
Panama 2003
Health
17
24
20
21
19
100 -0.046
100
-0.002
109
Table A-VI.4 (concluded)
Income quintile
Total
Gini
Quintile I Quintile II Quintile III Quintile IV Quintile V
Peru 2004
6
11
19
26
39
100
0.324
Ministry of Health (MINSA)
11
19
26
24
20
100
0.089
MINSA primary care
20
24
23
20
13
100
-0.068
5
15
29
27
24
100
0.205
17
27
25
22
9
100
-0.081
ESSALUD b
1
5
15
30
49
100
0.482
Armed forces
0
2
9
19
70
100
0.631
100
0.424
Total health
MINSA hospitals
SIS a
Private care
Dominican
Republic 1998
Uruguay 2003
4
8
14
25
49
Preventive medicine: vaccinations
25
23
21
19
13
100
-0.107
Preventive medicine: maternal hospital
services
31
25
20
15
9
100
-0.216
Preventive medicine: Papanicolau
26
24
21
19
10
100
-0.148
Preventive medicine: early childhood
31
24
21
15
8
100
-0.225
Curative medicine: hospital services
32
26
18
16
8
100
-0.232
Curative medicine: hospital services
(social insurance)
33
15
17
29
6
100
-0.160
Curative medicine: military hospital
18
5
19
16
42
100
0.236
Health
48
28
15
7
3
100
-0.438
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of household surveys.
Ministry of Health comprehensive health insurance.
Insurance for employed workers.
a
b
Table A-VI.5
THE COSTS OF ATTAINING SELECTED MILLENNIUM development goals IN LATIN
AMERICA AND THE CARIBBEAN: COMPARISON BETWEEN CURRENT ESTIMATIONS AND CMH
EXERCISES, AFTER RELEVANT ADJUSTMENTS
Year
2007
2015
Estimation
Annual cost
per inhabitant
(dollars)
Total cost
(millions
of dollars)
Annual cost
per inhabitant
(dollars)
Total cost
(millions
of dollars)
Current model
76.96
42 759
85.94
54 426
WHO Commission on
Macroeconomics and Health
67.36
37 425
71.44
45 243
Source: R. Bitrán and others, “Estimación del costo de alcanzar los objetivos del Milenio en salud en América Latina y el Caribe”, Santiago,
Chile, Economic Commission for Latin America and the Caribbean (ECLAC), March 2008, unpublished.
111
Chapter VII
HEALTH SYSTEMS AND THE CHALLENGES POSED BY THE MILLENNIUM
DEVELOPMENT GOALS: MAIN HEALTH POLICY GUIDELINES
“The Development Goals contained in the United Nations Millennium Declaration,
signed by our countries, have given us the chance to resume
the path of formulating plans to address the population’s social
and health problems so as to enhance social cohesion.
It is in this setting that eradicating poverty and overcoming inequality
should be priority goals in our countries”
Iquique Consensus, IX Ibero-American Conference of Ministers of Health,
Iquique (Chile), July 2007
Health is at the core of economic and social rights. Insofar as society can guarantee all its members
appropriate prevention and health care, it comes closer to achieving and upholding those rights. Effective
enjoyment of this element of citizenship strengthens peoples’ sense of belonging to society and thus
enhances democratic social cohesion. The region’s health reform agenda therefore should pursue a dual
objective. Firstly, solidarity mechanisms need to be designed to provide equitable access to health services
to the whole population, regardless of individual income or risk level; additional funding efforts are needed
to achieve this, as already noted. Secondly, to optimize the response to the technological, demographic and
epidemiological changes that are unfolding in the region, costs must be contained, and the scarce resources
available more efficiently allocated (ECLAC, 2000, 2006 and 2007a).
In those terms, the Pan American Health Organization (PAHO), in its resolution of 19 September
2002, defines the extension of social protection in health as a guarantee provided by society, through
different public authorities, to enable individuals or groups of individuals to satisfy their health needs and
requirements through adequate access to the services of the health system or any subsystem that exists in
the country, irrespective of their payment capacity.
The Millennium Development Goal indicators have made it possible to monitor the progress of
public policies in specific fields by defining minimum standards of satisfaction in certain aspects of wellbeing, whose achievement involves ensuring efficient resource allocation and service provision. This has
made it possible to identify situations of discrimination and exclusion, and to assess the efficiency of public
policies. Hence their unquestionable value in terms of social inclusion.
The living conditions of the Latin American and Caribbean population have improved significantly
over the last few decades. Greater access to health, supported by substantial investments in basic
infrastructure, have brought drinking water and basic sanitation services to a large and growing proportion
of the population. Life expectancy at birth has increased significantly in just 30 years, education levels have
risen, and there have been notable reductions in infant and under-fives mortality and malnutrition. These
positive trends show a convergence towards the corresponding indicators for countries of higher per capita
incomes (figure VII.1).
112
Figure VII.1
QUALITY-OF-LIFE INDICATORS: TRENDS TOWARDS CONVERGENCE BETWEEN
LATIN AMERICA AND 15 OECD COUNTRIES
Life expectancy at birth
Infant mortality rate
(Number of years)
(Number per 1,000 live births)
120
80
60
61
57
50
68
65
79
71
73
40
30
20
10
102
93
85
80
72
59
60
40
49
42
35
34
24
22
15
20
12
9
8
29
6
25
5
5
2005
2000
1995
1990
1985
1980
1975
1970
Access to improved sources of drinking
water and sanitation
(Net enrolment rate)
(Percentages of the population)
97.6
93.9
96.3
9.8
91.2
87.0
85.5
100 100
93.0
90
80
80
70
65.2
64.9
60
50
40
29.8
30
Primary education
1991
2001
2005
Secondary education
OECD (24 countries)
100
100
91
68
72
75
77
40
30
10
2005
89
86
100
100
50
10
2001
100
60
20
1991
83
100
99
70
20
0
1965
Latin America and the Caribbean
Timely access to primary and
secondary education
100 96.8
90
1960
2005
2000
1995
1990
1985
1980
1975
1970
1965
OECD (24 countries)
Net primary and secondary enrolment rate
100
0
1960
0
Access in percentages
Number of years
70
76
74
71
69
78
Infant mortality rate per 1,000 live births
90
0
1990
1995
2000 2004
Access to drinking water
1990
1995
2000 2004
Access to sanitation
Latin America and the Caribbean
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of World Bank, World Development Indicators
(WDI) [online database].
Secondly, as noted above, the low level and volatility of economic growth, and the highly unequal
income distribution have prevented a larger reduction in absolute poverty and exclusion. In the area of
interest for this study, this has meant wider gaps and tighter constraints on achieving the Millennium
Development Goals in the health domain, since better averages still conceal glaring inequities in health and
related indicators.
113
A large proportion of the gaps in poverty and health stem from this inequality, which is the greatest of
all regions of the world. When there is such an unequal socio-economic distribution of disease and mortality
—and also in certain realms such as malnutrition— the problem needs to be attacked at its roots, i.e.,
acting on the respective socio-economic determinants. Otherwise, the complex causal web confronts health
policies with tasks that clearly reach beyond sector boundaries and are impossible to resolve if addressed in
isolation. This calls for synergy between the various policies welfare-related policies —education, housing,
income— in a stable macroeconomic setting that promotes economic growth and a better distribution of
the fruits of development. This is the mission of the WHO Commission on Social Determinants of Health
(CSDH), mentioned above.
The situation in the region points out the imperative need to improve equity and expand social
health protection. The glaring inequities that exist at the present time —in particular gender, race, ethnic
and generational inequalities— make it impossible to uphold the right to development and health. They
also reproduce poverty levels, restrict the benefits of economic development, erode social cohesion and
put democratic processes at risk. The countries of the region must commit firmly to the imperatives of
equity and solidarity and must adopt synergetic measures to reduce unequal access to services. This
requires an expansion in the scope of social protection in health, improvements in the functioning of
institutions for the benefit of all, and respect for the cultural diversity of the different groups in society
(United Nations, 2005).
In 2003, on the occasion of the 25th anniversary of the Declaration of Alma-Ata and at the
request of its member countries, PAHO reviewed the values and principles which inspired the Declaration
to formulating strategic and programme-based guidelines on primary health care, and renewing health
systems with that development perspective. The resultant strategy was ratified by member states at the 46th
Directing Council of 2005 in the Declaration of Montevideo.
According to PAHO, the new coordination of primary health care (PHC) within health systems
involves “an overarching approach to the organization and operation of health systems that makes the right
to the highest attainable level of health its main goal, while maximizing equity and solidarity. A PHC-based
health system is composed of a core set of functional and structural elements that guarantee universal
coverage and access to services that are acceptable to the population and that are equity-enhancing. It
provides comprehensive, integrated, and appropriate care over time, emphasizes prevention and promotion,
and assures first contact care. Families and communities are its basis for planning and action. A PHC-based
health system requires a sound legal, institutional, and organizational foundation as well as adequate and
sustainable human, financial, and technological resources. It employs optimal management practices at
all levels to achieve quality, efficiency, and effectiveness and develops active mechanisms to maximize
individual and collective participation in health. A PHC-based health system develops intersectorial actions
to address other determinants of health and equity” (PAHO, 2007a).
The PAHO and its member states consider that a renewed strategy on primary health care is an
essential condition for achieving international development goals —such as those contained in the United
Nations Millennium Declaration— and addressing the fundamental determinants of health —such as those
defined by CSDH of the World Health Organization (WHO)— and to codify health as a human right.
Health systems must be able to respond to the challenges posed by the Millennium Development
Goals. Among other things, this requires implementing effective programmes in areas such as sexual
and reproductive health and the control of infectious diseases, while also developing health and systems
services that are essential to ensure that those programmes and related interventions benefit all citizens
(PAHO, 2004). In the pursuit of equity, attention also needs to be given to the areas of management, finance,
insurance and service provision (PAHO, 2002). Under equity criteria, the basic level of primary health care
should be expanded by integrating vertical approaches and strengthening inter-sectoral collaboration and
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social participation on health issues (PAHO, 2003). Box VII.1 summarizes several ongoing key primary
health-care initiatives. Additional investments in public health programmes are needed, by combining
a larger volume and more effective use of fiscal resources, an increase in social contributions, or both.
To address the determinants of health as a multidimensional phenomenon, such programmes should also
promote inter-sectoral and inter-agency policies.
Box VII.1
PROGRAMMES TO IMPROVE MATERNAL AND CHILD HEALTH CARE IN THE REGION
Programmes to deal with acute respiratory infections, using the short-stay hospitalization strategy
These programmes aim to reduce complications arising from respiratory infections and related mortality
among the under-fives, through prevention measures, timely care and monitoring. Within this framework, countries
such as Chile and Argentina have implemented the short-stay hospitalization strategy, which improves the care
quality of the services provided, increases capacity for resolving cases at the primary care level and reduces
hospitalization.
Mass deparasitization programmes
Intestinal parasitoses caused by geohelminths are considered a global public health problem in childhood,
which increases anaemia and malnutrition. Parasites are transmitted by ingestion of earth contaminated with human
faecal material carrying eggs or larvae. Through mass treatment of the population with appropriate medication
and health education to promote environmental sanitation measures, Argentina implemented the National Mass
Deparasitization Programme in areas containing urbanizations without basic health services, to sustainably reduce
the prevalence of this parasitosis among the 2-14 year-old population.
Reproductive health programmes
Mexico, Peru, Cuba, Chile, Uruguay and Argentina, among other countries, have implemented specific
programmes to improve universal access to reproductive health services and responsible parenthood, and to reduce
undesired pregnancies and sexually transmitted infections. In Argentina, contraceptive methods are provided cost
free on demand through health services in the public subsector, while social security covers 100% of costs under
the Obligatory Medical Programme (PMO).
Programmes to reduce vertical HIV transmission
In Argentina, Brazil, Uruguay and other countries, the detection of HIV in pregnant women is strengthened
through timely treatment and protection measures during pregnancy and childbirth, to avoid contagion of the virus
in newborn babies, including provision or coverage of medications by the State. The scope of these programmes
depends greatly on the type of coverage and quality of care during pregnancy.
Comprehensive care programmes for expectant mothers and children in their first few years of life
This includes programmes such as Nacer Argentina and Chile crece contigo, each with its own characteristics,
which aim to provide comprehensive care for the health of pregnant women and young children.
Source: United Nations Children’s Fund (UNICEF), on the basis of information from the relevant countries.
Nonetheless, the comprehensive nature of the policies should not dilute the crucial role played
by health systems, strictly defined, in reducing the major disparities in access to the relevant services. For
those purposes, the segmented nature of these systems —which reflects discrimination patterns prevailing
in their societies and poses a major obstacle to achieving the Millennium Development Goals— needs to
be overcome (PAHO/WHO/SIDA, 2003, p. 98). Moreover, their fragmentation complicates cost-effective
interventions and efficient resource use including adequate referral and counter-referral mechanisms. People
who are not affiliated to contributory systems, lack payment capacity, or both, generally rely on services
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provided by the public sector as the only source of coverage; and, to a very small extent, on certain services
provided by non-profit organizations. To fulfil the Millennium targets public policies need to focus on this
population group in particular.
Among other aspects, fragmentation reflects relations between the contributory and non-contributory
financing of health services, i.e., between the social security and public systems, whose logic varies from
country to country, as shown in table VII.1.
Table VII.1
LATIN AMERICA AND THE CARIBBEAN: INTERACTION BETWEEN PUBLIC FUNDING
AND SOCIAL SECURITY CONTRIBUTIONS IN THE HEALTH SECTOR
Type 1
Type 2
Type 3
Financing: general revenues, integrated
systems based on non-contributory
financing
Financing: integration of general revenues
and social security contributions
Financing: little or no integration
of general revenues and social
security contributions
Services delivery by public and private
providers is heterogeneous
In all cases there is some degree of explicit
separation of the financing and service
delivery functions. The level of financing
integration also varies
The structure of public services is
heterogeneous. Different types
of linkages exist between the
public and private sectors
Public and private service provision:
Bahamas, Barbados, Belize, Brazil,
Dominica, Grenade, Guyana, Haiti,a
Jamaica, Saint Kitts and Nevis, Saint
Vincent and the Grenadines, Suriname,
Trinidad and Tobago, Venezuela (Bolivarian
Republic of) b
Type 2A: Integrated, maintaining
contributory financing and uniform services
coverage delivered via social security:
Costa Rica
Argentina, Bolivia, Ecuador, El
Salvador, Guatemala, Honduras,
Mexico, Nicaragua, Panama,
Paraguay, Peru, Uruguay
Service provision through the public system
only: Cuba
Type 2B: Integrated, with coverage
differentiated by contributory and noncontributory financing: Antigua and
Barbuda,c Colombia, Dominican Republic
Type 2C: Dual model with partial
integration: Chile
Source: Economic Commission for Latin America and the Caribbean (ECLAC), Shaping the Future of Social Protection: Financing, Access and
Solidarity (LC/G.2294 (SES.31/3)), Santiago, Chile, 2006.
Note: In all countries, except Cuba, there is also a private subsector that provides health services.
In Haiti there is practically no social security, and the provision and financing of health services are undertaken basically by the public
sector and non-governmental organizations (NGOs).
b
The reforms of the last few years have fostered greater participation and coverage in the public system.
c
Health reforms both in Antigua and Barbuda and in the Dominican Republic are in transition towards a greater integration of financing.
a
Given the magnitude and composition of health expenditure in the various countries and its
distribution among the population, both of which were analysed in the previous chapter and alluded to in
the discussion of household out-of-pocket expenses, current expenditure and investments on health need
to be increased and made more redistributive. Synergy needs to be found with public policies affecting the
determinants of health in domains such as nutrition or adequate access to basic infrastructure. Several basic
approaches in the case of nutrition programmes have already been summarized in this document.
The various health-sector reform strategies that have been applied in the region, over the last two
decades at least, reflect each country’s heterogeneity and different starting point. The specifics of each
health system and its institutional setting thus generate different constraints and priorities that need to
be taken into account in the reform process. Nonetheless, beyond national characteristics, the design and
execution of all health-sector reforms, along with public policies for social protection in this domain, need
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to take into account several criteria. Firstly, the growing importance of nontransmissible diseases, along
with population ageing, raise the need to find ways to cover more expensive and complex pathologies.
Secondly, social exclusion and inequity in health services call for policies and instruments to move
towards universal coverages. Thirdly, the technological changes that affect the health sector, together
with steadily rising costs and projected growth in demand and funding requirements make efficiency
improvements and cost containment key elements of health reforms and policies (ECLAC, 2006;
PAHO, 2007a).
Strengthening and expanding health insurance will thus require integrated financing of systems
to achieve higher levels of solidarity. Insurance systems should avoid risk-based selection and move
towards assured equitable coverage. Secondly, efficiency needs to be improved by containing costs,
using suitable procurement mechanisms and regulation. Thirdly, effective expansion of health services to
cover the entire population requires public-health policies aimed, among other things, at expanding the
scope of primary health care and effective coordination of decentralised services, including compensation
for intra-regional differences. Although contributory and non-contributory health-care financing take
different forms and are interrelated in a variety of ways in Latin American and Caribbean countries,
greater integration between social security and the public system can increase their synergies and
thus have positive effects in terms of solidarity financing and equity. Furthermore, their articulation
can have a positive effect on efficiency by permitting a fuller utilization of installed capacity and
rationalization of resource use through the improved management and administration of those subsystems
(ECLAC, 2006).
Nonetheless, tax revenues are scarce in most countries of the region, and funds obtained from
social security contributions are a major funding source for health services. The primary goal, therefore,
is to achieve an equitable health system funded on a solidarity basis. To reduce the inequities that tend
to be associated with segmented schemes and delink access to adequate services from health risks and
individual payment capacity, it is essential to move towards an integration of the public health systems
and social security. Priority should be given to a clearly defined set of explicit and guaranteed universal
services, which would grow in line with each country’s financing possibilities. Policies for expanding
primary health care and adequately coordinating decentralised services should aim at enhancing healthservice coverage and access (ECLAC, 2006).
Further consideration should be given to the extent to which health reforms can contribute to
attaining the Millennium Development Goals in the health area. Clearly, this can only be done in a
tentative fashion because, firstly, there is little analysis and information on the health effects of reform
processes and, secondly, methodological difficulties make it hard to attribute a net health outcome to
specific interventions, clearly separating this from other aspects involved which also have significant
repercussions and depend on social determinants (Acuña, 2008, p. 126). This context makes it possible to
understand a number of paradoxes, such as the fact that in Chile infant mortality indicators have improved
and are outstanding in the region, but other specific inequalities persist and have even worsened, such
as the differential infant mortality rate depending on the mother’s level of schooling (Ministry of Health
of Chile, 2006).
Among the key reform factors that could provide a favourable framework for achieving the
Millennium Development Goals, progress on universalizing health coverage needs to be considered. The
emblematic cases in the region are, firstly, Brazil, where a single health system has been set up using
fiscal resources and therefore is non-contributory. Secondly, Colombia took a major step forward through
a law introducing competition both in insurance and in service provision, and, learning from the Chilean
experience, established a fund and other solidarity financing mechanisms to support two regimes: one
contributory and the other subsidised.
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At the other extreme are the most backward countries in terms of health system development,
e.g. Peru, Bolivia and several Central American countries, which have focused on removing access
barriers to services for the uninsured, particularly for primary health care. The latter countries can claim
several achievements in the last few decades, such as the reduction in maternal mortality in Honduras
(Rodríguez, 2007).
There are also examples of progress on insurance and service provision through a modification
of current systems; in Chile a set of guaranteed services was introduced, some of which related to the
prevention of infant and maternal mortality. This is one of the most advanced experiences in the world,
precisely because it has established coverage guarantees, financial protection, timeliness and access,
specifying in much greater detail than in other parts of the world the scope, obligations, subjects with these
rights and guaranteed or protection mechanisms, and also because the range of services include some highcost procedures. Meanwhile, the Popular Health Insurance scheme in Mexico includes funding guarantees
without changing the segmentation of the insurance, while adding internal resources channelled in a highly
complex way. It involves institutional amendments aimed at strengthening public health centres, and
changes the public-private mix by allowing participation of a larger number of private suppliers. One of its
challenges will be to regulate the quality of services provided, specifically in view of that mix and the great
complexity of the financing system (Sojo, 2006).
Unfortunately, as noted by PAHO, public health has sometimes been neglected in the reform
processes implemented by the various countries. This is important in relation to the Millennium Goals
because, as already analyzed, several of the health measures included depend specifically on public health,
especially at the primary care level (PAHO, 2000).
For example, experience shows that in reforms involving a separation of functions or a change in
the attributions of health organisations, the responsibilities and resources assigned to inmunization schemes
need to be clearly defined. PAHO detected early on that immunisation coverage in Colombia had deteriorated
since 1997, particularly in departments where living conditions are poorer and in rural areas, a trend that
has been confirmed in several later studies. The most recent research shows that national coverage rates
for certain inoculations have been restored since 2001. The deterioration has been blamed on the combined
effect of the decentralisation process and application of the 1993 health reform. In this regard, Glassman
(cited by Flórez and others, 2007) states that “despite the benefits of the reform, its implementation and
the decentralisation process have revealed gaps and/or duplications in jurisdictions between the different
agents, with negative repercussions on service provision and coverage levels.” The Colombian State took
steps to increase inmunization coverage by regulating processes and defining responsibilities. A recent
study by Flórez and others (2007) confirms the deterioration and subsequent recovery of the coverage of
full immunisation schemes, which slipped from 77.9% in 1990 to 71% in 1995 and 66% in 2000. In 2005
the rate rose to above 70%, but it has not yet recovered the levels achieved 15 years ago (78%). In spite of
the persistence of inequities in rural areas and among the poorest groups, the broader coverage achieved in
the last five years has been accompanied by greater regional equity. In other words, while the changes may
have not been complete, they have already had some positive effects.
From another point of view, to prevent out-of-pocket expenses precluding access to necessary
health services, the coverage effectively provided needs to be improved and universalized, working both
to expand insurance systems for universal and mandatory coverage and to strengthen the public health
system. This concern is echoed in the Iquique Consensus approved at the IX Ibero-American Conference
of Health Ministers held in Iquique in July 2007. This argued that social exclusion was clearly reflected in
the lack of access to medicines and strategic inputs among wide ranging population groups; and, secondly,
the increase in their prices makes it hard for Governments to guarantee access to these goods, and entails
greater direct expense for individuals. Hence, the resolution rejects measures and actions of any nature,
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origin, or both, that obstruct the population’s access to medicines and foods that are essential for saving
lives and preserving health, particularly among children and adolescents.
In chapter V, it was noted that higher out-of-pocket expenses affect insured population groups, such
as in Argentina, as well as households with very low levels of insurance, such as in Honduras; and both
involve serious consequences for the structure of family expenditure. On the other hand, a large number of
people in the region are not in a position to afford health services, even when they need them, because of
their low incomes. To improve equity, it is essential to promote policies aimed at reducing the burden of
out-of-pocket expenses and providing broader coverage. Several strategies in the region have attempted to
do this. Some are indirect and tend to reduce expenditure through preventive means, whereas direct policies
aim to reduce the level of expenditure after the fact. In this regard, measures involved in the primary care
strategy need to be consolidated, giving them an inter-sectoral and comprehensive orientation with regard
to the determinants of health. Their effects are seen in terms of major progress on universalisation of
immunisation to the point where certain diseases have been eradicated. Examples of programmes in the
region which aim to strengthen the strategy, include the Community Doctors programme in Argentina,
the Family Health programme in Brazil, and the Neighbourhood Mission in the Bolivarian Republic of
Venezuela. Secondly, there are also policies to enhance expenditure efficiency by curtailing costs. An
example is the prescription of generic medicines in countries such as Argentina and Brazil, which has made
it possible to reduce out-of-pocket expenses on medicines by giving patients the chance to choose on the
basis of pharmacy prices and thus counteract the interference exerted in this area by the medications industry
through permanent publicity and pressure on doctors to prescribe certain commercial brands. In Costa
Rica, social security has traditionally used generic products and has made high-volume purchases that have
helped to lower the cost of medications. The Remediar Plan in Argentina, which consists of centralising
Health Ministry procurements and subsequently distributing them to public primary-care institutions, has
made it possible to provide essential medicines to cover outpatient pathologies cost free to population
groups not covered by social schemes, and to expand access to treatment for the poorest individuals. In
Chile, one of the goals of the System of Universal Access with Explicit Guarantees (AUGE) is to reduce
expenditure on catastrophic diseases in households affiliated to the two insurance subsystems, by regulating
adverse selection while guaranteeing coverage.
The situation in Latin America and the Caribbean in terms of health needs and deprivations is highly
diverse and, in some cases, worrying. Whereas, at the aggregate level, the region is rapidly catching up the
developed countries in terms of the growing incidence of nontransmissible diseases, there are still many
diseases characteristic of a lower development level, such as transmissible and maternal-infant diseases.
This epidemiological lag is more accentuated among lower-income countries which display more glaring
inequalities in health, and pose a twin challenge for the relevant systems. Although it is essential to increase
investment in public health and make the service more effective in reducing the high levels of transmissible
and maternal-infant diseases, the growing importance of non-transmissible diseases imposes a high cost
even if resources are used efficiently, which gives rise to competition on resource allocation. Owing to
population ageing, the burden of nontransmissible diseases will rise unceasingly through time, so there is
likely to be increasing demand for more expensive health services. The need to bridge the epidemiological
gap, demographic transition processes, and progress on coverage, is raising pressure for increased funding.
Hence, any health policy should attempt to make coverage expansion and equal access compatible with cost
reduction and efficient resource allocation (ECLAC, 2006).
The need to change the allocation, distribution, and training of human resources, increase the
magnitude of public expenditure and review its allocation, and alter the geographic distribution of the
health services and infrastructure network, has been recognized (United Nations, 2005). In 2006, the WHO
analysed a variety of health outcomes in terms of the Millennium Development Goals, according to the
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availability of health-specialized human resources (WHO, 2006). The conclusion clearly shows the positive
repercussions on the health status of populations that have a supply of human resources, particularly in
terms of maternal-infant mortality. To guarantee a minimum coverage level for basic interventions, this
report proposed a density of human resources for health —which include doctors, nurses, and midwives—
of between 20 and 25 per 10,000 inhabitants. Although this figure is not specific, it represents a benchmark
for measuring the relative magnitude of current deficiencies. For its part, the relation between human
resources in health and the health situation is mediated by the organization of health services and by the
optimal combination of aptitudes and personnel in a given context (Macinko and others, 2006). Box VII.2
describes recent agreements on this subject.
Box VII.2
FIVE CRITICAL CHALLENGES AND 20 REGIONAL GOALS ON HUMAN RESOURCES FOR
HEALTH TO ACHIEVE THE MILLENNIUM DEVELOPMENT GOALS ON HEALTH, AGREED
UPON BY THE 27th PAN-AMERICAN HEALTH CONFERENCE HELD IN OCTOBER 2007
Challenge 1: Define long-range policies and plans to better adapt the workforce so it will be prepared
to meet expected changes in the health systems and to better develop the institutional
capacity for defining these policies and revising them periodically:
Goals
(1) All countries of the region will have achieved a human resources density ratio level of 25
per 10,000.
(2) The regional and subregional proportions of primary health care physicians will exceed 40%
of the total medical workforce.
(3) All countries will have developed primary health care teams with a broad range of competencies
that will systematically include community health workers to improve access, reach out to
vulnerable groups, and mobilize community networks.
(4) The ratio of qualified nurses to physicians will reach at least 1:1 in all countries of the region.
(5) All countries of the region will have established a unit of human resources for health responsible
for the development of human resources policies and plans, the definition of strategic directions
and the negotiation with other sectors, levels of government, and stakeholders.
Challenge 2: Place the right people in the right places by deploying the appropriate personnel into the
right positions and into the most suitable areas of the countries:
Goals
(6) The gap in the distribution of health personnel between urban and rural areas will have been
reduced by half in 2015.
(7) At least 70% of the primary health care workers will have demonstrable public health and
intercultural competencies.
(8) 70% of nurses, nursing auxiliaries and health technicians including community health
workers, will have upgraded their skills and competencies appropriate to the complexities of
their functions.
(9) 30% of health workers in primary health care settings will have been recruited from their
own communities.
120
Box VII.2 (concluded)
Challenge 3: Promote national and international initiatives for developing countries to retain their
health workers and avoid personnel deficits:
Goals
(10) All countries of the region will have adopted a global code of practice or developed ethical
norms on the international recruitment of health care workers.
(11) All countries of the region will have a policy regarding self-sufficiency to meet its needs in
human resources for health.
(12) All subregions will have developed mechanisms for the recognition of foreign-trained
professionals.
Challenge 4:Generate labour relationships between the workers and the health organizations that
promote healthy work environments and foster commitment to the institutional mission
to guarantee quality health services for all the population:
Goals
(13) The proportion of precarious, unprotected employment for health service providers will have
been reduced by half in all countries.
(14) 80% of the countries of the region will have in place a policy of health and safety for health
workers, including the support of programmes to reduce work-related diseases and injuries.
(15) At least 60% of health services and programme managers will fulfil specific requirements for
public health and management competencies, including ethics.
(16) 100% of the countries of the region will have in place effective negotiation mechanisms
and legislation to prevent, mitigate or resolve labour conflicts and ensure essential services
if they happen.
Challenge 5:Develop mechanisms of cooperation between training institutions (universities and
schools) and health service institutions so that it is possible to adapt the education of
health workers to a universal and equitable model of providing quality care to meet the
health needs of the entire population:
Goals
(17) 80% of schools of clinical health sciences will have reoriented their education towards primary
health care and community health needs and adopted inter-professional training strategies.
(18) 80% of schools of clinical health sciences will have adopted specific programmes to recruit
and train students from underserved populations with, when appropriate, a special emphasis on
indigenous, or first nation, communities.
(19) Attrition rates in schools of nursing and medicine will not exceed 20%.
(20) 70% of schools of clinical health sciences and public health will be accredited by a recognized
accreditation body.
Source: Pan American Health Organization (PAHO), “La renovación de la atención primaria de la salud en las Américas”, Washington,
D.C., 2007.
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Argentina, Bolivia, Ecuador, Mexico and Peru, have started to structure a maternal-child insurance policy
as part of the services provided by public health insurance schemes. This reflects a strategy for targeting social
programmes on overcoming the country’s alarming levels of inequality. Although this type of insurance is focused
on services for women and children, these are limited insofar as they are essentially concerned with maternity and
ignore other basic components of sexual and reproductive health such as prevention of cancer, violence, fertility,
and differentiated care for adolescents of both sexes. The experiences of Bolivia, Chile, Cuba and Honduras
demonstrate the possibility of significantly reducing maternal mortality, and were adequately documented in the
first interagency review of the Millennium Development Goals (United Nations, 2005, p. 167).
The progress made shows the importance of including these issues on the government agenda for
achieving the Millennium Development Goals on health, which also benefits from the close relationship that
exists between the goals themselves, e.g. the link between women’s health and education and infant mortality.
This sheds some light on the synergies that could be achieved between health programmes that historically have
arisen independently and which operate separately, e.g. tuberculosis, HIV/AIDS, malaria and reproductive and
maternal-infant health programmes. In this regard, the exercise of reproductive rights needs to be combined with
professional obstetric care, professional care at childbirth, and the prevention and cure of certain diseases.
Without wishing to exempt public health systems from responsibilities relating to insurance, financing
and service provision, guided by principles of universality and solidarity, the positive effects of certain civil
society initiatives should also be recognized. Examples include experiences aimed at reducing infant and maternal
mortality, as documented in box VII.3.
Box VII.3
COMMUNITY INITIATIVES THAT HAVE HAD AN INFLUENCE ON REDUCING INFANT AND
MATERNAL MORTALITY
The contest entitled “Experiences in social innovation in Latin America and the Caribbean”, organized by ECLAC
with support from the W.K. Kellogg Foundation, identifies innovative social development initiatives that put
forward ideas to improve health, education, nutrition, the environment, income-generating capacity, gender equity
and enterprise social responsibility, among other areas. The aim is to disseminate these initiatives to help improve
practices and policies for the benefit of the poorest population groups. The 2006-2007 cycle recorded a total of 806
innovative community initiatives from 20 Latin American and Caribbean countries, a figure that demonstrates the
interest aroused by the programme in the region. One in every six of them aimed at improving the population’s
health. Two award-winning projects on maternal and infant health are outlined below.
(1) The Four-Leaf Clover - Strategy to Reduce Maternal, Pre-Natal and Infant Morbidity and Mortality
Rates (Brazil), winner of the first prize in the 2006-2007 contest
“Four-leaf Clover” is the name given to the strategy developed by the Secretary of Health and Social Action
in Sobral, Ceará, Brazil, designed to reduce infant-maternal morbidity and mortality rates. The strategy is organized
to provide medical attention to expectant mothers on four fronts or areas: pre-natal, labour, postpartum and neonatal. These represent each of the four leaves of the clover.
The Four-Leaf Clover team is responsible for organizing the Committee for the Prevention of Maternal,
Perinatal and Infant Mortality, acting as an interagency network, with participation from teaching institutions
and municipal councils on health, the rights of the child and adolescents, and women’s rights. The Committee
investigates all maternal, foetal and infant deaths, to identify and analyse their determining factors. Deaths are
classified in terms of the factors that could have been avoided, with a view to proposing intervention measures to
improve the quality of maternal-infant care.
Maternal-infant care indicators are permanently monitored by evaluating information contained in the
Mother-Child Health booklet and interviews with mothers who have recently given birth in maternity hospitals.
High-risk cases that need monitoring by the Four-Leaf Clover scheme are also identified. The Four-Leaf Clove
team includes a group of “social mothers” who makes home visits to expectant mothers reluctant to go to a medical
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Box VII.3 (concluded)
centre for pre-natal care. During these visits, social mothers elaborate a basic care plan, not only for pregnant
women but also for postpartum women and for children at risk (health or social risk). This plan is elaborated by the
assigned family health team and family members.
Participation by “social mothers” is crucial for the success of the strategy. These are women from the same
community whose function is to support mothers or children at risk who do not have family support. For this purpose
they receive training as caregivers in homes or in hospital, aimed at promoting health, preventing complications
and premature deliveries, support for breast-feeding, strengthening of self-esteem and family links, as well as
improving personal care, maternity and paternity. Community participation, through a monthly contribution as
“social godparents” to support women and children at risk, makes it possible to provide social support to these
families. In addition, it highlights the actions of “social coordinators”, who are volunteers participating in permanent
actions of dissemination, social events and fund raising. In 2006, the project served 1,148 families at a cost of
US$ 175 per year each. Since its inception in 2001, it has succeeded in increasing the rate of prenatal care and
lowering the infant mortality rate in the locality from 29.7 to 16.2 per thousand live births in 2006.
(2) The Lèt Agogo (Milk in abundance) programme - Haiti, winner of the first prize in the
2004-2005 contest
Lèt Agogo is a programme to support and develop household milk production in Haiti, an initiative of
the Haitian non-governmental organization Veterimed, which aims to help improve living conditions among
campesinos by providing technical support for their family units. Initially, Veterimed received external financial
support (Oxfam, CORDAID, VSF) to organize the first experimental unit; and at the present time products are made
in 10 small units distributed throughout the country. The other nine milk producers began with internally-generated
funds from community groups and campesino associations. The project organizes small-scale milk producers to
improve production conditions and income, and is based on a participatory diagnostic system which results in the
creation of micro units for milk processing, and the creation of a producers association. Alongside this, they manage
to legalize land ownership, working in conjunction with government institutions. They have also developed fodder
production techniques and new livestock management schemes to improve water access.
All the dairy producers in the national network operate under supervision and advice from Veterimed, which
is owner of the “Lèt Agogo” brand. The persons responsible have received training from the entity and there are
now roughly 500 campesinos organized in associations supplying the different dairies in the network. Over the
last 10 years, training has been provided to over 1,000 campesino veterinary agents. These have set up the Entévét
network and, since 1999, most have received official recognition from the Ministry of Agriculture to provide
immunization on farms. Technical services are strengthened at each dairy and health programmes are established.
Haiti imports over US$ 40 million of dairy products per year, which makes milk its second-largest food
import. National output accounts for under 30% of consumption, and most commercial units in the domestic market
have closed in the last decade. Thus, the Lèt Agogo project makes a significant contribution to the country’s food and
nutritional security because its units are practically the only firms that process and enhance locally produced milk.
This initiative, which has made it possible for small-scale dairy producers to improve their production conditions,
marketing and incomes, gained first prize in the contest.
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of Bank of Experiences [online]
http://www.cepal.org/dds/innovacionsocial/e/proyectos.
In general, the region has improved the quality of policies, programmes and standards on sexual
and reproductive health based on the concept of reproductive rights within human rights, on social and
gender equity, and on the empowerment of women and adolescents. National programmes of adolescent
health have been developed, and special units created to provide care in suitable establishments, together
with the provision of promotion, prevention and treatment services which emphasize sexual health; and
activities are undertaken that explicitly aim at preventing unplanned pregnancy and providing services
for adolescent mothers. At the same time, human resource training has been strengthened in terms of care
123
practices, improvement of the quality of health services, supply of contraceptives to adolescents, among
other initiatives through workshops that inform groups of young people about their reproductive and health
rights. Nonetheless, it should be repeated that despite these multiple activities, greater political support is
needed to ensure that reform processes in the health sector give priority to activities related to the sexual and
reproductive rights and health of adolescents, given that it would be impossible to achieve the Millennium
Development Goals on maternal health without investing resources and adopting effective measures
targeting adolescents and young people (United Nations, 2005).
The relevance of the Millennium Development Goals has been widely recognized. The Iquique
Consensus adopted by the Ninth Ibero-American Conference of Health Ministers, held in July 2007 in
Iquique, Chile, stressed their importance for policies that promote social cohesion from the health standpoint,
with a rights-based, multisector and intercultural perspective. This distinguishes health determinants,
including aspects of gender and ethnicity, and recognizes, for these purposes, the principles and strategies
of primary health care as a key element in successfully increasing social protection in this domain.
Nonetheless, the commitment assumed by governments in relation to the Millennium Development
Goals in the region remains a challenge because there are few circumstances in which they have been fully
integrated into their policies. This report notes the need to strengthen political will, not only at the national
level, but also in the subregional and regional domains, in order to prioritize the public health agenda;
this is vital for future progress. It is important to avoid complacency when individual targets for certain
Millennium Development Goal indicators are attained because these indicators must be viewed within
an interrelated context. For example, a given threshold for professional attendance at childbirth does not
guarantee a reduction in maternal mortality, since this also depends on the effectiveness and quality of care
provided by health services and other socio-economic and environmental factors.
In conclusion, it is worth stressing that the right to health entails strengthening democratic
governance in a framework of social cohesion and human rights, based on the principle that no citizen
should be excluded from the benefits of development or deprived of the right to health. Only in this way
will it be possible for our region to achieve the universal aim expressed by the Millennium Development
Goals on health.
125
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