Latin American Health Systems Face Toughest Test

Underspending

Low levels of health spending and a relative scarcity of hospital beds are indicators that most countries in the region do not guarantee universal access to healthcare and risk being overwhelmed by the wave of the new coronavirus. The Latin American average for health spending is less than 4% of gross domestic product (GDP), compared to 8% in Europe. Moreover, just half of the Latin American figure comes from the central government with the rest made up from private contributions or NGOs. Out-of-pocket spending, the amount people spend directly on a service, is low in Cuba, Costa Rica or Uruguay, where it ranges from 10% to 20% and very high in others such as Venezuela, Guatemala or the Dominican Republic, where it is between 45% to 65%. These out-of-pocket payments by individuals illustrate the inadequacy of public health provision, as well as of social security or private insurance, and the fact that the poor are the most vulnerable because they sometimes refrain from seeking care that they cannot afford.

"Bolivia, Guatemala, Haiti, Honduras, Nicaragua and Venezuela are the Latin American countries most at risk…"

Approximately 30% of the 630 million people in Latin America and the Caribbean do not have regular access to health services, mainly due to geographic or income issues, according to the Pan-American Health Organisation (PAHO), an affiliate of the World Health Organisation (WHO). That figure is in line with the proportion of people living in poverty, according to the Economic Commission for Latin America and the Caribbean (ECLAC), which counts 185 million poor people in the region, and reports that over 10% of the total regional population, 68 million people, live in extreme poverty.

In 2014, the region’s governments committed to raising health spending to at least 6% of GDP, but only Cuba on 10.6%, Costa Rica on 6.8% and Uruguay on 6.1% have met that goal. On average Latin American countries spend around $1,000 per person. Argentina, Chile, Cuba and Uruguay are the most generous, spending around $2,000 per person, but Haiti, Honduras and Venezuela spend less than $400. If the Covid-19 pandemic continues to spread in the region, Bolivia, Guatemala, Haiti, Honduras, Nicaragua, Paraguay and Venezuela are “the Latin American countries most at risk,” according to PAHO. Interestingly Paraguay has held up very well with one of the best Latin American responses to coronavirus.

We compare four Latin American health services to see how they will cope.

Brazil – strong health system undermined by inequality

Over the last three decades, the largest country in the region, with a population of 211 million, has developed a unique public health system, with programmes such as Mais Médicos, Farmácia Brasil Poupa Lar and Estratégia Saúde da Família. The latter is a strategy enabling a team of doctors, nurses and assistants to care for up to 3,000 people at a local level.

The social gap is widening, since public health, with 44% of the hospital beds, must serve 75% of the population, while private clinics have more than half of the beds for 25% of the inhabitants. In 2009, Brazil had 18.7 beds per 10,000 inhabitants, which dropped to 17.2 in 2017, half of them in four of its 27 states, in the wealthier southeast. It has 47,000 intensive care beds, but for every one in the public health system – 90% of which are occupied – there are 4.6 in the private health sector.

"Brazil is not prepared to face the coronavirus epidemic, not so much because of a lack of resources, but due to their poor distribution, the high level of inequality in terms of access to services, poor management and lack of equity,” says epidemiologist Eduardo Costa, an international cooperation advisor at the National School of Public Health. Brazil’s success against coronavirus will depend on its ability to realign those resources – with private beds perhaps going to public patients.

Cuba - exporting health

The Cuban health system, touted by the socialist government as one of the achievements of the revolution, is public and free of charge for the country’s population of 11.2 million, with 90 doctors for every 10,000 inhabitants, according to official figures. Although there are no precise figures on how many of its 45,000 beds are for intensive care – and there are complaints from the public about delays for non-urgent surgical procedures – Health Minister José Ángel Portal said the island nation has 274 beds to treat seriously ill coronavirus patients and plans to add another 200.

One of Cuba’s flagship programmes is the international medical cooperation missions, which began in 1963 and have sent 407,000 doctors, technicians and assistants to 164 countries. The annual income from this programme – 29,000 doctors worked in 65 countries in 2019 – was more than $6billion last year. This is a tool for increasing soft-power and earning hard currency. The coronavirus crisis may even allow Cuba to increase its reach. It is creating 14 medical brigades with 600 members to offer international health services.

Chile - well prepared

In Chile, a country of 18.7 million people, health coverage is public for 14 million and private for three million, and there is a separate system for the 400,000 members of the armed forces. All workers are required to contribute 7% of their wages to the health institution of their choice. Those who are covered by the public health system complain about long waits of weeks or months to see a doctor and of up to a year or even more for surgery. These were some of the shortcomings that fuelled the mass protests that broke out in Chile in October 2019.

Chile has 22 hospital beds for every 10,000 inhabitants. That is a total of about 32,000, with 3,300 for emergencies, which the government aims to increase to 5,200 in the face of the pandemic. Nelly Alvarado, a professor at the Diego Portales University and a public health specialist, told IPS that “the health system’s capacity is never going to be enough in the face of an unexpected situation coming from the rest of the world.” However, so far Chile’s response is one of the best in the region, with the most testing per capita and a sophisticated partial lockdown strategy.

Venezuela - on the verge of collapse

Official health statistics became unavailable in Venezuela over the past decade. But studies by non-governmental organisations warn that the health care system is on the verge of collapse and that the country is experiencing a “complex humanitarian emergency.” The health crisis is part of the general collapse of basic services that has accompanied the economic recession over the past five years and hyperinflation over the past three years, driving the exodus of almost five million of Venezuela’s 32 million inhabitants. Among those who have emigrated were more than 22,000 doctors, according to the medical association.

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Venezuela is at the bottom of the regional charts in terms of health spending and the provision of hospital beds. The NGO Doctors for Health reports that during 2019, 63% of the large hospitals it monitors saw extended power cuts, while 78% went without water. Barrio Adentro, a programme launched in 2003 that brought thousands of Cuban doctors to low-income areas, has almost disappeared and most of its premises have closed.

“We are at the bottom of a PAHO list of 33 countries in the hemisphere in terms of preparing for Covid-19,” Oletta said. “And the pandemic follows setbacks in vaccination campaigns and containment of preventable diseases that have re-emerged, such as malaria, measles and tuberculosis.”

Latin America, lagging behind in health care and spending, should heed the call of Maria Neira, WHO Director for the Department of Public Health, Environmental and Social Determinants of Health: “Something we have all forgotten is that investment in public health and health systems should not be regretted…it is always going to be a profitable investment.”

This article was published in partnership with the Inter Press Service News Agency