Patricia Frenz

Health-system reform and universal health coverage in Latin America

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens--with defined and enlarged benefits packages--and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

Overcoming social segregation in health care in Latin America

Latin America continues to segregate different social groups into separate health-system segments, including two separate public sector blocks: a well resourced social security for salaried workers and their families and a Ministry of Health serving poor and vulnerable people with low standards of quality and needing a frequently impoverishing payment at point of service. This segregation shows Latin Americas longstanding economic and social inequality, cemented by an economic framework that predicted that economic growth would lead to rapid formalisation of the economy. Today, the institutional setup that organises the social segregation in health care is perceived, despite improved life expectancy and other advances, as a barrier to fulfilling the right to health, embodied in the legislation of many Latin American countries. This Series paper outlines four phases in the history of Latin American countries that explain the roots of segmentation in health care and describe three paths taken by countries seeking to overcome it: unification of the funds used to finance both social security and Ministry of Health services (one public payer); free choice of provider or insurer; and expansion of services to poor people and the non-salaried population by making explicit the health-care benefits to which all citizens are entitled.

Veratridine-induced release of endogenous glutamate from rat brain cortex slices: a reappraisal of the role of calcium.

The efflux of endogenous glutamate from thin slices of rat brain cortex superfused in vitro with artificial cerebrospinal fluid (ACSF) was studied. Initially, glutamate efflux was very high (2.5 nmol/mg protein/min), possibly because of the cutting procedure, but declined sharply, and at 30 min of superfusion was 25 pmol/mg protein/min. In ACSF without added calcium, spontaneous glutamate efflux was always higher than that in calcium-containing medium, e.g. at 30 min it was 75 pmol/mg protein/min. Addition of 10 microM veratridine for 2 min, between 30 and 32 min of superfusion, led, in ACSF with calcium, to an increase in glutamate efflux of 288%, when the maximum efflux following veratridine is compared to the glutamate efflux that immediately preceded the application of this drug (from 25 to 97 pmol/mg protein/min), while in ACSF without added calcium, veratridine induced an increase of only 117% (from 75 to 163 pmol/mg protein/min). These results are interpreted as due to the dual effect of veratridine. In calcium-containing ACSF, veratridine increases sodium influx which depolarizes the neurons and opens voltage-sensitive calcium channels. The increased intraneuronal calcium induces glutamate release from synaptic vesicles, while increased intracellular sodium enhances the release of soluble cytoplasmic glutamate by the reverse operation of the plasma membrane, sodium-dependent glutamate carrier. In ACSF without calcium, the release of vesicular glutamate is suppressed, while the sodium-dependent mechanism remains. This appears as if veratridine-induced glutamate efflux were only partially calcium-dependent.

Assessment of universal health coverage for adults aged 50 years or older with chronic illness in six middle-income countries.

Abstract Objective To assess universal health coverage for adults aged 50 years or older with chronic illness in China, Ghana, India, Mexico, the Russian Federation and South Africa. Methods We obtained data on 16 631 participants aged 50 years or older who had at least one diagnosed chronic condition from the World Health Organization Study on Global Ageing and Adult Health. Access to basic chronic care and financial hardship were assessed and the influence of health insurance and rural or urban residence was determined by logistic regression analysis. Findings The weighted proportion of participants with access to basic chronic care ranged from 20.6% in Mexico to 47.6% in South Africa. Access rates were unequally distributed and disadvantaged poor people, except in South Africa where primary health care is free to all. Rural residence did not affect access. The proportion with catastrophic out-of-pocket expenditure for the last outpatient visit ranged from 14.5% in China to 54.8% in Ghana. Financial hardship was more common among the poor in most countries but affected all income groups. Health insurance generally increased access to care but gave insufficient protection against financial hardship. Conclusion No country provided access to basic chronic care for more than half of the participants with chronic illness. The poor were less likely to receive care and more likely to face financial hardship in most countries. However, inequity of access was not fully determined by the level of economic development or insurance coverage. Future health reforms should aim to improve service quality and increase democratic oversight of health care.

Aplicación de una aproximación metodológica simple para el análisis de las desigualdades: El caso de la mortalidad infantil en Chile

BACKGROUND the infant mortality gradient by maternal education is a good indicator of the health impact of the social inequalities that prevail in Chile. AIM to propose a systematic method of analysis, using simple epidemiological measures, for the comparison of differential health risks between social groups that change over time. MATERIAL AND METHODS data and statistics on births and infant deaths, obtained from the Ministry of Health, were used. Five strata of maternal schooling were defined and various measures were calculated to compare infant mortality, according to maternal education in the periods 1998-2001 and 2001-2003. RESULTS of particular interest is the distinction between a measure of effect, Relative Risk (RR), which indicates the size of the gap between socioeconomic extremes and the etiological strength of low maternal schooling on infant mortality, and a measure of global impact, the Population Attributable Risk (PAR%), which takes into account the whole socioeconomic distribution and permits comparisons over time independently of the variability in the proportions of the different social strata. The comparison of these measures in the two periods studied, reveals an increase in the infant mortality gap between maternal educational extremes measured by the RR, but a stabilization in the population impact of low maternal schooling. CONCLUSIONS these results can be explained by a decline in the proportion of mothers in the lowest educational level and an increase in the proportion in the highest group.

Universal health coverage for elderly people with non-communicable diseases in low-income and middle-income countries: a cross-sectional analysis

Abstract Background Population ageing and the growing burden of non-communicable diseases are crucial challenges for low-income and middle-income countries, especially because of their effects on the economy and on development and competitiveness indicators. In 2005, WHO urged countries to establish financing insurance mechanisms ensuring equitable universal health coverage. We assessed health coverage for elderly people with non-communicable diseases. Methods We did this cross-sectional analysis of people aged older than 50 years who had non-communicable diseases in six low-income and middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) from the WHO Study on global AGEing and adult health (SAGE) Wave1 (2007–10). We analysed individual and household data for 17 752 participants with regards to doctor visits, treatment, supervision, effectiveness of care, catastrophic health spending, and equitable distribution of health coverage across socioeconomic groups. We estimated weighted population means, and fitted logistic regression models and standardised concentration curves. Findings Effective coverage ranged from 20·7% (95% CI 15·2–27·5) of patients in Mexico to 48·2% (43·9–52·5) in South Africa. Insured patients were significantly more likely to have effective coverage than were uninsured patients in Ghana (odds ratio 1·8, 95% CI 1·4–2·5), India (3·1, 1·9–4·9), and Mexico (3·0, 1·7–5·3). The effect of social determinants on effective coverage varied across countries. Catastrophic health spending ranged from 8·1% (95% CI 5·9–11·2) in South Africa to 45·7% (42·0–49·4) in India, even among people with insurance. Pro-rich inequities existed for effective coverage (except in South Africa) and catastrophic health spending (except in Russia). Interpretation Health insurance is associated with health coverage in all the countries studied, but it is insufficient to ensure universal health coverage. Differences in effectiveness and equity within and between low-income and middle-income countries relate to the social circumstances in each country, which determine the challenges of achieving universal health coverage. Funding None.

A public-health campaign to raise awareness of children's wellbeing with images drawn by children

1that showed that, in 2000, 74% of children living in Chile were maltreated in their homes, the Metropolitan South Health Service called on the primary-care units in the municipalities of South Santiago under its control to develop a comprehensive programme of interventions, the objective of which was to strengthen family relationships and to lend support to families and children vulnerable to abuse. In response to the call for action, the health and education units of San Joaquin began work on a programme called Skills for Life. 2 Results of preliminary research done as part of the programme showed that one in every four children aged 6–9 years was affected in some way by violence—including family and peer violence— that interfered with their adaptation to the schoolroom setting or with the establishment of good family relationships. The Skills for Life intervention was designed to strengthen the school environment by making it conducive to learning and by protecting children’s mental health. As a starting point, and to trigger community awareness of violence against children, the Health Promotion Unit of the municipality undertook a campaign to promote the wellbeing of children.

Latin America: priorities for universal health coverage

www.thelancet.com Vol 385 April 4, 2015 e31 To achieve universal health coverage, a defi nition of what coverage everybody is guaranteed is needed. In view of the gap between what is medically possible and what is fi nancially feasible, some type of rationing is inevitable in all societies. So the decision is not about whether to prioritise, but how best to achieve this. However, this issue is often neglected or is an afterthought in the debate about universal health coverage. This situation arises because explicit priority setting is contentious, politically charged, and technically challenging, and it is rarely studied and poorly understood. Thus, lessons from Latin America are especially relevant. More than any other part of the world, countries in this region have introduced explicit priority setting to defi ne their health benefi t plans. Advocates argue that the results are potentially more eff ective, equitable, transparent, and effi cient than are implicit rationing practices, which include waiting lists, quality adjustments, or user fees. The fi rst lesson is that benefi t plans take diff erent shapes and sizes, and are not restricted to a list of essential services for societies with severe resource constraints. Giedion and colleagues highlight the heterogeneity of approaches used by Latin American countries to establish priorities and to design and deliver benefi t plans. The scope ranges from broad to narrow, in terms of types of technologies used, disease control priorities, and eligible populations. For example, Uruguay’s Plan Integral de Atención en Salud (PIAS) is comprehensive for everybody and provides integral universal care for health disorders throughout the life cycle, mainly at primary care level, and an extensive catalogue of more complex diagnostic and therapeutic services, independent of provider. Chile’s Acceso Universal con Garantías Explícitas (AUGE) plan includes legally enforceable entitlements to a comprehensive set of services for a prioritised group of diseases, but does not deny health care for other disorders, which remain subject to waiting lists. Thus, AUGE is comprehensive for some diseases. Colombia’s Plan Obligatorio de Salud Subsidiado (POSS) selects interventions across disease groups to establish a set of health-care services guaranteed by the state, which means that all people can receive a limited set of services. Other plans are designed for eligible subpopulations. The Mexican Seguro Popular benefi t plans for people outside the social security system prioritise catastrophic coverage for complex benefi ts (Fondo de Protección contra Gastos Catastrófi cos [FPGC]) coupled with groups of interventions in Catálogo Universal de Servicios Esenciales de Salud (CAUSES). Peru’s Plan Essential de Aseguramiento en Salud (PEAS) prioritises health disorders, but provides more limited essential health-care services for specifi c groups. Plan Nacer in Argentina and Paquete Básico de Salud (PBS) in Honduras focus on health care for poor mothers and children. All of these programmes are examples of coverage of specifi c population groups with some interventions, rather than universal plans. A second lesson relates to the large institutional capacities needed to defi ne and regularly update benefi t plans. Institutions fi nd fulfi lling their promise very resource intensive; sustained political and technical leadership backed by legal underpinnings are required. Good technical processes are a sine qua non, encompassing health needs assessment and appraisal of new technologies and intervention alternatives, and planning and service delivery organisation. Politically, balancing various, at times confl icting, interests is needed. Robust regulatory measures need to be in place to keep vested interests from serving narrow parochial interests of industry, specifi c groups, or organisations, and consequently distorting national health goals. For example, by law in Chile the defi nition of AUGE requires the use of epidemiological, burden of disease, and cost-eff ectiveness studies and must consider social preferences and feasibility. Mandatory consultative Latin America: priorities for universal health coverage

Seguimiento de cobertura sanitaria universal con equidad en Chile entre 2000 y 2011 usando las Encuestas CASEN

BACKGROUND The Chilean health reform aimed to expand universal health coverage (UHC) with equity. AIM To analyze progress in health system affiliation, attended health needs (health visit for a recent problem) and direct payment for services, between 2000 and 2011. MATERIAL AND METHODS We evaluated these outcomes for adults aged 20 years or older, analyzing databases of five National Socioeconomic Characterization Surveys. Using logistic regression models for no affiliation and unattended needs, we estimated odds ratios (OR) and prevalences, adjusted for socio-demographic characteristics. RESULTS The unaffiliated population decreased from 11.0% (95% confidence interval (CI) 10.6-11.4) in 2000 to 3.0% (95% CI 2.8-3.2) in 2011. According to the model, self-employed workers had a higher adjusted prevalence of no affiliation: 27.4% (95% CI 24.1-30.6) in 2000 and 7.8% (95% CI: 5.9-9.7) in 2011. The level of unmet needs decreased from 33.5% (95% CI 31.8-35.1) to 9.1% (95% CI 8.1-10.1) in this period. Not being affiliated to the health system was associated with higher unmet needs in the adjusted model. Indigent affiliates, entitled to free care in the public system, reported payments for general and specialist visits in a much lower proportion than other groups. However, direct payments for visits increased for this group during the decade. CONCLUSIONS Concurrent with the introduction of new health and social policies, we observed significant progress in health system enrolment and attended health needs. However, the percentage of impoverished people who made direct payments for services increased.

The how: a message for the UN high-level meeting on NCDs

This September’s UN General Assembly high-level meeting (HLM) on noncommunicable diseases (NCDs) provides a strategic opportunity to propel the response—from “where do we want to be” to “how do we get there”. The WHO Independent High-Level Commission on NCDs made a number of solid proposals to inform HLM negotiations. These include a call for governments to enhance regulatory frameworks to protect health, for example, through a code on the marketing of some health–harming products and a full–cost accounting of these products. The draft of the HLM’s political declaration prioritises universal health coverage, including affordable treatment, and promotion of mental health but falls short on the primary prevention of NCDs and promot ing healthy societies as per Agenda 2030. The transition from health-harming to health-enhancing products and processes requires action across multiple sectors and strengthened public institutions. We propose an agenda for member state HLM negotiators (panel). First, accountability must be assigned at the highest political levels. The WHO NCD Commission called on heads of government to lead the NCD response, as was the case with effective AIDS responses. This will ultimately empower ministers of health by ensuring all government departments are accountable to national leadership and are enabled to manage political opportunities, barriers, and trade-offs for NCD prevention. Rather than create new vertical structures, the NCD agenda should be integrated into national Sustainable Development Goal (SDG) plans. The declaration must commit to distributed ownership, impact assessments, policy coherence, and accountability across ministries. Second, improving fiscal policies should be prioritised. Countries should implement a synergistic approach to taxing sugar (not just sugarsweetened beverages but also sugary snacks), tobacco and alcohol, as well as unhealthy nutrients. The international community should provide technical advice on taxation and removing subsidies for processed foods, alcohol, and fossil fuels, and for divesting from tobacco, alcohol, and fossil fuels; governments should also support healthy local food systems. Third, additional financial resources must be mobilised. The declaration should call for dramatic financial increases for NCDs over the US