Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Main Messages • Between May and September 2021, across 24 Latin American and Caribbean (LAC) countries, an average of 25.3 percent of households reported having a sick member and 33.6 percent reported needing health care. During this same period, 2.1 percent of total households experienced a disruption of services due to either postponed or foregone care.1 The picture varies, however. Disruptions were reported by over 7 percent of households in Ecuador, Haiti, and Colombia, for instance, but only 0.3 percent or fewer in Honduras, Costa Rica, Brazil, and Panama. • Despite the low prevalence of service disruptions among households in need, these disruptions varied by service type. Dental health was the most disrupted service, with 5.4 percent of households in need of this service reporting disruptions. Obstacles were also prevalent in the provision of adult care, with 4.1 percent of households in need of this service unable to access it. This was followed by children's health care, where disruptions affected 3.1 percent of households in need. On the other hand, individuals in need of ophthalmologic care, COVID- 19 vaccination, and programmed hospitalizations (e.g., surgeries) faced very few disruptions, with problems of access affecting fewer than 0.1 percent. • Among households unable to access health care during the pandemic, 57.3 percent reported reorganization of the health system as the reason behind the disruption (e.g., shortage of medical staff, medication/drug unavailable, no appointment slots, long waiting times). This suggests that the capacity of the health system represented a significant hurdle to accessing services during the pandemic. Of those households unable to access care, 15.9 percent identified financial concerns as the main reason. This correlates with high, out-of-pocket health spending in most LAC countries – a problem aggravated by household financial distress during the pandemic. • As part of the response to the COVID-19 pandemic, health systems had to innovate. A clear example is the introduction of, and subsequently heavy reliance upon, virtual health care (i.e., telemedicine). On average, 6.5 percent of households that could access health care received at least one service through virtual means. The largest report of virtual care among households with access was observed in Colombia (26.0 percent) and Uruguay (24.8 percent). In comparison, the lowest was reported in Haiti and Brazil (less than 0.2 percent) and was non-existent in Saint Lucia and Antigua and Barbuda. The use of these services is correlated to the type of confinement imposed by governments. • Concerning COVID-19 vaccination, on average, between May and July 2021, 51.1 percent of respondents had received a vaccine, while 40.8 percent had not yet been vaccinated but planned to receive a vaccination at some point. The remaining 8.1 percent of those surveyed were not intending to get vaccinated. Among this group, a perceived lack of safety (32.8 percent) and a lack of effectiveness (23.3 percent) were given as the main reasons for not getting vaccinated. This possibly shows that misinformation about COVID-19 vaccines is the most relevant barrier to effective vaccination campaigns. Among the unvaccinated, reluctancy to receive a vaccine was higher for people living in rural areas, for those aged 55 years old or more, and for those with primary or less education; there were no significant gender differences. * This note was prepared by Adriana Camacho, Estefany Hernandez, and Pablo Hernandez from UNDP LAC SDG and Development Policy Team; and Cristian A. Herrera, Julia M. Dayton, Amanda Kerr, Julie Ruel Bergeron, Jeremy Veillard, and Jakub J. Kakietek from the World Bank . 1 Respondents reported all the services that all members of their household needed in the 30 days preceding the survey. Therefore, there can be more than one service need reported by each respondent. Households that experienced a disruption are defined as those in which at least one of the services needed was postponed or foregone. This approach could overstate the rate of individual care disruptions but shows the magnitude of households that experienced at least one disruption. An alternative approach consists of randomly selecting a service for each respondent. In this case, service disruptions also amounted to 2.1 percent of households in need. 1 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Introduction Despite being home to only 8.5 percent of the world's population, the SARS-CoV-2 virus (which causes COVID-19) had infected over 79 million people in Latin America and the Caribbean (LAC) by October 19th, 2022, representing around 13 percent of all global cases. By this date, the pandemic had caused over 1.75 million deaths, nearly 27 percent of all deaths worldwide.2 At the same time, health care services were disrupted due to pandemic-related lockdowns and other public health containment measures, coupled with changes to patient behavior and increasing constraints on the health care workforce and resources. As a result, patients have interrupted routine care that they would otherwise have received through medical appointments, emergency consultations, surgeries, and preventive actions, among other delivery options. Vaccination has constituted the most effective response to save lives and reactivate economies and societies. By October 19th, 2022, almost 1,300 million COVID-19 vaccine doses had been administered in LAC. However, lingering gaps in achieving target vaccination levels throughout the region are especially concerning as new SARS-CoV-2 variants continue to emerge. At the regional level, Chile and Cuba were ahead with almost 91 and 89 percent of the population having completed their initial vaccination protocol, respectively. At the other end of the spectrum, Jamaica and Haiti lagged the rest of the region, with only 26 percent and 2 percent of their populations vaccinated, respectively.3 The 2021 High-Frequency Phone Surveys (HFPS) provide insight into these issues by taking the pulse of household health care needs and barriers to access a year and a half into the COVID-19 pandemic. Using the information from the first wave of the 2021 HFPS, this note aims to present an overview of the disruption of health care services, the need for preventive and non-preventive health care services, and the status of COVID-19 vaccinations. The data The survey The first phase of the LAC HFPS was launched in 2020 by the World Bank to monitor the impacts of the COVID-19 crisis on household welfare across the region. The World Bank and United Nations Development Programme (UNDP) jointly administered the first wave of the second phase (HFPS 2021) between May and September 2021 in 24 countries across the region.4 This wave covered an average of 1,175 individuals per country for a total of over 28 thousand observations in the region. The sample was selected using random digit dialing and is nationally representative of individuals aged 18 or older with access to a phone. Weights were calibrated to reflect population projections of the United Nations Economic Commission for Latin America and the Caribbean (ECLAC). 2 Pan American Health Organization. Accessed on October 19th, 2022. 3 Our World in Data – COVID-19 Vaccinations (November 30, 2021).https://ourworldindata.org/covid-vaccinations Consulted on October 19th, 2022. 4 The countries included are Antigua and Barbuda, Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominica, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Lucia, and Uruguay. The survey includes modules on labor markets, household income, access to services (including health and banking), digital connectedness, food insecurity, schooling services, and demographic and household characteristics. 2 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 This note focuses on the disruptions caused by the pandemic on health care services and features insights related to COVID-19 vaccination, all self-reported by individuals. The COVID-19 pandemic has obstructed care that would have otherwise been routinely provided to those in need. These obstacles can be classified across a spectrum ranging from postponed services that could be provided at a later date to foregone care that cannot be administered later.5 What we find Disrupted care The COVID-19 pandemic may have brought about a higher rate of disruptions in health care provision due to the overcrowding of medical services. It is not possible to test for the percentage of households with an unsatisfied need for emergency services or unplanned hospitalizations because the sample size at the country level for this type of disruption is too small. However, Figure 1 presents suggestive evidence of a positive correlation at the country level between the share of households with a need for emergencies or unscheduled hospitalizations, on the one hand, and the percentage of households with at least one member with a positive COVID-19 diagnosis in the past, on the other. Figure 1. Share of households where someone had COVID-19 and a demand for emergency hospitalization6 50% PE 40% % of households with at least one member BO EC previously diagnosed with COVID-19 PA 30% PY MX LAC AR CO HN 20% CR DO CL UY SV GT BZ NI 10% LC JM GY AG HT DM 0% 0% 5% 10% 15% 20% 25% 30% % of households needing medical services: emergency/ unscheduled hospitalization Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data. 5 Giannouchos et al. (2021). 6 Brazil is excluded from this figure due differences in the wording of the questionnaire that overstates the reporting of emergency/hospitalization needs. To reflect this exclusion, the weighted regional average here corresponds to 23 countries only. 3 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 At the regional level, only 2.1 percent of households could not access health services when needed in 2021 (Figure 2).7 While access to health services has been considerably restored in El Salvador and Honduras, countries such as Ecuador, Haiti, and Colombia still face some limitations in providing access to care. For instance, 11.9 percent of households in Ecuador were without access – albeit a significant improvement from 2020, when close to 50 percent of Ecuadorian households fell into this category.8 Figure 2. Share of households where someone experienced a disruption in accessing health services when needed, 2020 and 2021 14% 60% HFPS II HFPS I (secondary axis) 12% 50% 10% 40% 8% 30% 6% 20% 4% 2.1 10% 2% 0% 0% Ecuador Haiti Colombia Peru Antigua & Barbuda Bolivia Paraguay St. Lucia Argentina Dominica ALC Chile Belize Dominican Republic Guatemala Guyana Uruguay Mexico Jamaica Nicaragua El Salvador Honduras Costa Rica Brazil Panama Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data, and LAC HFPS I (Wave 1), 2020 data. 7 The percentage of households experiencing disruptions when needing health services presented in this health note and included in Figure 2 differs slightly from the one previously included in UNDP and the World Bank’s publication: An Uneven Recovery: Taking the Pulse of Latin America and the Caribbean Following the Pandemic - 2021 LAC High Frequency Phone Surveys (November 2021), then equivalent to 3.7 percent. This difference stems from the fact that the weighted regional average was formerly restricted to the group of 13 countries sampled for both phase 1 (2020) and phase 2 (2021) of the survey in order to draw comparisons across time. In contrast, this note focuses on the situation between May and September of 2021, and thus includes a weighted regional average derived from the entire sample of 24 countries. In any case, 3.7 percent constitutes a significant improvement compared to 2020, when disruption for access to health services oscillated between 10 percent (Costa Rica) and 48 percent (Ecuador). 8 Ecuador was the first country to be surveyed in this wave (May 2021). The widespread closure of services and lockdowns at this time might explain the comparatively higher number for the country. 4 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Despite the region-wide recovery in access to health care, certain services continued to face obstacles. As shown in Figure 3, most types of assistance went uninterrupted during mid-2021. That said, disruptions in access to dental and adult health affected 5.4 percent and 4.1 percent of households in need, respectively. Children's health followed closely, with 3.1 percent in need of this service reporting drawbacks. Similarly, 2.1 percent and 1.6 percent of households needing COVID-19 testing and family planning could not access these services, respectively. Figure 3. Share of households with disrupted services when needing health care by service type, mid-20219 6% 5.4 5% 4.1 4% 3.1 3% 2.1 2% 1.7 1.6 1% 0.7 0.6 0.6 0.3 0.0 0.0 0.0 0% Dental health Adult health Child health COVID test Other Family planning Emergency/unscheduled Pharmacy/Prescriptions Child vaccination Maternal health Programmed hospitalization COVID-19 vacccination Ophthalmology Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data. Demand for preventive health services indicates that households were able to return to the health system more broadly (Figure 4). A small proportion of households in the region (4.7 percent) sought COVID-19-related services, while the rest sought health services for non-COVID-19 matters. For the remainder of households accessing health services, the split between those seeking non-preventive and preventative reasons was even (47.4 vs. 47.8 percent). This level of preventive health services might indicate that by mid-2021 health systems were no longer overwhelmed by the pandemic. It also reveals that households could focus on broader areas of care and potentially prevent future illnesses. In Brazil and Guyana, non-preventive care was still more pronounced than preventive care. However, in most countries, demand for preventive services was higher. At the time of the survey, 19.4 percent of households in Uruguay and 12.5 percent of households in Costa Rica still needed COVID-19-related services. 9 Service need is non-exclusive, meaning that one household may report the need for more than one service. 5 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Figure 4. Type of health services demanded by households that needed medical assistance, 202110 Preventive Non-preventive COVID-19 related Colombia Ecuador Haiti Guatemala Panama Argentina El Salvador Nicaragua Paraguay Mexico Honduras Chile Antigua & Barbuda St. Lucia Bolivia Dominican Republic Peru Dominica Belize Jamaica LAC 47.4 47.8 4.7 Costa Rica Guyana Uruguay Brazil 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data. Despite the reductions in disrupted care reported above, around 57.4 percent of all the reasons reported for disrupting services were due to the reorganization of health systems as they responded to the ongoing pandemic (e.g., shortage of medical staff, medication/drug unavailable, no appointment slots, long waiting times) (Figure 5). This may suggest that the operational capacity and delivery capability of the region’s health systems remain major issues for accessing services in the region. Disruptions due to health system reorganization were highest in Ecuador and Peru. This has been described in several previous reports. Even so, it remains a priority topic for health policy that needs to be addressed by governments and other stakeholders soon.11 Financial concerns represented 16.0 percent of all reasons given by respondents for disruptions. This correlates with the high, out-of-pocket health spending in most LAC countries – a problem that was aggravated by the financial distress experienced by households during the pandemic. Financial concerns were particularly high in Haiti. This is consistent with the difficult economic situation in that country during the pandemic, as highlighted by other indicators such as lower incomes and greater food insecurity. 10 Preventive health services include children’s health, child vaccination, maternal health, adult health, family planning, dental service, and ophthalmology. Non- preventive health services include emergency services, scheduled and non-scheduled hospitalization, and pharmacy or medical prescription. COVID-19-related health services include relevant vaccinations and tests. Households needing more than one service are classified as having demanded preventive services if at least one of the services demanded was preventive. 11 The Organization for Economic Cooperation and Development (OECD) and the World Bank (2020). 6 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Figure 5. Reasons for health care being disrupted, 202112 70% % of households facing disruptions in health care access 60% 57.4 50% 40% 30% 20% 16.0 15.1 10% 8.0 0.0 0% Health system Financial Others Personal decision Government reorganization concerns related to COVID-19 restrictions Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data. As part of the response to the COVID-19 pandemic, health systems had to innovate. A case in point is the introduction and substantial use of virtual health care (i.e., telemedicine). On average, 6.5 percent of all services received were virtual (Figure 6). The largest share of households reporting virtual access to health care was observed in Colombia (26.0 percent) and Uruguay (24.8 percent). Notable exceptions exist. Saint Lucia and Antigua and Barbuda reported zero uptake, for example, while Haiti reported a mere 0.2 percent. The confinement restrictions imposed by governments could be related to the adaptability of individuals to use virtual services that were atypical prior to the pandemic. For example, countries like Peru, Colombia, Paraguay, Panama, and Ecuador had very long and mandatory mobility restrictions throughout their territories. This contrasts with the case of Mexico or, at a more extreme level, with Brazil, where confinement restrictions were shorter and less geographically widespread. Uruguay represents an outlier here in that it had high access to virtual health services as well as partial confinement.13 12 Service condition of access is non-exclusive, meaning that one household may report disruptions for more than one service depending on whether it needed more than one service during the period of reference. 13 Inter-American Development Bank (2020). 7 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Figure 6. Share households that accessed at least one health care service through virtual means among those that received health care services when needed, 202114 30% 25% Virtual access to health care services 20% (% households that received health care when needed) 15% 10% 6.5 5% 0% Colombia Uruguay Peru Paraguay Argentina Costa Rica Ecuador Guatemala LAC El Salvador Chile Panama Nicaragua Mexico Dominican Republic Bolivia Honduras Jamaica Guyana Belize Dominica Haiti Brazil Antigua & Barbuda St. Lucia Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data. An additional concern relates to food insecurity, which could become an additional trigger of vulnerability for households in terms of their short- and long-term health. Lower access to enough food as well as to food of good quality would be detrimental to the population's well-being. Figure 7 uses data from countries in Latin America and shows a positive correlation between the change in the percentage of households that report not having resources to buy food in the last 30 days (between mid-2021 and February 2020) with the share of households reporting having at least one sick member. 14 The subgroup on which the indicator of virtual access to health care is based (i.e., households that received health care when needed) presented in Figure 6 differs slightly from that presented on the World Bank’s Interactive COVID-19 Household Monitoring Dashboard. This difference stems from the inclusion of some households that could access health services (virtually or in-person) when in need in the numerator and some that had the need but did not try to access in the denominator, all of which had previously been left out when excluding observations assigned to “didn’t answer/no response” from the computation. 8 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Figure 7. Share of households with sick members and change in food insecurity15 40% % of households where at least one member was sick (past 30 days) PE 35% PY BO EC CO 30% SV BR HN CL 25% LA DO CR NI GT 20% AR UY PA MX 15% 0pp 5pp 10pp 15pp 20pp 25pp Change in % of households that ran out of food: Pre-pandemic v.s Mid 2021 (percentage points) Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data. Vaccination status Vaccination rates have improved significantly in the region but hesitancy to get vaccinated is still a concern, particularly in various countries in the Caribbean. By mid-2021, 51.1 percent of respondents had received a COVID-19 vaccine, while 40.8 percent had not received a vaccine but were planning to get vaccinated. A small proportion (8.1 percent) had no intentions to receive a vaccine. Among this latter group, the most reported reason for not getting vaccinated was because the respondent thought it was either unsafe (32.9 percent) or ineffective (23.3 percent). This possibly shows that the most relevant barrier to achieving universal vaccination relates to misinformation about the vaccine. There is no evident correlation between the share of people who do not trust the various vaccines (for not being safe or effective) and the share who do not have information about how to access them. Vaccine hesitancy was higher among people living in rural areas (i.e., those aged 55 years old or more) and those with low education levels (primary or less). 15 This graph excludes countries from the Caribbean. 9 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 No significant gender differences exist. Within the region, people in the Caribbean show the highest levels of vaccination hesitancy. Close to 59.3 percent of respondents in Haiti were reluctant to get vaccinated, followed by Jamaica and St. Lucia, at 49.1 percent and 42.9 percent, respectively (Figure 8). These are all countries where the vaccination campaign has progressed slowly, particularly in Haiti. Figure 8. Self-reported vaccination status by country, 202116 Vaccinated Not vaccinated, planning to get vaccinated Not vaccinated, not plannning to get vaccinated Chile Brazil Uruguay Dominican Republic Antigua & Barbuda LAC 51.1 40.8 8.1 Guyana Dominica El Salvador Mexico Costa Rica Argentina Belize St. Lucia Colombia Panama Bolivia Peru Honduras Jamaica Ecuador Nicaragua Paraguay Guatemala Haiti 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: World Bank and UNDP. LAC HFPS II (Wave 1), 2021 data. 16 This information is self-reported by each respondent; therefore, it could differ from the official information by country. 10 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 Conclusions In May/July 2021, approximately 18 months after the onset of COVID-19, disruptions of health care services caused by the pandemic appear to be lower as compared to 2020. However, reports in Ecuador and Colombia regarding disruptions to services when needed still remain relatively high. The most reported reason for disruption relates to the reorganization of health care services, followed by the unaffordability of services. This suggests that governments and other stakeholders could build on efforts adopted during the pandemic to strengthen the current and future capacity of health systems. When doing so, it is important to keep in mind the equity, quality, and sustainability of these systems. Preventive care services such as dental, adult, and child health services (e.g., routine controls) were the most disrupted. Strengthening primary health care (PHC) delivery will help recover services in these areas. It will also serve to save lives and money, while also making health systems work better for all people. The COVID-19 crisis has created a once-in-a-generation chance to transform health systems. This provides a unique opportunity to adopt a multi-disciplinary, team-based approach to health care, as well as to reform health care workforces and sustainably finance PHC systems.17 Additionally, progress in the introduction of new technologies for virtual care could be analyzed in order to better understand the quality of the care provided and the satisfaction levels of patients. In this way, those technologies that are shown to be good substitutes for in-person assistance can potentially be expanded. Concerns about patient safety, privacy, and the potential for fraud are still valid. However, as restrictions temporarily eased for the pandemic, telemedicine's benefits became more readily apparent; there is a new call for collaboration and policy reform.18 Vaccination continues to be a leading intervention to end the COVID-19 pandemic. Improving vaccination access in all countries must therefore remain a high priority. This is borne out by the fact that two out of five people in the region plan to get vaccinated but have not done so for several reasons. Some countries have made great strides in expanding access to vaccinations, but efforts must be made to reach this as-yet unvaccinated population as soon as possible. In addition, vaccine reluctance and misinformation can be addressed by deploying mass communication and community engagement to increase literacy in the population. This can be helped with out-of-the-box strategies such as ‘entertainment education,’ also known as 'edutainment.’ This approach involves the placement of public health messages in mainstream entertainment, and incentives. Such an edutainment approach would need to be closely evaluated.19 The LAC region has been hard hit by the COVID-19 pandemic. Its case numbers relative to its population mean that the region is overrepresented at a global level. Despite some initial signals that the region is on the recovery path with respect to its health care services, efforts to strengthen the capacity and financial protection towards building equitable and resilient health systems must continue. At the same time, COVID-19 vaccination programs must remain a crucial priority. The aim of these programs should be to cover underserved and hard-to-reach population groups, while contributing to the global solidarity vaccination movement.20 17 World Bank (2021). 18 Mrazek and Shukla (2020). 19 De Walque and Orozco (2021). 20 Murthi and Reed (2021). 11 Public Disclosure Authorized DISRUPTION OF HEALTH CARE SERVICES AND COVID-19 VACCINATION IN LATIN AMERICA AND THE CARIBBEAN BY MID-2021 November 2022 References De Walque, D., & Orozco, V. 2021. "How to tame COVID-19 vaccine hesitancy: Edutainment and lotteries?" https://blogs. worldbank.org/developmenttalk/how-tame-covid-19-vaccine-hesitancy-edutainment-and-lotteries Giannouchos, T., Brooks, J. M., Andreyeva, E., & B. Ukert. 2021. "Frequency and Factors Associated with Foregone and Delayed Medical Care due to COVID-19 Among Non-Elderly US Adults from August to December 2020." https://doi. org/10.22541/au.163254005.55721805/v1 IDB. 2020. Del confinamiento a la reapertura: Consideraciones estratégicas para el reinicio de las actividades en América Latina y el Caribe en el marco de la Covid-19. Mrazek, M., & R. Shukla. 2020. "After coronavirus, telemedicine is here to stay." https://blogs.worldbank.org/ digital-development/after-coronavirus-telemedicine-here-stay Murthi, M., & T. Reed. 2021. "Feasible actions to expand COVID-19 vaccine supply before the end of 2021." https://blogs. worldbank.org/health/feasible-actions-expand-covid-19-vaccine-supply-end-2021 OECD/The World Bank. 2020. Health at a Glance: Latin America and the Caribbean 2020. Paris: OECD Publishing https:// doi.org/10.1787/6089164f-en Pan American Health Organization (PAHO). 2021. "Region of the Americas Update COVID-19 Daily Update: 30 November 2021." https://iris.paho.org/bitstream/handle/10665.2/55233/COVID-19DailyUpdate30November2021_eng. pdf?sequence=1&isAllowed=y. World Bank. (2021). Walking the Talk: Reimagining Primary Health Care After COVID-19. Washington DC: World Bank. https:// openknowledge.worldbank.org/handle/10986/35842 12