Health at a Glance: Latin America and the Caribbean 2020 Health at a Glance: Latin America and the Caribbean 2020 This work is published under the responsibility of the Secretary-General of the OECD. The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD, its member countries, the World Bank, its Board of Executive Directors, or of the governments they represent. This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area. The names of countries and territories used in this joint publication follow the practice of the OECD. Please cite this publication as: OECD/The World Bank (2020), Health at a Glance: Latin America and the Caribbean 2020, OECD Publishing, Paris, https://doi.org/10.1787/6089164f-en. ISBN 978-92-64-69289-3 (print) ISBN 978-92-64-83524-5 (pdf) Photo credits: Cover © Tati Nova photo Mexico/Shutterstock.com. Corrigenda to publications may be found on line at: www.oecd.org/about/publishing/corrigenda.htm. © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 This Work is licensed under the Creative Commons Attribution Non-Commercial No Derivatives 3.0 IGO license (CC BY-NC-ND 3.0 IGO). FOREWORD Foreword Health at a Glance: Latin America and the Caribbean 2020 compares key indicators for population health and health systems across the 33 LAC countries. It builds on the format used in other editions of Health at a Glance, including the versions for the OECD member and partner countries, and the regional editions for Asia-Pacific and Europe. It presents comparable data on health status and its determinants, health care resources and activities, health expenditure and financing, and health care quality, along with selected health inequality indicators. This is the first LAC regional edition of Health at a Glance and was prepared jointly by the OECD Health Division in the Directorate for Employment, Labour and Social Affairs and the World Bank, led by Cristian A. Herrera from the OECD Health Division and Tomás Plaza-Reneses from the World Bank, with close collaboration from Gabriel Di Paolantonio from the OECD Health Division. The production of Health at a Glance: Latin America and the Caribbean 2020 would not have been possible without the contribution from LAC countries that either provided data directly to the OECD or the World Bank, or supplied the data contained in this publication to other international organisations, such as the Pan American Health Organisation or the World Health Organization. After a revision round of the publication’s draft with LAC countries, we acknowledge the responses and comments received from Belize, Colombia, Costa Rica and Mexico. The authors wish to thank the valuable inputs and support received from Frederico Guanais, Deputy Head of the OECD Health Division, and Michele Gragnolati from the World Bank. The report benefited from thorough comments and suggestions from Ian Forde, Aakash Mohpal and Jeremy Veillard from the World Bank. From the OECD, we acknowledge the contributions from Stefano Scarpetta, Mark Pearson, Francesca Colombo, Rie Fujisawa and Niek Klazinga from the Directorate for Employment, Labour and Social Affairs, from Sebastian Nieto, Paula Cerutti and Juan Vazquez from the LAC Unit of the Development Centre, and the support from Jose Antonio Ardavin from the Division for LAC of the Global Relations Secretariat. We thank Claudia Allemani and Michel Coleman for their comments on the cancer survival section. Lucy Hulett (OECD) helped with the formatting and editing of the publication. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 3 TABLE OF CONTENTS Table of contents Editorial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Reader’s guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 1. Universal health coverage and country dashboards. . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Universal Health Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Population health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Coverage and services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Financial protection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Quality of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Health inequality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Chapter 2. Identifying and tackling wasteful spending in Latin American and Caribbean health systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Clinical care waste. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Operational waste. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Governance waste. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Chapter 3. Health status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Life expectancy at birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Infant mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Under age 5 mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Mortality from all causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Mortality from cardiovascular diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Mortality from cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Mortality from injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Maternal mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Mosquito borne diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Ageing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Chapter 4. Determinants of health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Family planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Preterm birth and low birth weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Infant and young child feeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Child malnutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Adolescent health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 5 TABLE OF CONTENTS Overweight and obese adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Water and sanitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Tobacco. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Road safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Physical activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Drug use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Chapter 5. Health care resources and activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Doctors and nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Consultations with doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Medical technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Pregnancy and birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Infant and child health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Mental health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Blood glucose and blood pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Chapter 6. Health expenditure and financing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Health expenditure per capita and in relation to GDP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Financing of health care from government and compulsory health insurance schemes. . . . . 136 Financing of health care from households’ out-of-pocket payments, voluntary payment schemes and external resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Financial protection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Chapter 7. Quality of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Childhood vaccination programmes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 In-hospital mortality following acute myocardial infarction and stroke. . . . . . . . . . . . . . . . . . . . . 146 Cancer survival. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Avoidable hospital admissions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 6 Follow OECD Publications on: http://twitter.com/OECD_Pubs http://www.facebook.com/OECDPublications http://www.linkedin.com/groups/OECD-Publications-4645871 http://www.youtube.com/oecdilibrary OECD Alerts http://www.oecd.org/oecddirect/ This book has... StatLinks2 A service that delivers Excel® les from the printed page! Look for the StatLinks2at the bottom of the tables or graphs in this book. To download the matching Excel® spreadsheet, just type the link into your Internet browser, starting with the http://dx.doi.org pre x, or click on the link from the e-book edition. EDITORIAL Editorial Addressing the COVID‑19 pandemic in Latin America and the Caribbean While writing the first edition of Health at a Glance: Latin America and the Caribbean, very few of us could have imagined that a pandemic would have exposed the world to the worst health emergency in a century, with massive human, economic and social costs. The Latin America and the Caribbean (LAC) region was hit by the epidemic a few weeks later than Europe, with the first cases of COVID‑19 registered in Brazil by the end of February 2020. Since then, it has spread to all countries in the region, with the highest number of cases reported in Brazil, Peru, Mexico and Chile at the moment of writing. The complete account of the human, social, and economic costs of the COVID‑19 crisis in LAC will have to wait, but we already know that its impacts are profound. The high levels of inequality and informality in the region make the situation potentially more catastrophic than in other parts of the world. Those who do not have access to social protection have no choice but to continue to work to make a living, limiting their capability to follow social distancing measures and thus protect themselves and their relatives. Those who do not have health coverage face barriers for accessing health when needed. Furthermore, nearly 8% of people are aged 65 or older, over 80% of the population are urban, and 21% of the urban population live in slums, informal settlements or inadequate housing where basic services are not available. This combination exacerbates the epidemic’s risks among the most vulnerable groups. A critical task for health systems confronted with the spread of COVID‑19 is to protect the health of all citizens. This requires that both diagnostic testing and appropriate care should be readily available, affordable and provided in a safe environment, and that other hygiene and protective measures to prevent infections are adopted. A main barrier for accessing such health services arise from out-of- pocket health expenditures, which in LAC represent on average 34% of total health spending, well above the 21% average in OECD countries. The high level of out-of-pocket expenditures in LAC are an indication of weaker health systems, lower levels of health services coverage and, overall, a worse baseline scenario to confront this pandemic when compared to most OECD countries (Figure 1). Health inequalities also loom as a critical aspect that is affecting LAC health systems’ response and outcomes throughout the pandemic. In ten LAC countries, on average, under age‑5 mortality rate for the lowest income quintile exceeds that of the highest income quintile by 21 deaths per 1 000 live births, showing large, persisting inequalities in population health outcomes. Moreover, in 12 LAC countries, children aged 15‑23 months in low-income households have 11% lower full immunisation coverage than those in high-income households, which indicates the difficulties that countries might have in making a future COVID‑19 vaccine available in an equitable way. Such inequalities delineates a landscape where vulnerable populations are likely to be disproportionally affected by the pandemic. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 9 EDITORIAL Figure 1. Out-of-pocket spending as a share of current expenditure on health in 33 LAC countries, 2017 Out-of-pocket spending as a share of current expenditure on health (%) 80 63 60 54 52 49 48 46 45 45 44 41 40 40 39 40 35 34 34 33 33 32 31 31 31 29 28 27 26 25 24 22 21 18 17 16 15 20 10 0 Source: WHO Global Health Expenditure Database 2020; OECD Health Statistics 2019. See Chapter 6. Health system resources to face the demand surge from COVID‑19 Health workforces are key to a timely and effective response to COVID‑19. Not only do doctors and nurses need to treat cases of COVID‑19, but they also need to maintain continuity of services in all other health care needs. On average, the LAC region has two doctors per 1 000 population, but a number of countries stand well below the OECD average of 3.5, with only Cuba, Argentina and Uruguay being above this number (Figure 2). In particular, Haiti, Honduras and Guatemala have the lowest number at or below 0.3 per 1 000 population. The gap in the availability of nurses is even more pronounced: the average number of nurses per 1 000 population is one third of the average of OECD countries (3 versus 9). The number of nurses per population is highest in Cuba, Saint Vincent and the Grenadines and Dominica, and the lowest in Venezuela, Jamaica, Haiti, Honduras and Guatemala, where there are less than one nurse per 1 000 population. Figure 2. Number of doctors and nurses in 33 LAC countries, 2017 or latest year available Practising nurses per 1 000 population 10 9 OECD36 8 CUB 7 VCT DMA (7.56; 8.42) 6 GRD 5 BHS ATG 4 KNA TTO BRB LCA LAC33 MEX CRI 3 PAN SUR PER ARG 2 BLZ PRY SLVBRA ECU CHL URY HTI HND NIC BOL COL 1 GUY DOM VEN GTM JAM 0 0 1 2 3 4 5 6 Practising doctors per 1 000 population Source: OECD Health Statistics 2019; WHO Global Health Observatory Data Repository. See Chapter 5. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 10 EDITORIAL The number of beds is another key marker of how well-prepared health systems are for tackling the increased demand for hospital services due to the COVID19 pandemic. In LAC, the average number of hospital beds is 2.1 per 1 000 population, less than half of the OECD average of 4.7 (Figure 3). Barbados, Cuba and Argentina stand above the OECD average, whereas the stock is below one bed per 1 000 population in Guatemala, Honduras, Haiti, Venezuela and Nicaragua. Figure 3. Number of hospital beds in LAC countries and OECD average, latest year available Hospital beds per 1 000 population 7 5.8 6 5.2 5.0 5 4.7 3.8 3.7 4 3.1 3.0 2.9 2.8 3 2.3 2.3 2.1 2.1 2 1.7 1.7 1.6 1.6 1.6 1.5 1.4 1.3 1.3 1.3 1.3 1.1 1.1 0.9 0.8 0.7 0.7 0.6 1 0 Source: OECD Health Statistics 2019; World Bank World Development Indicators 2019. See Chapter 5. Even more central for coping with the increased demand of COVID‑19 patients with severe respiratory illness is the critical care capacity, such as intensive care unit (ICU) beds, which typically are equipped with ventilators. According to data gathered just before the pandemic, the average of ICU beds in 13 LAC countries is 9.1 per 100 000 population, lower than the average of 22 OECD countries of 12. Brazil, Uruguay and Argentina are above the regional average, while the lowest rates are observed in El Salvador, Costa Rica and Peru (Figure 4). Nevertheless, due to the fragmented nature of most health systems in LAC, not all of these beds may be readily available to patients covered by public schemes. Most privately owned beds are geographically concentrated in larger and wealthier urban areas, and are often unaffordable or not accessible to a vast part of the population. In Brazil, for example, only 40.6% of total ICU beds are managed by the Sistema Único de Saúde (SUS), the publicly funded health care system. Similarly, in Ecuador and Paraguay 53.2% and 41.4% of ICU beds, respectively, are present in the public sector of health systems. In LAC countries, spending better on health is as important as spending more The current pandemic is placing a huge burden on people and the economy around the world, to which governments have responded with unprecedented public support packages. This presents an opportunity for a needed expansion in public expenditure on health in the LAC region, which is low at 3.8% of GDP compared to OECD countries at 6.6% of GDP. Moreover, the share of total health expenditure covered by government and compulsory insurance is much lower in LAC compared to the OECD (54.3% versus 73.6%). A switch to a greater emphasis on public spending, rather than private, may help increase the equity and efficiency of health spending. An expansion in expenditure levels must also come with a reduction in wasteful spending – that is spending that does not deliver any improvement in health outcomes. Such wasteful spending means HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 11 EDITORIAL Figure 4. Capacity of intensive care beds in selected LAC countries and OECD average, 2020 (or nearest year) ICU beds per 100 000 population 25 20.6 19.9 20 18.7 15 12.0 10.5 10.3 10 9.1 8.1 7.3 6.9 5.5 5 3.3 2.9 2.7 1.1 0 Note: There may be differences in the notion of intensive care affecting the comparability of the data. Data refers to adults ICU beds only in Peru. Data include only public ICU beds in Costa Rica, Dominican Republic, Peru, El Salvador and Uruguay, and both public and private in other LAC countries. Information was collected to reflect the situation of ICU beds before the emergency measures due to the COVID19 pandemic. Source: REPS-Nation’s Attorney General Colombia 2020; Ministry of Health of Argentina 2020; RUSNIS-Ministry of Health of Peru 2020; DATASUS Brazil 2020; Chilean Society of Internal Medicine 2020; Ministry of Health of Mexico 2020; La Nación reported by Leticia Pintos, Division of Therapies at the Ministry of Health of Paraguay 2020; Ministry of Health of Uruguay 2018; Diario Delfino reported by Costa Rica’s Social Security Institute (CCSS) 2020; Ministry of Health of Ecuador 2018; Diario El Salvador reported by Milton Brizuela, President of the Medical College of El Salvador 2020; Diario Acento reported by National Health Service (SNS) – Ministry of Health of the Dominican Republic 2020; National Institute of Statistics and Census of Panama 2018. that the LAC region is achieving sub-optimal results – in terms of quality of people’s lives, safety and effectiveness of care – given the resources it devotes to health systems. As highlighted in Chapter 2 of this publication, there are several areas and activities where wasteful spending could be tackled in LAC health systems. Despite being widely performed, activities such as tonsillectomies in children and hysterectomies or prostatectomies in benign conditions do not have demonstrated effects in improving health and well-being of most patients and may even be a source of harm. They may represent a source of public resources waste. In addition, governance of health systems may well lead to waste as 42% of the people across 12 LAC countries considers the health sector to be corrupt (higher than the 34% in 28 OECD countries); and bribery rates in public health centres reaches 11% across 18 LAC countries. At a structural level, the fragmented nature of health systems in LAC is likely to affect the response to the epidemic. It is key to ensure that all resources can be channelled to address the emergency. For example, unused capacity in private laboratories and hospitals can coexist with shortages in public ones, creating health inequities and representing a significant source of waste. The crisis provides an opportunity to consider longer-term reforms to build stronger, more integrated systems in the path towards high-quality universal health coverage. Building capacity to tackle the current and future epidemics The current epidemic is putting health systems in the LAC region to a severe test. In the coming months, along with containment and mitigation policies to limit the spread of COVID‑19, the main challenges for LAC health systems will be: 1. ensuring access of vulnerable populations to diagnostics and treatment, both to test people, track patients and trace contacts, and to provide care for patients with various symptoms at different levels of the health system. Particularly important will be to consider existing health and social HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 12 EDITORIAL inequalities to assure the most equitable distribution of resources and actions within countries and across the region; 2. strengthening public health capacity and particularly infectious disease surveillance, so that populations -especially the most vulnerable- are not afflicted by other infectious disease outbreaks. Disruptions in vector surveillance and control, immunisation and other basic public health services could put vulnerable populations at risk for diseases such as dengue fever, and pathogens such as diphtheria, pertussis or others. Moving forward, investing in, and building up, higher performing public health systems should be a major priority for countries, not only to control COVID‑19, but also pandemic influenza, antimicrobial resistance and other potential public health risks exposing the health of populations and economies at large; 3. reinforcing and optimising health system capacity, through mobilising staff (to diagnose and treat patients), supplies of required equipment (to diagnose people safely, and provide them with acute treatment when needed), and space (to diagnose people quickly and safely, to isolate suspected and confirmed cases, and to treat patients in hospital or in their home); 4. leveraging digital solutions and data to better detect, prevent, respond to, and recover from COVID‑19, while managing the risks of diversion of resources to potentially ineffective digital tools, exacerbation of inequalities, and violation of privacy, both during and after the outbreak; 5. generating the best possible health and social intelligence by closely coordinating with other sectors, such as finance, education, transport, among others, to improve decision making around the crisis; while promoting transparency and accountability about how decisions are made; and 6. fostering international cooperation within the region and globally to boost and accelerate R&D, while assuring that coordinated efforts will guarantee an equitable access to new diagnostics, treatments and vaccines in the near future. The COVID‑19 pandemic is the biggest test that national health systems and global health institutions have had to face in generations. In the long run, this pandemic can offer an opportunity to prioritise health as a good investment for countries and reinforce health systems as a whole. Whilst more resources need to be allocated to health, the identification and reduction of wasteful spending would also help to better allocate additional resource to the health sector, while improving quality of care and outcomes for the population. We hope that the data and analysis reported in this publication will help policy makers and other key stakeholders make further progress towards universal health coverage through more equitable, high quality and people-centred health systems across the LAC region. Stefano Scarpetta Muhammad Pate OECD Directorate for Employment, Global Director, Health, Nutrition and Population Labour and Social Affairs Director, Global Financing Facility for Women, Children OECD and Adolescents (GFF) World Bank HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 13 EXECUTIVE SUMMARY Executive summary Health at a Glance: Latin America and the Caribbean 2020 presents key indicators, collected before the onset of COVID‑19 crisis, on health and health systems in 33 Latin America and the Caribbean (LAC) countries, including on equity, health status, determinants of health, health care resources and utilisation, health expenditure and financing, and quality of care. Overall population health status has improved, but progress remains unequal across and within countries • Life expectancy in LAC increased by almost four years between 2000 and 2017. Given these trends, the share of the population above 65 and 80 years old is expected to reach over 18% and 5%, respectively, by 2050. • Infant mortality fell by 35% and under age 5 mortality has declined by 46% between 2000 and 2017. However, countries such as Venezuela and Grenada experienced increases in both indicators. • Maternal mortality has been reduced by 26% between 2000 and 2017, a lower reduction than the 40% in the OECD. In five countries, maternal mortality has increased in the same period (Saint Lucia, Dominican Republic, Haiti, Venenzuela and Jamaica). Improvements in non-communicable diseases outcomes have been slower in LAC than in OECD countries, while communicable diseases and injuries persist as relevant health issues • Cardiovascular diseases and cancers were responsible for over 82% of all deaths, while 10% was due to communicable diseases, maternal and perinatal illness, and 8% due to injuries. Interpersonal violence was the type of injury with the largest growth, having increased by 33% between 1990 and 2017. • Deaths attributable to high blood glucose between 2010 and 2019 increased by 8% in LAC while it decreased by 14% in the OECD, although still with higher rates in the latter. The prevalence of both diabetes and mortality attributable to high blood glucose are higher than the LAC average in Antigua and Barbuda, Barbados, Belize, Brazil, Guyana, Jamaica, Saint Lucia, Saint Vincent and the Grenadines, Suriname and Trinidad and Tobago. • Tuberculosis incidence has been reduced by 10% between 2000 and 2018; nevertheless, in 12 out of 33 countries it has either maintained or increased in the period. The largest increase was observed in Grenada and El Salvador (over 100%) followed by Suriname and Uruguay (over 50%). • Between 2010 and 2018, HIV incidence has increased in five countries in the region: Chile, Brazil, Costa Rica, Bolivia and Uruguay, but they remain below the regional HIV prevalence average. The 15 EXECUTIVE SUMMARY region stands at 55% of antiretroviral coverage among people living with HIV, substantially below the goal of 90%. Smoking, alcohol drinking and especially overweight are critical risk factors for poor health in LAC • Overweight is one of the most relevant risk factors for health in LAC, representing a high burden in the present and for the future. Overweight is present in almost 8% of children under age 5, 28% of adolescents, and in over 53% of adult men and more than 61% of adult women. • Regarding unhealthy behaviours, 35% of the adult population do not engage in enough physical activity; daily consumption of fruit and vegetables is under the recommended 400 grammes per person per day in all countries; and sugar consumption is much higher than the recommended 50‑grammes per person per day, which is surpassed simply by considering the intake of sweetened beverages. • Nearly one in four men and close to one out of ten women aged 15 and above smoke daily, both slightly lower than the OECD average. Among adolescents aged between 13 and 15 years old, tobacco use prevalence for men was 15% and almost 12% for women. • Although average alcohol consumption in LAC is lower than in the OECD, it has increased by 3% between 2010 and 2016. Among people who drink, one in two men and one in five women declared to have had a heavy drinking episode in the last 30 days. Almost 35% and 22% of road traffic accidents among men and women, respectively, are attributable to alcohol. • In 2017, on average one out of four people living in rural areas and one out of eight people living in urban areas lacked access to basic sanitation. However, rural and urban basic sanitation can be lower than 50% in some countries. Quality of care is the missing link in the unrealised promise of universal health coverage in LAC • Twelve out of the 33 LAC countries fall short of attaining the minimum immunisation levels recommended by the WHO to prevent the spread of diphteria, tetanus and pertussis (90%) and 21 out of 33 fail to meet this target for measles (95%). • In terms of acute care in hospitals, according to data from six LAC countries, the case-fatality rate for acute myocardial infarction was 54% higher than in the OECD, while for ischemic stroke was 50% higher. • Survival rates for cancer reflect quality of preventive and curative care. Among six LAC countries with data, women with early diagnosis for breast cancer had a 78% probability of surviving at least five years, while for colon cancer it was 52% and for rectum cancer it was 46%, all lower than the 85%, 62% and 61% survival respectively in OECD countries. Cervical cancer survival in LAC was 60%. While health expenditure has grown in LAC, it remains well below that of OECD countries and it is more dependent on private spending • Between 2010 and 2017, health expenditures per person have outpaced economic growth in LAC. On average, health spending grew 3.6% per year, while gross domestic product (GDP) grew 3% per year. However, spending on health was about USD 1 000 per person in LAC, one fourth of what was spent in OECD countries (adjusted for purchasing power). As a share of GDP, this accounted for 6.6% of in LAC in 2017 and 8.8% in OECD countries in 2018. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 16 EXECUTIVE SUMMARY • Government and compulsory health insurance represented an average of 54.3% of current expenditure on health in LAC in 2017, lower than 73.6% in the OECD in 2018. The remaining are covered by voluntary private insurance and out-of-pocket expenditures by households. • In the LAC region, 34% of all health spending is paid out-of-pocket, well above the OECD average of 21%, and progress in reducing it has been slow, only by 1.5 percentage points between 2010 and 2017. • Nearly 8% of the population in 16 LAC countries spend more than 10% of their household consumption or income in health. Furthermore, 1.7% of the population of 15 LAC countries is pushed below the poverty line due to out-of-pocket health care expenditures compared to 1.2% in OECD countries. Poor allocation of health spending is slowing down if not halting the path towards universal health coverage in LAC • The average of caesarean section rates among 27 LAC countries is 32 per 100 live births, above the OECD average of 28, and twice as high as WHO’s recommendation of no more than 15. • Antibiotics are often used inappropriately in LAC countries, which does not add benefits to many patients and causes harm in the form of antimicrobial resistance. Brazil, Bolivia and Paraguay consume more antibiotics per capita than the OECD average. • Health technology assessment is a tool that ensures that public financing is prioritised and made available for those drugs, devices and procedures that have demonstrated effect in improving health and other outcomes. However, only 5 out of 21 LAC countries report to use it systematically to make coverage decisions and none report to use it for reimbursement purposes. • Health systems fragmentation in LAC is a key source of waste, given that most countries have subsystems with duplicate functions of governance, financing and services provision. • Weak health information systems contribute to a lower understanding of public expenditure and the results that are being obtained. Across 22 LAC countries, an average of 10% of all deaths are never reported in public mortality databases. • Forty two percent of the people across 12 LAC countries considers the health sector to be corrupt, higher than the 34% in 28 OECD countries. Moreover, bribery rates in public health centres reaches 11% across 18 LAC countries. Bottlenecks of human and physical resources prevent an effective response to people’s health care needs • LAC has an average of two doctors per 1 000 population, and most countries stand below the OECD average of 3.5. The region has less than three nurses per 1 000 population, three times lower than the OECD average of almost nine. • The average number of hospital beds in LAC is 2.1 per 1 000 population. In LAC, only Argentina, Barbados, and Cuba have more hospital beds than the OECD average of 4.7. • The LAC region has a much lower availability of medical technologies than the OECD: more than three times less of computed tomography scanners; more than five times less of MRI units; almost half less of mammography units; and more than five times less of radiotherapy units. • Resources for mental health care are scarce. The availability of psychiatrists is almost five times lower than in the OECD, while the availability of nurses and beds for mental health care are around three times lower. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 17 READER’S GUIDE Reader’s guide Structure of the publication Health at a Glance: Latin America and the Caribbean 2020 is divided into seven chapters: Chapter 1 Country dashboards takes Universal Health Coverage as a basis and shows a set of key indicators to compare performance across countries in each of the following dimensions: population health (health status and determinants of health); coverage and services; financial protection; and quality of care. Furthermore, a fifth dimension on health inequalities covers selected indicators of the other dimensions. For each dimension, a set of 3 to 6 indicators are presented in the form of country dashboards. The indicators are selected based on their policy relevance, but also on data availability and interpretability. In order to assess comparative performance across countries, each country is classified for every indicator based on how they compare against the median of the LAC countries with available data. Chapter 2 on Wasteful spending in LAC health systems focuses on the importance of waste identification and reduction, particularly in the areas of clinical care, operational and governance waste. It explores different sources of waste and provides data and policy analysis around them, stating that there is enough potential for both savings and improved outcomes. Chapter 3 on Health status highlights the variations across countries in life expectancy, infant and childhood mortality and major causes of mortality and morbidity, including both communicable and non-communicable diseases. Chapter 4 on Determinants of health focuses on non-medical determinants of health. It features the health of mothers and babies, through family planning issues, low birthweight and breastfeeding. It also includes lifestyle and behavioural indicators such as smoking and alcohol drinking, unhealthy diets, underweight and overweight, and drugs use, as well as water and sanitation. It also includes an indicator on road safety. Chapter 5 on Health care resources and activities reviews some of the inputs, outputs and outcomes of health care systems. This includes the supply of doctors and nurses and hospital beds, as well as the provision of primary and secondary health care services, such as doctor consultations and hospital discharges, as well as a range of services surrounding pregnancy, childbirth and infancy. Chapter 6 on Health expenditure and financing examines trends in health spending across LAC countries. It looks at how health services and goods are paid for, and the different mix between public funding, private health insurance, direct out-of-pocket payments by households and external resources. It also looks at financial protection measures such as impoverishment due to health care out-of-pocket payments. Chapter 7 on Quality of care builds on the indicators used in the OECD’s Health Care Quality Indicator programme to examine trends in health care quality improvement across LAC countries. Latin America and the Caribbean countries For this first edition of Health at a Glance: Latin America and the Caribbean 2020, 33 regional countries were included as seen in Table 1. Countries were selected based on their geographical location to either Latin America or the Caribbean, and if they are sovereign states. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 19 READER’S GUIDE Table 1. Latin American and Caribbean countries included and their ISO codes Country ISO Code Country ISO Code Antigua and Barbuda ATG Guyana GUY Argentina ARG Haiti HTI Bahamas BHS Honduras HND Barbados BRB Jamaica JAM Belize BLZ Mexico MEX Bolivia BOL Nicaragua NIC Brazil BRA Panama PAN Chile CHL Paraguay PRY Colombia COL Peru PER Costa Rica CRI Saint Kitts and Nevis KNA Cuba CUB Saint Lucia LCA Dominica DMA Saint Vincent and the Grenadines VCT Dominican Republic DOM Suriname SUR Ecuador ECU Trinidad and Tobago TTO El Salvador SLV Uruguay URY Grenada GRD Venezuela VEN Guatemala GTM Selection and presentation of indicators The indicators have been selected on the basis of being relevant to monitoring health systems performance, taking into account the availability and comparability of existing data in the LAC region. The publication takes advantage of the routine administrative and programme data collected by the World Health Organization, the World Bank Group and the OECD, as well as special country population surveys collecting demographic and health information. The indicators are presented in the form of easy-to-read figures and explanatory text. Each of the topics covered in this publication is presented over two pages. The first page defines the indicator, provides brief commentary highlighting the key findings conveyed by the data, and provides a few key references. On the facing page is a set of figures. These typically show current levels of the indicator and, where possible, trends over time. In some cases, an additional figure relating the indicator to another variable is included. Where an OECD average is included in a figure, it is the unweighted average of the OECD countries presented, unless otherwise specified. Limitations in data comparability are indicated both in the text (in the box related to “Definition and comparability”) as well as in footnotes to figures. Health and health system’s situation can evolve rapidly, arguably even more so in low and middle- income countries than in high-income ones. Therefore, it is important to note that some indicators might not reflect the latest situation for some countries. The authors have collected the latest available data so the landscape depicted in each chapter and section of the publication shows the most updated scenario as possible. Indicators from LAC countries that are OECD member or partner countries Three LAC countries are OECD member states: Chile, Colombia and Mexico. The OECD average includes Chile and Mexico. Colombia was not an OECD Member at the time of preparation of this publication. Accordingly, Colombia does not appear in the list of OECD Members and is not included in the zone aggregates. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 20 READER’S GUIDE On 15 May 2020, the OECD Council invited Costa Rica to become a Member. However, Costa Rica is not included in the OECD zone aggregates in this publication because, at the time of its preparation, the deposit of Costa Rica’s instrument of accession to the OECD Convention was pending. Argentina, Brazil and Peru are partner countries to the OECD. For these seven LAC countries, some figures in this publication considered the data that has been reported directly to the OECD, instead of using international sources. This is to maintain consistency among what it is informed in other OECD publications (e.g. Health at a Glance 2019) and what is available in the online database OECD Health Statistics on OECD.Stat at https://oe.cd/ds/health- statistics. These differences are noted in the footnotes of correspondent figures throughout the chapters. Note on COVID‑19 pandemic All the data presented in this report was collected prior to the COVID‑19 pandemic that began early 2020. The only exception corresponds to the data about intensive care unit beds in LAC and in OECD countries that was included in the Editorial. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 21 Health at a Glance: Latin America and the Caribbean 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 Chapter 1 Universal health coverage and country dashboards This chapter uses Universal Health Coverage as the basis to analyse a core set of indicators on health, health systems and inequalities in the Latin American and Caribbean (LAC) region. Country dashboards shed light on how LAC countries compare amongst themselves and with the OECD, across five dimensions: population health, coverage and services, financial protection, quality of care, and health inequalities. This overview provides a first glimpse on the overall situation of LAC countries and establishes linkages and dependencies between the indicators that the full report contains. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 23 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS Introduction The aim of this chapter is to present a set of key indicators related to population health and Universal Health Coverage (UHC) that informs the organisation of the report and establish linkages and dependencies between the indicators it contains. Table 1.1 shows a summary of these selected indicators. Table 1.1. Population health and universal health coverage: summary indicators Dimension Indicator Population health Health status (Chapters 3 and 4) Life expectancy at birth for females and males (2017) Survival to age 65 for females and males (2017) Under age 5 mortality rate (2017) Determinants of health Smoking among persons aged 15 and above (2016) Alcohol consumption in litres per capita among persons aged 15 and above (2016), Prevalence of overweight among adults (2016) Access to basic drinking water (2017) Access to basic sanitation (2017) Coverage and services Number of hospital beds per 1 000 population (latest year available) (Chapter 5) Doctors per 1 000 population (latest year available) Nurses per 1 000 population (latest year available) Psychiatrists per 100 000 population (latest year available) Mothers receiving at least four antenatal visits during pregnancy (latest year available) Financial protection Total health spending per capita (2016) (Chapter 6) Proportion of total health spending attributed to out of pocket payments (2016) Proportion of population that are overspending in health (latest year available) Proportion of population being pushed into the poverty line by health expenditures (latest year available) Quality of care Diphtheria, tetanus toxoid and pertussis vaccination coverage (2017) (Chapter 7) Measles vaccination coverage (2017) Breast cancer five‑year net survival indicators (2010‑14) Cervical cancer five‑year net survival indicators (2010‑14) Colon cancer five‑year net survival indicators (2010‑14) Health inequality Difference between poorest and wealthiest quintile of the population (latest year available) for: (throughout the Mortality rate, under‑5 (per 1 000) (lowest) publication) Contraceptive prevalence, modern methods (% of females ages 15‑49) Births attended by skilled health staff (% of total) Pregnant women receiving prenatal care of at least four visits (% of pregnant women) Diarrhoea treatment (% of children under 5 who received ORS) Immunisation, full (% of children ages 15‑23 months) For each dimension, a set of indicators is presented in the form of country dashboards. The indicators are selected based on their policy relevance, but also on data availability and interpretability. Indicators where coverage is highest are therefore prioritised. Universal Health Coverage Universal health coverage (UHC) is achieved when all people, communities and social groups have access to health services they need, that these services have a high degree of quality, and that HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 24 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS Methodology, interpretation and use Country dashboards In order to allow for cross-country comparisons of performance, the central tendency measures presented for all indicators are medians. The classification of countries being close to, better or worse than the LAC countries average is based on an indicator’s standard deviation (a common statistical measure of dispersion). This method is preferred to using a fixed percentage or fixed number of countries per category, since it reflects the degree of variation, i.e. how far a country is from the LAC countries average. Countries are classified as “close to the LAC average” (blue) whenever the value for an indicator is within half of a standard deviation from the LAC average for the latest year. For a typical indicator, and assuming a standard normal distribution of the data, about 38.2% of the countries (12‑13 countries) will be close to the OECD average, with the remaining 61.8% performing significantly better (green) or worse (red). This classification applies to all indicators, with a caveat for the dashboard on coverage and services: given the nature of the indicators presented, high levels cannot be classified as being clearly better or worse performance, the symbols simply imply that the values are significantly higher or lower than the median. When the number of countries that are close to the LAC average is higher (or lower), it means that cross-country variation is relatively low (or high) for that indicator. users are not vulnerable to financial hardship through the use of health services (WHO and World Bank, 2017[1]). Despite recent progress, in 2019, at least half of the world’s population still did not have full coverage of essential health services. Lack of financial protection pushes about 100 million people into poverty worldwide as a result of health care related payments, and nearly a billion spend more than 10% of the household’s budgets in health-related expenses. UN member states have agreed to achieve UHC by 2030, as part of the Sustainable Development Goals (SDGs) (WHO and World Bank, 2017[1]). The definition of UHC includes three related dimensions: • Access to health services – all people in need of health services should be able to receive care, independent of socio-economic characteristics, location, wealth or any other vulnerability. • Financial protection – all people should be safe from financial risk when incurring health care expenses, therefore service affordability and mechanisms that facilitate access to care should be prioritised. • The quality of health services should be at a standard where it is effective in providing care and improving outcomes, while it is also cost effective and sustainable. Access without quality can be considered an empty universal health coverage promise (OECD/WHO/World Bank Group, 2018[2]). This chapter also considers an important factor that must be included in every discussion on UHC: inequalities. There are gaps in population health in all three of these UHC dimensions across different socio-economic groups. The 200+ indicators included in this publication offer the reader a comprehensive sense of LAC health systems, and how countries compare. Population health UHC has as its ultimate goal the improvement of health status and the reduction of risk factors across all population groups. Ensuring access to services, quality and financial protection are key contributors to better population health, but several other societal factors determine final health status. The following two dashboards offer an overview of health status and risk factors for health using a partial list of the indicators discussed in Chapter 3 (Health Status) and Chapter 4 (Determinants of Health). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 25 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS Health Status The five indicators presented in this dashboard offer a general view of health status based on mortality indicators. This includes life expectancy at birth for females and males (2017), survival to age 65 for females and males (2017) and under age 5 mortality rate (2017). They provide an overview of where countries stand in terms of lowering mortality (see Table 1.2). Table 1.2. Dashboard on health status Life expectancy at Life expectancy at Survival to age 65 Survival to age 65 Under age 5 birth (F) birth (M) (F) (M) mortality rate Country In years In years % % Per 1 000 live births LAC31 77.4 71.6 83.2 73.8 18.6 OECD36 83.4 78.1 90.9 84.1 4.5 Antigua and Barbuda 78.9 ⦿ 74.0  85.1 ⦿ 78.6  7.0  Argentina 80.4  73.0 ⦿ 87.8  76.8 ⦿ 10.4  Bahamas 78.8 ⦿ 72.7 ⦿ 83.7 ⦿ 73.7 ⦿ 7.2  Barbados 78.4 ⦿ 73.6  88.0  79.9  12.4 ⦿ Belize 73.6  67.9  80.3  67.6  14.2 ⦿ Bolivia 72.1  67.0  74.3  66.6  34.9  Brazil 79.3  72.1 ⦿ 85.2 ⦿ 73.4 ⦿ 14.8 ⦿ Chile 83.1  77.4  89.0  83.5  7.4  Colombia 78.2 ⦿ 71.0 ⦿ 85.0 ⦿ 73.3 ⦿ 14.7 ⦿ Costa Rica 82.9  77.8  90.1  83.6  9.0  Cuba 81.9  78.0  88.7  83.8  5.4  Dominican Republic 77.3 ⦿ 71.0 ⦿ 81.5 ⦿ 71.1 ⦿ 29.9  Ecuador 79.3  73.9  85.9  77.4  14.5 ⦿ El Salvador 78.1 ⦿ 69.1  84.3 ⦿ 67.1  14.5 ⦿ Grenada 76.3 ⦿ 71.4 ⦿ 84.2 ⦿ 72.6 ⦿ 16.7 ⦿ Guatemala 76.8 ⦿ 70.4 ⦿ 82.1 ⦿ 71.1 ⦿ 27.6  Guyana 69.2  64.5  72.1  62.3  31.3  Haiti 65.8  61.4  67.1  59.0  71.7  Honduras 76.3 ⦿ 71.2 ⦿ 81.2 ⦿ 73.7 ⦿ 18.2 ⦿ Jamaica 78.5 ⦿ 73.7  85.0 ⦿ 77.4  15.2 ⦿ Mexico 77.9 ⦿ 72.9 ⦿ 86.4  78.8  13.4 ⦿ Nicaragua 78.6 ⦿ 72.6 ⦿ 83.6 ⦿ 73.9 ⦿ 17.2 ⦿ Panama 81.3  75.3  87.3  78.6  16.1 ⦿ Paraguay 75.5  71.1 ⦿ 80.2  73.8 ⦿ 21.0 ⦿ Peru 77.9 ⦿ 72.6 ⦿ 84.6 ⦿ 76.3 ⦿ 15.0 ⦿ Saint Lucia 78.4 ⦿ 73.0 ⦿ 83.7 ⦿ 75.1 ⦿ 16.6 ⦿ Saint Vincent and the 75.6 ⦿ 71.2 ⦿ 80.8 ⦿ 74.1 ⦿ 16.0 ⦿ Grenadines Suriname 74.9  68.4  80.7  67.6  20.0 ⦿ Trinidad and Tobago 74.4  67.4  79.8  66.9  26.0  Uruguay 81.0  74.0  87.4  79.0  8.0  Venezuela 78.9 ⦿ 70.8 ⦿ 84.9 ⦿ 72.6 ⦿ 31.0  Determinants of Health Health status depends not only on the provision of health care, but also on the behaviour of people and the environment in which they live. The five indicators presented in this dashboard offer an overview of the prevalence of risk factors or behaviours (smoking among persons aged 15 and above – 2016, alcohol consumption in litres per capita among persons aged 15 and above – 2016, and HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 26 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS prevalence of overweight among adults – 2016) and of environmental factors that affect health (access to basic drinking water – 2017 and access to basic sanitation – 2017) (see Table 1.3). Table 1.3. Dashboard on determinants of health  Better than ⦿ Close to  Worse than LAC countries average Access to drinking Alcohol Sanitation Smoking Overweight adults water consumption Country % of the % of the % of daily % of male % of female Litres per capita population population smokers population population LAC33 86 95 16 6 36 32 OECD36 99 100 18 9 41 29 Antigua and Barbuda 88 ⦿ 97 ⦿ .. 7 ⦿ 29  30  Argentina 96  100  22  10  39  30  Bahamas 95  99  12 ⦿ 4  36 ⦿ 30  Barbados 97  98 ⦿ 8  10  30  29  Belize 88 ⦿ 98 ⦿ .. 7 ⦿ 32  30  Bolivia 61  93 ⦿ .. 5  38 ⦿ 34  Brazil 88 ⦿ 98 ⦿ 10 ⦿ 7 ⦿ 39  30  Chile 100  100  25  8  49  44  Colombia 90 ⦿ 97 ⦿ 13 ⦿ 5  39  35  Costa Rica 98  100  5  4  39  33 ⦿ Cuba 93  95 ⦿ 35  6 ⦿ 36 ⦿ 32 ⦿ Dominica .. .. .. .. 35 ⦿ 30  Dominican Republic 84 ⦿ 97 ⦿ 14 ⦿ 7 ⦿ 36 ⦿ 31 ⦿ Ecuador 88 ⦿ 94 ⦿ 7  4  38 ⦿ 35  El Salvador 87 ⦿ 97 ⦿ 11 ⦿ 4  38  33 ⦿ Grenada 91 ⦿ 96 ⦿ .. 9  30  30  Guatemala 65  94 ⦿ .. 3  36 ⦿ 34 ⦿ Guyana 86 ⦿ 96 ⦿ .. 6 ⦿ 29  30  Haiti 35  65  13 ⦿ 6 ⦿ 33 ⦿ 31 ⦿ Honduras 81 ⦿ 95 ⦿ .. 4  36 ⦿ 33 ⦿ Jamaica 87 ⦿ 95 ⦿ 17 ⦿ 4  32  30  Mexico 91 ⦿ 99  8  4  45  43  Nicaragua 74  82  .. 5  37 ⦿ 32 ⦿ Panama 83 ⦿ 96 ⦿ 6  8  38  34 ⦿ Paraguay 90 ⦿ 100  13 ⦿ 7 ⦿ 37 ⦿ 30  Peru 74  91  .. 6 ⦿ 40  36  Saint Kitts and Nevis 88 ⦿ 98 ⦿ .. 9  30  29  Saint Lucia 87 ⦿ 95 ⦿ .. 10  27  29  Saint Vincent and the .. .. .. .. 32  30  Grenadines Suriname 84 ⦿ 95 ⦿ 25  5  35 ⦿ 31 ⦿ Trinidad and Tobago 93  98 ⦿ .. 8  26  29  Uruguay 97  99  17 ⦿ 11  40  30  Venezuela 94  96 ⦿ .. 6 ⦿ 41  35  Coverage and services Access to health care depends firstly on whether there are enough resources available to provide the necessary care. The dashboard illustrating progress in the coverage and services dimension uses one indicator of medical infrastructure availability (number of hospital beds per 1 000 population – latest year available), three indicators of human resources availability (doctors per 1 000 population – HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 27 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS latest year available, nurses per 1 000 population – latest year available and psychiatrists per 100 000 population – latest year available) and one indicator of coverage for maternal and child health services (mothers receiving at least four antenatal visits during pregnancy – latest year available) (see Table 1.4). Table 1.4. Dashboard on coverage and services  Better than ⦿ Close to  Worse than LAC countries average Hospital beds Doctors Nurses Psychiatrists Antenatal care % of women attending Country Per 1 000 Per 1 000 Per 100 000 at least four antenatal Per 1 000 population population population population visits during pregnancy LAC33 2.1 2.0 2.8 3.4 87 OECD36 4.7 3.5 8.8 16.8 .. Antigua and Barbuda 3.8  3.0  4.5  1.0  83 ⦿ Argentina 5.0  4.0  2.6  21.7  90 ⦿ Bahamas 2.9  2.0 ⦿ 4.6  1.4  83 ⦿ Barbados 5.8  2.5 ⦿ 3.1  .. 98  Belize 1.3  1.1  2.3  .. 93  Bolivia 1.1  1.6 ⦿ 1.6  1.1  85 ⦿ Brazil 2.3 ⦿ 1.8 ⦿ 1.5  3.2 ⦿ 91 ⦿ Chile 2.1 ⦿ 2.5 ⦿ 2.7 ⦿ 7.0  .. Colombia 1.7 ⦿ 2.2 ⦿ 1.3  1.8  90 ⦿ Costa Rica 1.1  3.1  3.4  3.9  98  Cuba 5.2  8.4  7.6  9.1  98  Dominica .. 1.1  6.4  .. 85 ⦿ Dominican Republic 1.6 ⦿ 1.5 ⦿ 1.4  2.3  95  Ecuador 1.5 ⦿ 2.0 ⦿ 2.5  0.5  80  El Salvador 1.3  1.6 ⦿ 1.8  0.9  82  Grenada 3.7  1.4 ⦿ 6.3  1.9  67  Guatemala 0.6  0.4  0.1  0.5  86 ⦿ Guyana 1.6 ⦿ 0.8  1.0  0.9  87 ⦿ Haiti 0.7  0.2  0.7  0.1  67  Honduras 0.7  0.3  0.7  0.7  89 ⦿ Jamaica 1.7 ⦿ 1.3 ⦿ 0.8  1.1  86 ⦿ Mexico 1.4  2.4 ⦿ 2.9 ⦿ 0.2  94  Nicaragua 0.9  1.0  1.5  0.7  88 ⦿ Panama 2.3 ⦿ 1.6 ⦿ 3.1  4.0  99  Paraguay 1.3  1.4 ⦿ 1.7  .. 78  Peru 1.6 ⦿ 1.3 ⦿ 2.4  2.9  94  Saint Kitts and Nevis .. 2.7 ⦿ 4.2  5.5  .. Saint Lucia 1.3  0.6  3.2  0.6  90 ⦿ Saint Vincent and the .. 0.7  7.0  .. 73  Grenadines Suriname 3.1  1.2  2.8 ⦿ 1.3  67  Trinidad and Tobago 3.0  4.2  4.1  .. 100  Uruguay 2.8 ⦿ 5.1  1.9  14.1  97  Venezuela 0.8  1.9 ⦿ 0.9  .. 84 ⦿ HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 28 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS Financial protection Access to health also depends on whether people can afford care. The indicators included here provide an overview of the expenditure level of the countries of the region (shown as overall health spending per capita – 2016 and the proportion of total health spending which is out of pocket payments – 2016) and the prevalence of financial vulnerability that exists in countries (shown as the proportion of population that are overspending in health – latest year available and the proportion of population being pushed by health expenditures into the poverty line, defined as the higher of the USD 1.90 (USD PPP 2011) poverty line and a 50% of the median consumption poverty line – latest year available) (see Table 1.5). Table 1.5. Dashboard on financial protection  Better than ⦿ Close to  Worse than LAC countries average Population pushed by Population spending more Health spending per Out-of-pocket OOP health care than 10% budget on OOP capita expenditure on health expenditure below the Country health care expenditure societal poverty line USD PPP, per capita Share of health spending % % LAC33 1026 34 7.8 1.7 OECD36 3994 21 6.0 1.2 Antigua and Barbuda 1071 ⦿ 35 ⦿ .. .. Argentina 1907  15  .. .. Bahamas 1746  31 ⦿ 2.7  0.1  Barbados 1317 ⦿ 46  16.4  1.4 ⦿ Belize 473  24  .. .. Bolivia 480  25  6.0 ⦿ 1.7 ⦿ Brazil 1280 ⦿ 27  .. .. Chile 2182  34 ⦿ 14.6  2.6  Colombia 960 ⦿ 16  8.2 ⦿ 1.8 ⦿ Costa Rica 1285 ⦿ 22  9.8 ⦿ 1.2 ⦿ Cuba 2484  10  .. .. Dominica 636  31 ⦿ .. .. Dominican Republic 978 ⦿ 45  .. .. Ecuador 954 ⦿ 39 ⦿ 10.3  2.4  El Salvador 582  29 ⦿ 1.7  0.4  Grenada 714 ⦿ 52  .. .. Guatemala 470  54  1.4  0.4  Guyana 385  32 ⦿ .. .. Haiti 83  40 ⦿ 11.5  3.3  Honduras 373  49  .. .. Jamaica 532  17  .. .. Mexico 1138 ⦿ 41  1.6  0.8  Nicaragua 468  33 ⦿ 14.8  5.2  Panama 1786  33 ⦿ .. .. Paraguay 864 ⦿ 44  7.1 ⦿ 1.4 ⦿ Peru 680  28 ⦿ 9.2 ⦿ 1.4 ⦿ Saint Kitts and Nevis 1442  48  .. .. Saint Lucia 661  45  .. .. Saint Vincent and the Grenadines 522  31 ⦿ .. .. Suriname 944 ⦿ 26  4.9  .. Trinidad and Tobago 2206  40 ⦿ 3.9  1.0  Uruguay 2102  18  .. .. Venezuela 141  63  .. .. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 29 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS Quality of care Health care which is of low quality can harm patients and waste resources. The quality of care dashboard includes two vaccination coverage indicators (diphtheria tetanus toxoid and pertussis – 2017 and measles – 2017) and three five‑year cancer net survival indicators (breast – 2010‑14, cervical – 2010‑14 and colon – 2010‑14). Gaps in data availability for these and other quality indicators remain substantial in the region (see Table 1.6). Table 1.6. Dashboard on quality of care  Better than ⦿ Close to  Worse than LAC countries average DTP3 immunisation MCV1 immunisation Breast cancer Cervical cancer Colon cancer coverage coverage Country % of population % of population Five-year survival Five-year survival Five-year survival rate aged around 1 aged around 1 rate rate LAC33 90 90 78 60 52 OECD36 95 95 84 66 62 Antigua and Barbuda 95  96  .. .. .. Argentina 86 ⦿ 94 ⦿ 84  53  54 ⦿ Bahamas 90 ⦿ 89 ⦿ .. .. .. Barbados 95  85  .. .. .. Belize 96  97  .. .. .. Bolivia 83  89 ⦿ .. .. .. Brazil 83  84  75  60 ⦿ 48 ⦿ Chile 95  93 ⦿ 76  57 ⦿ 44  Colombia 92 ⦿ 93 ⦿ 72  49  35  Costa Rica 94 ⦿ 94 ⦿ 87  78  60  Cuba 99  99  75  73  64  Dominica 94 ⦿ 84  .. .. .. Dominican Republic 94 ⦿ 95  .. .. .. Ecuador 85  83  76  52  48 ⦿ El Salvador 81  81  .. .. .. Grenada 96  84  .. .. .. Guatemala 86 ⦿ 87 ⦿ .. .. .. Guyana 95  98  .. .. .. Haiti 64  69  .. .. .. Honduras 90 ⦿ 89 ⦿ .. .. .. Jamaica 97  89 ⦿ .. .. .. Mexico 88 ⦿ 97  .. .. .. Nicaragua 98  99  .. .. .. Panama 88 ⦿ 98  .. .. .. Paraguay 88 ⦿ 93 ⦿ .. .. .. Peru 84  85  82  57 ⦿ 59  Saint Kitts and Nevis 97  96  .. .. .. Saint Lucia 95  86  .. .. .. Saint Vincent and the 97  99  .. .. .. Grenadines Suriname 95  98  .. .. .. Trinidad and Tobago 99  90 ⦿ .. .. .. Uruguay 91 ⦿ 97  .. 57 ⦿ 54 ⦿ Venezuela 60  74  .. .. .. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 30 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS Health inequality Finally, this dashboard illustrates another important consideration necessary to measure a country’s progress towards UHC: the level of inequality experienced by population groups in their health status and health determinants, as well as their access to, affordability of, and coverage of health services. This dashboard displays the average difference between the poorest and the wealthiest income quintile for each indicator in each LAC country and compares them with the regional average. If the difference is larger than the average, a red icon is displayed, while a green one is shown when the difference is smaller than the average. The available international comparable data for this dashboard was taken from the Health Equity and Financial Protection Indicators database (World Bank, 2019[3]). Table 1.7. Dashboard on health inequalities  Better than ⦿ Close to  Worse than LAC countries average Pregnant women Contraceptive Diarrhoea receiving Immunisation, prevalence, modern Births attended treatment (% of Under‑5 mortality prenatal care of at full (% of children methods (% of by skilled health children rate least four visits aged 15‑23 mont females staff (% of total) under‑5 who (% of pregnant hs aged 15‑49) received ORS*) women) Country Difference Difference between lowest Difference Difference Difference Difference between between lowest and highest between lowest between lowest between lowest lowest and highest and highest income quintiles, and highest and highest and highest income quintiles, income expressed in income quintiles, income quintiles, income quintiles, expressed in % quintiles, deaths per 1 000 expressed in % expressed in % expressed in % expressed in % live births LAC (available 21.3 9.4 15.6 12.2 8.7 11.0 countries) Barbados .. 9.9 (2012) ⦿ .. .. .. .. Belize 17.7 (2016) ⦿ 15.8 (2015)  6.8 (2012) ⦿ 2.7 (2015)  .. 13.1 (2015) ⦿ Colombia 20.3 (2016) ⦿ 3.5 (2015)  10.8 (2015) ⦿ 167.0 (2015)  .. .. ⦿ Dominican Republic 7.9 (2015)  0.1 (2014)  1.5 (2014)  4.3 (2014)  13.4 (2014)  11.3 (2014) ⦿ El Salvador 17.5 (2015) ⦿ 4.7 (2014)  5.5 (2014) ⦿ 12.5 (2014) ⦿ 3.1 (2014)  11.7 (2014) ⦿ Guatemala 36.0 (2015)  29.7 (2014)  56.8 (2014)  14.2 (2014) ⦿ 5.9 (2014) ⦿ 16.0 (2014) ⦿ Guyana 8.7 (2015)  4.3 (2014)  20.2 (2014) ⦿ 8.3 (2014) ⦿ .. 6.1 (2014) ⦿ Haiti 41.6 (2013)  .. 68.9 (2014)  35.8 (2016)  12.1 (2016)  39.9 (2016)  Honduras 18.7 (2012) ⦿ 12.2 (2011) ⦿ 7.1 (2016) ⦿ 16.3 (2011) ⦿ 9.9 (2011) ⦿ 2.0 (2011) ⦿ Jamaica .. .. 3.5 (2010) ⦿ 13.3 (2011) ⦿ .. 20.0 (2011)  Mexico .. 10.2 (2015) ⦿ 5.7 (2010) ⦿ 9.9 (2015) ⦿ 0.9 (2015)  0.3 (2012)  Panama .. 16.1 (2013)  27.9 (2015)  22.6 (2013)  4.5 (2013)  3.4 (2013) ⦿ Paraguay 25.0 (2016) ⦿ 8.4 (2016) ⦿ 12.1 (2013) ⦿ 13.0 (2016) ⦿ 9.2 (2016) ⦿ 3.7 (2016) ⦿ Peru 19.3 (2016) ⦿ 12.2 (2016) ⦿ 14.2 (2016) ⦿ 8.4 (2016) ⦿ 19.4 (2016)  3.9 (2016) ⦿ Saint Lucia .. 5.2 (2012)  .. .. .. .. Suriname .. 23.2 (2010)  11.8 (2016) ⦿ 9.6 (2010) ⦿ .. .. Trinidad and Tobago .. 2.7 (2011)  1.6 (2010) ⦿ 2.4 (2011)  .. .. Uruguay .. .. 1.1 (2011)  4.3 (2012)  .. .. * ORS: oral rehydration solution. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 31 1. UNIVERSAL HEALTH COVERAGE AND COUNTRY DASHBOARDS References [2] OECD/WHO/World Bank Group (2018), Delivering Quality Health Services: A Global Imperative, World Health Organization, Geneva 27, https://dx.doi.org/10.1787/9789264300309-en. [1] WHO and World Bank (2017), Tracking universal health coverage: 2017 global monitoring report: executive summary, World Health Organization and International Bank for Reconstruction and Development / The World Bank, https://apps.who.int/iris/bitstream/handle/10665/260522/WHO-HIS-HGF-17.2-eng.pdf. [3] World Bank (2019), Health Equity and Financial Protection Indicators (HEFPI), http://datatopics.worldbank.org/ health-equity-and-financial-protection/ (accessed on 19 November 2019). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 32 Health at a Glance: Latin America and the Caribbean 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 Chapter 2 Identifying and tackling wasteful spending in Latin American and Caribbean health systems Mobilising additional resources for health financing in Latin America and the Caribbean (LAC) is necessary to achieve high-quality universal health coverage. However, LAC countries must balance investments in their health systems with other needs in a context of limited public funding and competing priorities. This chapter focuses on the importance of reducing wasteful expenditures particularly in the areas of clinical care, operational and governance waste, as a way to accelerate the path towards universal health coverage. Addressing waste in health systems entails reviewing structures, regulations, services and processes that are either harmful or do not deliver expected benefits, as well as costs that could be avoided by substituting cheaper alternatives with comparable or superior benefits. Policy- makers and managers in LAC should consider such waste-reduction initiatives as tools at their disposal to build higher quality and more sustainable health systems. In the LAC region, spending better on health is as important as spending more. Without cutting budgets and even in a scenario of increasing government health expenditure, being more efficient and achieving better results for more people can be a self- reinforcing strategy, if properly designed so as to be synergic. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 33 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Introduction Understanding wasteful health spending: experience in Latin America and the Caribbean While health expenditure has grown in LAC, it is remains well below that of OECD countries and it is more dependent on private spending. The path to high-quality universal health coverage requires expansion of government health expenditures in most countries. However, spending better on health is as important as spending more. Increasing efficiency and reducing waste in health systems should be high on the agenda for all countries, regardless of differences in economic and epidemiological outlooks. The bottom line is that health systems should offer the best possible value to people, which includes not only the best possible care to address patients’ needs and preferences, but also the least possible cost. In LAC, this coincides with a moment where there is a growing middle-class, which has raised the expectations of people in terms of both coverage and quality of health services (OECD et al., 2019[1]), putting more pressure on health budgets. Wasteful health spending can be understood as the resources destined to: i) services and processes that are either harmful or do not deliver benefits; and ii) costs that could be avoided by substituting cheaper alternatives with identical or better benefits (OECD, 2017[2]). In no case, this should be misunderstood as reducing or making cuts on health expenditure. In fact, wasteful spending can and should be tackled in both expansive and austere health budgeting times, as a way to mobilise the necessary amount of resources to obtain the best health outcomes. Limiting waste means that health systems are able to mobilise sufficient resources and spend them with the highest possible value to improve the population’s health, in a context of growing expectation for better services, increasingly stringent fiscal limitations, and continuous cost pressures from technological development and an ageing population. In the short run, reducing waste frees up existing resources in the system and increases societal willingness to mobilise additional resources for health. In the long run, it ensures sustainability and resilience against current or future lack of public funding or emerging issues and shocks to the health system. It is estimated that around 20‑30% of all health sector resources are wasted even in highly developed countries with advanced medical care and significant legislative/media/academia oversight of care, costs, and outcomes (OECD, 2017[2]). Hence, there is a strong likelihood that such problems occur in less developed countries/systems, even if data constraints limit the ability to precisely document their status. Indeed, data limitations have hindered such analyses in LAC, but available evidence suggests that a very significant proportion of resources is wasted. For instance, in 2009, 19% of all hospitalisations were estimated to be avoidable, accounting for a potential saving of 1.5% of total health expenditure related to this specific dimension of waste alone (Guanais, Gómez- Suárez and Pinzón, 2012[3]). Most LAC countries are still in the process of improving care access and coverage, and still rely primarily on curative, specialist, and hospital care, rather than less expensive, more efficacious preventive care (Pinto et al., 2018[4]), underscoring the simultaneous potential for savings and improved outcomes. Figure 2.1 illustrates the three dimensions of waste reflecting low value and high cost, leading to concrete examples of inefficiency (OECD, 2017[2]). First, patients may receive unnecessary or low- value care that makes little or no difference to their health outcomes and in some cases may even HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 34 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.1. A pragmatic approach to identifying and categorising wasteful spending on health Unnecessary duplication of tests and services Avoidable adverse events Patients do not receive the right care Low-value care: ineffective or inappropriate Waste occurs when… Discarded inputs (e.g. unused medicines) Benefits could be obtained with fewer resources Overpriced input (e.g. generic vs brand medicines) High cost inputs used unnecessarily (e.g. physician instead of nurse, inpatient Resources are instead of outpatient care) unnecessarily taken away from patient care Administrative waste Fraud, abuse and corruption Note: Adapted from OECD (2017[2]), Tackling Wasteful Spending on Health, https://dx.doi.org/10.1787/9789264266414-en. prove inherently detrimental (for example, when hospitals are vectors of infection). This type of waste occurs at the clinical level and has the largest impact on health, since low-value care hinders recovery and wellbeing of patients. Second, comparable outcomes can often be achieved with fewer resources. For example, some health systems have low utilisation of generic medicines; others provide care in resource-intensive places such as hospitals, when it could be provided in primary care. Third, administrative processes may add no medical value, and associated funds may be lost to fraud and corruption – which typically flourish more (and are harder to detect and address) in complex, multi- process organisational structures. This type of waste occurs outside the clinical level, produced by flawed processes originally in place to contribute to the smooth running of the health system. The impact associated with this type of waste grows larger the more of it takes place. The larger the corruption and fraud, the more challenging they become to tackle. It is important to understand that waste often derives or at least is supported by institutions or flawed processes that are generated by dependent, inefficient instances at different levels of a health system. Such a structure will produce more of these arrangements and will perpetuate unbalanced practices and institutions. Even highly transparent, advanced, and thoroughly monitored health systems will fall short of perfection. Building an efficient health system is less about investing substantial resources to eliminate waste, than it is about implementing mechanisms to identify waste more promptly and building capacity to address it. A truly efficient system is dynamic and flexible, and it allows for adjustments for the benefits of patients and its own sustainability (OECD, 2017[2]). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 35 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Wasteful spending has begun to be addressed in LAC mainly as part of financial sustainability policies, but it remains to be thoroughly evaluated To tackle waste effectively in all its components and levels, health sector stakeholders and policy-makers must incorporate waste as a priority focus within the agenda encompassing the entire system. It is likely that policy-makers, health professionals, and patients in all LAC countries are already concerned about efficiency in different degrees, but evidence suggests that most countries do not use all the available tools at their disposal to implement waste-tackling measures. The LAC Health System Characteristic Survey (Lorenzoni et al., 2019[5]) records the health system administrative arrangements put in place by countries. One of the elements explored by the survey is the existence of mechanisms designed to contain public health spending. Fourteen countries set ceilings for public health spending across several health system actors (levels of government, insurance funds, etc.). The budgetary ceilings are set by the central budgetary authority (usually the Ministry of Finance) and must be approved through the national legislature. Thirteen of these countries have an early warning system that signals when expenditures might exceed the ceilings. There are several measures to respond to budgets exceeding initial ceilings. Most countries, except Brazil, Costa Rica, and Panama, make supplemental budget appropriations. Other measures include deficit increases by subnational levels of government and providers. Cuts in the procurement of medicines is a widely used cost containment tool (Lorenzoni et al., 2019[5]). It is critical that countries establish mechanisms to further control expenditure and ensure institutional accountability, in addition to reacting to budget overspendings. As health budgets confront increasing pressures, some LAC countries have faced rising debts accrued by different actors in the system, for instance, with hospitals and entities providing goods and services to hospitals or primary care centres (e.g. pharmaceutical companies, laboratory or radiological services). Examples of recent debt-related waste-reduction measures in Chile and Colombia are provided in Box 2.1. Box 2.1. Recent waste-related measures developed in LAC that still remain to be evaluated ‘Acuerdo de Punto Final’ in Colombia The ‘Acuerdo de Punto Final’ (Full-Stop Agreement) in Colombia is focused on reducing the accumulated public hospital debt owed by the central government through the country’s private health insurers (Entidades Promotoras de Salud, EPS). The plan began with the payment of more than USD 0.5 billion to providers, which will enable them to improve their human resources, infrastructure, and technologies and thus enhance quality and efficiency over the long term. The agreement also describes measures to reduce waste to avoid further debt accumulation. These include updating the Health Benefit Plan (Plan de Beneficios de Salud, PBS), control of drug prices, centralised purchasing of medical goods, and other administrative and organisational adjustment to streamline processes and mechanisms. Hospital debt reduction in Chile Chile has implemented initiatives to reduce the debt owed to entities that provide goods and services to public institutions, such as hospitals, which have accumulated in the present decade. In 2019, the public insurer (FONASA) paid special attention to ensuring that both base and supplemental-yearly funds were used to reduce payment arrears/ delays to providers rather than to cover other needs. Efforts to reduce existing debt include building capacity to operate at higher efficiency. These measures have been agreed upon with providers and payment mechanisms will now take the efficiency produced by hospitals into account. Other measures include the reduction of hospital activities outside of regular working hours, increasing centralisation of HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 36 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Box 2.1. Recent waste-related measures developed in LAC that still remain to be evaluated (cont.) medicine purchases through the National Procurement Agency (CENABAST), and technical support from the central level to less efficient hospitals. These plans and policies remain to be assessed, both in the short and long term, from an economic perspective pertaining the public budgets and from the impact on service provision, equity, quality, and patient outcomes. Clinical care waste Measuring differences in health care utilisation and quality Detecting and understanding differences in utilisation and quality is a prerequisite to addressing waste. Varying circumstances between in-country regions or facilities will factor into such differences, but differences will also reflect different degrees of waste. Evidence from several countries shows that clinical and administrative practices account for a greater degree of variation than differences in illness or patient preference (Wennberg, 2011[6]). While benchmarking waste against a global or regional standard provides a useful guide/spur for countries, it is more important for them to understand the extent, how, and where resources are wasted domestically (since it is these that enable them to better serve their citizens, and in doing so rise within the global/regional ranks). Variations across geographic areas can be as high or higher than cross-country ones, and naturally tend to fall under the control capacity of national governments to a greater extent than international variations. Public reporting of geographic variations potential over- and under-use of resources, including through visual displays of ‘atlases’/maps, can be a key step toward addressing domestic variations in an easily comparable and comprehensive way that implicitly raise questions about why these variations exist (OECD, 2014[7]). Colombia, for example, has invested in developing an atlas of variations in recent years (Kim, 2014[8]). The atlas (see Box 2.2 and Figure 2.2) was developed from a pilot study financed by the World Bank Group in 2015 and focuses on the utilisation of acute care services and the differences in caesarean utilisation (two main potential sources of waste discussed later in this chapter). Using atlases to track variations allows for regionally specific targets to be set, although it is important to recognise that they do not directly indicate what factors led to the variation. In some cases, services are under- or over-provided, which reflects in differing outcomes or performance indicators. However, it is a useful method to detect systemic waste around several services, which is often correlated in affected areas. Once variations are identified, further analysis is needed to determine the underlying factors behind instances of overuse and underuse. Regional target setting can then be combined with other interventions to address specific challenges. Measuring the compliance with clinical practice guidelines (CPGs) is another useful tool for improving patient outcomes and avoiding unnecessary costs. An analysis of compliance with CPGs for 324 000 diabetic patients in Colombia affiliated with private insurers (EPS) of the contributory regime revealed that only 15% of the diabetic population was provided all recommended tests, including yearly blood glucose, cholesterol, and kidney function tests. The variation in compliance was substantial across regions and between EPS providers. For example, complete testing compliance varies from 27% for the best EPS provider to nearly zero for the worst. In addition, the study estimated that complete blood glucose (HbA1c) monitoring lowers the average annual total per patient by USD 430, representing 15% of total costs. Thus, efficiency is not only about the average level of prevention, but also about homogeneous provision across regions and providers (Izquierdo, Pessino and Vuletin, 2018[10]). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 37 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Box 2.2. Atlas of Geographical Variations – Colombia The Colombian Atlas of Geographical Variations covers a variety of indicators related to health status, activities, quality, and use of resources. Such a tool helps identify waste by highlighting outliers in the geographical data. Thus, for example, the map below displays the varying rates of surgical cancellations (a wasteful practice) observed in Colombian departments in 2018. Figure 2.2. Rates of surgical cancellations per 100 programmed surgeries in Colombian Departments, 2015 Source: MINSALUD (2019[9]), Colombian Atlas of Geographical Variation, https://sig.sispro.gov.co/sigmsp/index.html. Reducing unnecessary procedures Wasteful clinical care refers to situations when patients do not receive the right care, but also when they receive ineffective and inappropriate care. The latter category is sometimes known as low- value care, and in several countries efforts have been put in place to reduce it. Despite being widely performed, activities such as tonsillectomies in children and hysterectomies or prostatectomies in benign conditions do not have demonstrated effects in improving health and well-being of most patients, and may even be a source of harm, representing a potential source of waste when used excessively or unnecessarily. C-sections are a classic example of a surgical procedure that can be lifesaving when clinically necessary, but for which the benefits of its wide use are disputed. C-section carries an increased risk of infections for mothers and respiratory distress for new-borns, as well as precluding the benefits HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 38 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS associated with passing through the birth canal. C-sections have been linked to several health risks during infancy, such as Type 1 diabetes, celiac disease, allergies and asthma, and obesity (Magne et al., 2017[11]). Evidence indicates that a rate of C-sections above 15% is not associated with further reductions in maternal, neonatal or infant mortality (Stordeur et al., 2016[12]). Some estimates for LAC show that more than half of all new-borns are delivered by C-section (Magne et al., 2017[11]). C-section rates have been climbing up worldwide despite WHO recommendations, from 6.7% in 1990 to 19.1% in 2014. South America has been the region with the highest rates since the 1990s, with Brazil in particular having very high rates in public sector facilities (40‑50%) and even higher rates in private sector (80‑95%) (Magne et al., 2017[11]). In 27 LAC countries, 32% of all births are performed through C-section, higher than the 28% in 34 OECD countries. The highest rates are observed in the Dominican Republic and Brazil, and the lowest in Haiti, Guyana, and Trinidad and Tobago (see Figure 2.3). Figure 2.3. Caesarean section rates in 27 Latin American and Caribbean countries, 2016 or latest year available Per 100 live births 58 60 56 49 49 48 46 46 50 40 39 40 34 33 32 32 32 31 30 29 28 28 26 30 24 21 21 19 19 19 18 17 20 10 5 0 Source: WHO (2019[13]), Global Health Observatory data, https://www.who.int/gho/en/. OECD Health Statistics (2019[14]) for Chile and Mexico, https://doi.org/10.1787/ health-data-en. StatLink 2 https://stat.link/nkgptu The first intervention to be revised to reduce overuse of C-section surgeries should be elective C- sections among low-risk women. Other interventions can include promoting behaviour change through dedicated tools, feedback, and audits; financial incentives to discourage providers from delivering C-sections when unwarranted; and producing and publishing information on overuse, to raise awareness and enable providers to benchmark against their peers (OECD, 2017[2]). As with other drivers of waste, the region still must also cover gaps in coverage. LAC countries must continue working to ensure that all women in need of a C-section can access one, as well as driving down cases where there is overuse. Tools such as the Robson classification, promoted by WHO as a way of identifying high-risk women in need of a C-section, enable providers to direct resources to the women most in need of them, functioning well in combination with measures that are specifically designed to drive down C-section rates (WHO, 2015[15]). Internationally, Choosing Wisely® is a health educational campaign aimed at improving patient- doctor relationships and reducing unnecessary health care by pulling evidence-based medicine into HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 39 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS the public domain (ABIM Foundation, 2020[15]). For instance, clinical guidelines exist in several OECD countries to promote a more rational use of costly MRI and CT exams, when these are unnecessary. Similar tools exist in virtually every medical area of specialisation. Promoting a rational use of antibiotics and preventing antimicrobial resistance Rational use of antimicrobial medicines is key not only in terms of monetary savings and broader health system efficiency, but also to preserve their clinical effectiveness. However, PAHO estimates that around 50% of antibiotic use is inappropriate, which hurts sustainability and health outcomes (PAHO and FIU, 2018[17]). Misuse of antimicrobials causes allergic and adverse drug reactions, morbidity and mortality, increased duration of hospital stays, infections from antibiotic-resistant pathogens, microbiota changes, and overall increased health care costs. It medicalizes certain conditions for which other treatments are more effective and it puts patients at risk of adverse effects (and the increased costs associated with treating them). The majority of antibiotic prescribing occurs at the primary care level, most of them for respiratory tract infections. Table 2.1 illustrates the volumes of antibiotics consumed in five reporting LAC countries. Consumption is lowest in Peru and highest in Brazil. The low figure for Peru might be explained because the data does not include all institutions in the health sector but only shows the best approximation to antibiotic use. The average estimated daily defined dose (DDD) consumption of 17.2 DDDs per 1 000 inhabitants per day in the five LAC countries is higher than in other countries such as Canada (17.05), Germany (11.49), Netherlands (9.78) and Sweden (13.23), and close to the Ibero-American countries of Portugal (17.72) and Spain (17.96). In the OECD, the average for 31 countries with data is 18. Table 2.1. Total consumption of antibiotics, DDD per 1 000 inhabitants per day, 2016 DDD/1 000 inhabitants per day Brazil 22.8 Bolivia 19.6 Paraguay 19.4 OECD31 18.0 LAC5 17.2 Costa Rica 14.2 Peru 10.3 Note: DDD, daily defined doses. Source: WHO (2018[18]) WHO Report on Surveillance of Antibiotic Consumption: 2016 - 2018 Early implementation and OECD (2019[14]), OECD Health Statistics, https://doi.org/10.1787/health-data-en. The relatively high levels of antibiotic usage can lead to antimicrobial resistance, which has been declared as one of the most critical emergent public health challenges of our times. In seven LAC countries, average resistance proportions across eight antibiotic-bacterium combinations are estimated to have increased from 21.3% (range: 16‑33%) in 2005 to 31.9% (range: 21‑39%) in 2015, and may go up further to 32.1% (range: 22.3‑39%) by 2030 if current trends in resistance, and correlates of resistance, continue into the future and no policy actions are taken (see Figure 2.4). However, the trend toward 2030 is not the same in all countries: only Chile and Brazil are expected to substantially increase antimicrobial resistance, while the other five countries remains similar to the situation in 2015. The WHO report on surveillance of antibiotic consumption (WHO, 2018[18]) noted which LAC countries have implemented systems to control or monitor the use of antimicrobials. As of 2016, HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 40 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.4. Average proportion of infections (including 2030 projections) caused by bacteria resistant to antimicrobial treatment for eight antibiotic-bacterium combinations in 2005, 2015, and 2030 2005 2015 2030 % 45 40 35 30 25 20 15 10 Note: All seven countries are missing more than 50% of observations, across all eight antibiotic-bacterium pairs, between 2005 and 2015. Source: OECD (2018[19]), Stemming the Superbug Tide: Just A Few Dollars More, https://dx.doi.org/10.1787/9789264307599-en. StatLink 2 https://stat.link/k5q2vz 13 countries did not have a national plan or system in place to monitor antimicrobial use. Brazil, Chile, and Colombia have implemented Antimicrobial Stewardship Programs (ASPs), with the objective of tackling misuse, with the specific goals of reducing or stabilising antimicrobial resistance, reducing prescriptions, and improving clinical outcomes. These three countries and Mexico also introduced legislation to reduce antibiotic consumption by establishing mandatory prescriptions of antibiotics, to reduce self-medication. Effective ASPs can reduce adverse events associated with antibiotic use while keeping the treatment of infection optimal, and can accomplish these goals while saving costs. Evidence from Colombia (Hernández-Gómez et al., 2016[20]) found that the implementation of ASPs in three hospitals resulted in a 52.3% reduction of antibiotic consumption, with an average monetary saving of more than USD 15 000 per hospital. The average cost of implementing the ASP program was USD 4 300 per month. To tackle antimicrobial misuse, it is important for countries to accurately and promptly measure pharmaceutical consumption – for which an integrated and timely information system and response mechanism are needed to identify problem areas and tackled them rapidly. Interventions such as improving hand hygiene in health care facilities, implementing stewardship programmes to increase awareness and rationalising prescription practices, deploying rapid diagnostic tests to confirm the need of antimicrobial treatment before, delayed antimicrobial prescribing, and promoting mass media campaigns, have proven to be cost-effective (OECD, 2018[19]). Operational waste Using Health Technology Assessment to improve coverage prioritisation processes Health Technology Assessment (HTA) is a fundamental tool to foster better clinical and financing decisions, and thus reduce waste in health systems. HTA enables policy-makers to know what methods or goods are most effective to accomplish positive health outcomes. They are a comparative, multi-disciplinary process used to evaluate the added benefit or impact of health technologies, and they can inform decision-makers’ assessment of the opportunity cost of replacing an existing standard HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 41 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS of care with an alternative. In this way, selection and coverage decisions can avoid displacing high- value products with ones of lesser value to the health system. HTAs can also be used to review the value for money offered by existing technologies, and to adjust prices to reflect a desired level of cost- effectiveness or willingness to pay. The HSC survey results (Lorenzoni et al., 2019[5]) show that 13 of the responding countries conduct HTA, mainly in the public sector, but only a handful use HTA systematically to determine coverage decisions. No country reported using HTA to determine reimbursement levels (e.g. prices). Most countries that reported employing HTAs did so through the main purchaser at the central level; while only four did so through an independent body, whereas an increasing number of OECD countries use HTAs to provide evidence related to new medical technologies for decision-making. In LAC, only 10 countries report to use HTAs to inform coverage for all technologies, either systematically or under certain circumstances (see Table 2.2). Table 2.2. Countries using HTA systematically or occasionally to make coverage decisions or set reimbursement levels Type of technology Use of HTA to make decisions Countries Systematically used to make coverage Brazil, Trinidad and Tobago, Uruguay decisions Medical procedures Used in some circumstances to make coverage Argentina, Belize, Chile, Colombia, Guyana, decisions Mexico, Paraguay Used to determine reimbursement level - Systematically used to make coverage Belize, Jamaica, Mexico, Paraguay, Uruguay decisions Pharmaceuticals Used in some circumstances to make coverage Argentina, Brazil, Chile, Costa Rica, El decisions Salvador, Guyana, Peru Used to determine reimbursement level - Systematically used to make coverage Brazil, Trinidad and Tobago, Uruguay decisions Implantable medical devices Used in some circumstances to make coverage Argentina, Chile, Colombia, Costa Rica, decisions Mexico, Paraguay Used to determine reimbursement level - Source: Reproduced from Lorenzoni, et al (2019[5]) “Health systems characteristics: A survey of 21 Latin American and Caribbean countries”, https://doi.org/10.1787/0e8da4bd-en. There is also variation in the circumstances in which HTAs are used in LAC. One-third of LAC countries use HTAs to establish practice guidelines, whereas only Argentina and Peru reported their use to determine the objectives of pay-for-performance schemes. Around half of the countries use HTA to support the design of public health policies (see Table 2.3). Table 2.3. Circumstances in which Health Technology Assessments are used Circumstances Countries To establish practice guidelines for health professionals Argentina, Belize, Brazil, Chile, Mexico, Paraguay, Peru, Uruguay To determine objectives for pay-for-performance schemes Argentina, Peru Argentina, Belize, Brazil, Colombia, El Salvador, Mexico, Paraguay, Peru, To support the design of public health policies Trinidad and Tobago, Uruguay Source: Reproduced from Lorenzoni et al. (2019[5]). “Health systems characteristics: A survey of 21 Latin American and Caribbean countries”, https://doi.org/10.1787/0e8da4bd-en. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 42 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS International collaboration can be also fostered, as HTAs can be used by different countries in different contexts. This means that the knowledge obtained through HTAs can be shared among decision-makers, which (if acted upon) reduces costs and facilitates coherent approaches regardless of geographical location. Through international cooperation, countries with more limited resources can seek assistance from foreign HTA agencies, be informed of available new technologies, and contribute to the production of common tools and knowledge. This is the case of the Regional Database of Health Technology Assessment Reports in the Americas (BRISA), which shares the HTA reports produced by member organizations of the Health Technology Assessments Network for the Americas (RedETSA) (PAHO, 2019[21]). Reducing potentially avoidable hospital admissions A number of conditions can be effectively treated at the primary-care level, such as asthma, chronic obstructive pulmonary disease, and congestive heart failure. A strong primary care system can provide effective services for patients in need of preventive care and treatment for these conditions, saving costly hospital resources. Primary care services can also tackle these conditions sooner and more effectively than a hospital setting would. The inability of the primary care system to deal with these patients results in overutilisation of hospital resources, which is a significant source of inefficiency and waste and may expose patients to additional risks such as hospital-acquired infections. Estimates from six LAC countries have suggested that between 8.1 and 10 million hospitalisations in 2012 were preventable, representing as high as 2.5% of the reported total health expenditure in 2009 (Guanais, Gómez-Suárez and Pinzón, 2012[3]). Figure 2.5 reflects the available data on avoidable hospitalisations in LAC countries with available data. There is variation among LAC countries, although their rates are generally lower than the OECD average. This could indicate success in the implementation of effective primary care systems. However, in the context of the LAC region it is important to mention that access remains relatively unequal, and that a certain degree of underutilisation of hospital resources might be taking place. Finding an adequate balance to ensure the least wasteful level of hospital utilisation, while ensuring adequate access across the entire population should be the ultimate goal. Another factor to consider is that the NCD burden is relatively lower in LAC than in OECD countries, given the respective demographic and epidemiological profiles. However, variation across these LAC countries suggests that Costa Rica might be having issues regarding the ambulatory management of asthma, Uruguay and Colombia for chronic obstructive pulmonary disease, Uruguay and Brazil for congestive heart failure, and Mexico for hypertension and, especially, diabetes. As LAC countries advance in the demographic and epidemiological transitions, the burden placed by NCDs on hospital use and on the health system as a whole is likely to increase even further. Scaling up primary care systems is the key for tackling this growing burden, and potentially contribute to significant financial savings. Strong and integrated primary care services would not only be less costly but they would also improve health outcomes by detecting conditions earlier and addressing them before emergency hospital care is necessary. A well-integrated system would allow for agile referral of patients that do need to make use of hospital resources as well, to ensure the best possible clinical outcomes. Several countries have introduced mechanisms to screen patients at the primary level to avoid overutilization of specialized care. Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Guyana, Jamaica, Mexico, Panama, Suriname, and Trinidad and Tobago have established gatekeeping mechanisms by driving patients to seek a referral from a primary health care physician except in emergencies. However, registration with a primary care physician is only mandatory in HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 43 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.5. Avoidable hospital admissions in adults for selected conditions in five LAC countries and the OECD average, 2017 or latest year available Brazil Chile Mexico Colombia Costa Rica Uruguay LAC5/6 OECD Age-sex standardised rates per 100 000 population 300 250 200 150 100 50 0 Asthma COPD CHF Hypertension Diabetes Note: COPD = chronic obstructive pulmonary disease; CHF = congestive heart failure. Source: OECD Health Statistics (2019[14]) for Chile, Colombia, Costa Rica, and Mexico, https://doi.org/10.1787/health-data-en. Data for Brazil and Uruguay provided by their respective health ministries StatLink 2 https://stat.link/4875an Brazil, Chile, and Suriname; it is incentivised in Argentina, El Salvador, and Panama (Lorenzoni et al., 2019[5]). It is important to acknowledge that overuse of hospital resources is a more significant challenge in some countries in the region, while others are still mostly concerned with a lack of access to said services. However, the importance of strong primary care services remains valid for all, as PHC can also benefit underserved areas, and a rational approach to hospital use is beneficial even when scaling up hospital services in underserved areas. Innovative provision arrangements, such as e-health delivery, one‑stop shop facilities, community-level interventions, can complement the implementation of primary care centres to further reduce the burden on hospital resources. They can also be effective ways of reaching populations that are vulnerable to exclusion from traditional service delivery mechanisms. Reaching a good balance between access and length of stay in hospital care Average length of stay (ALOS) it is a useful measure related not only to the use of hospital resources but also to other health system units in place. Longer-than-ideal ALOS may arise from clinical reasons, but also from lack of coordination within the hospital or between health facilities, home-care services, or other post-discharge care settings. A recent review suggests that extra bed- days could account for up to 30.7% of total hospitalisation costs, and cause cancellations of elective operations, treatment delay, and repercussions for subsequent services, especially for elderly patients (Rojas-García et al., 2017[22]). Delayed discharges also contribute to higher costs through their adverse effects on patients’ health. Longer hospital stays increase the risk of infections and lead to more rapid health decline and worse outcomes, especially for older patients. Figure 2.6 shows the trend in ALOS for hospital acute care in four LAC countries with comparable data: Chile, Colombia, Costa Rica, and Mexico. All four countries rank below the OECD average, which has maintained relatively stable the ALOS between 2010 and 2016. In contrast, Colombia has increased hospital ALOS, while Chile and Mexico have maintained it relatively stable in the period. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 44 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.6. Average length of hospital stay, 2010 to 2016 Chile Mexico Colombia Costa Rica OECD36 Days 8 7 6 5 4 3 2 1 0 2010 2011 2012 2013 2014 2015 2016 2017 Source: OECD Health Statistics (2019[14]), https://doi.org/10.1787/health-data-en. StatLink 2 https://stat.link/lxr90a To tackle hospital overstays, countries can move to prospective payment methods, often based on diagnosis-related groups (DRGs), to set payments based on the estimated cost of hospital care in advance of service provision. These payment methods encourage providers to reduce the cost of each episode of care; for example, by reducing the duration of hospital stays. (In LAC, however, DRG- based payments are rare, particularly among public hospitals (Lorenzoni et al., 2019[5]). In addition, policies must ensure adequate integration between levels of care and providers, so that patients can be transferred or given specialized care as quickly as possible. This goal can be fostered by payment mechanisms that encourage better coordination and follow-up of patients, as well as by more robust processes that ensure the timely transfer of patients. As with other interventions suggested in this chapter, this type of incentive seeks to establish a behavioural shift among providers to inhibit default into more costly, already established approaches. Countries can also invest in non-hospital care settings to provide long-term or intermediate care to patients. In LAC, efforts to strengthen home-based care and follow-ups in places with limited access to health facilities can foster more rapid and safe discharge of patients. Day surgery is another alternative to reduce hospital stay times, provided hospitals have the technical capacities and a proper follow-up can be established for patients. Readmission rates are another issue to consider when looking for the proper balance between access to hospital care and ALOS. Early hospital readmissions (following premature discharge) have been recognised as a common and costly source of waste, particularly among elderly and high-risk patients. Reviews have found that effective interventions to reduce unnecessary readmissions are often complex and depend upon enhanced patient capacity to access post-discharge care reliably including, for instance, risk-prioritised telephone follow-up, specialised pharmaco-therapeutic counselling, self-management education programmes, individualised care plans at discharge, among others (Leppin et al., 2014[23]; Renaudin et al., 2016[24]). Data on ALOS and hospital readmissions in LAC is limited, in part because of decentralisation and lack of integration among providers. It is important that countries monitor ALOS, delayed discharges, and readmissions more closely; this will open the door for further options to tackle these challenges. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 45 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Increasing value in the pharmaceutical market by expanding the use of generics The pharmaceutical sector is one of the largest sources of health expenditure in LAC (see Chapter 6). As medicines are a substantial financial burden for both governments and people, several areas are subject of policy concerns. In this context, the development of generic markets stands out as an opportunity to increase efficiency in pharmaceutical spending; but many countries do not fully exploit this potential. Underutilisation of generic drugs is a substantial source of waste. Although generics usually have comparable therapeutic effects as branded alternatives, typically they are significantly less expensive. In seven LAC countries with data, the introduction of generics has been a challenge, for varying reasons. Figure 2.7 shows that on average, LAC countries have a larger proportion of generics in their markets (79%) compared to the OECD average (52%). However, it is important to note that the majority of these generics are branded generics (52%). Branded generics (or similares), like unbranded ones, are copies of off-patent products that are sold to the public using a trade name instead of, or in addition to, the name of the molecule. Their prices are usually higher than those of non-branded generics. In contrast, in OECD countries, branded or unbranded generics do not make a major cost difference, mainly because health systems provide coverage for them irrespective of this classification. In addition, in several LAC countries, not all generics are mandated to demonstrate therapeutic equivalence, and some regulatory agencies still need to be strengthened, which poses a quality challenge in the pharmaceutical markets of the region. Figure 2.7. Volume share of generics in the retail pharmaceutical market in seven LAC countries, April 2019 Share of generics Share of similar / branded generics % of pharmaceutical market 90 80 70 60 44 46 28 47 50 45 54 37 40 65 30 52 20 40 34 34 29 29 10 23 3 16 0 Argentina Brazil Chile Colombia Ecuador Mexico Peru LAC7 OECD Note: OECD average is calculated with data for 2017 or nearest year. Source: Adapted from IQVIA (2019[25]), Precio de los Medicamentos en América Latina, Análisis Comparativo. OECD data from OECD Health Statistics (2019[14]), https://doi.org/10.1787/health-data-en. StatLink 2 https://stat.link/o62ymg In complement to the volume of generics in LAC markets, Figure 2.8 displays the value share of generic markets, which may be expressed, depending on the country, in terms of the turnover of pharmaceutical companies or the amount paid for pharmaceuticals by consumers. The value of generics as percentage of the total retail pharmaceutical market is higher in LAC countries than in the OECD (64% versus 25%), chiefly because of common use of branded generics (or similares), which typically have higher prices than unbranded generics. In general, this means that difference in prices HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 46 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS between originator and generic medicines is smaller in LAC than in OECD countries. In line with these findings, a recent study by the Chilean National Economic Prosecutor found that profit margins obtained by pharmaceutical companies in Chile are higher for branded generics than for non-branded generics, which may be another reason for the larger presence of branded generics in LAC pharmaceutical markets. In addition, the study found that the population has a low trust in generics, meaning that this is another area to address from a policy point of view (FNE, 2019[26]). Figure 2.8. Value share of generics in the retail pharmaceutical market in seven LAC countries, April 2019 Value of generics Value of similar / branded generics % of pharmaceutical market 80 70 60 50 41 40 44 68 33 55 54 30 51 38 20 28 25 10 19 16 2 6 6 7 5 0 Argentina Brazil Chile Colombia Ecuador Mexico Peru LAC6 OECD Note: OECD average is calculated with data for 2017 or nearest year. Source: Adapted from IQVIA (2019[25]), Precio de los Medicamentos en América Latina, Análisis Comparativo. OECD data from OECD Health Statistics (2019[14]), https://doi.org/10.1787/health-data-en. StatLink 2 https://stat.link/txdsrv Some LAC countries have already implemented incentives to promote the production or registration of generics. Colombia applies lower tariffs, Mexico awards tax exemptions, Ecuador eases bureaucratic processes, and El Salvador supports small and medium-size pharmaceutical producers working on generics. In addition to targeting registration, distribution, and production of generics, countries could invest in information campaigns, designed to educate the population on the advantages of using generics as well promoting their use at doctors’ offices and pharmacies. Examples include promoting mass media campaigns to educate patients about the safety and quality of generics; making it mandatory for pharmacists to remind patients whenever there is a generic alternative to the prescription they are receiving; and encouraging pharmacies to sell more generics through performance-based payment mechanisms. Evidence from Argentina (Maceira and Palacios, 2016[27]) suggests that consumer and pharmacists’ attitudes must be taken into account when regulating and promoting the use of generics. Consumers will often express interest in spending less when purchasing drugs but often they are not willing to pick the cheapest generic alternative, even when the pharmacist suggests alternatives at the point of sales. A study of the Chilean experience between 2002 and 2017 of the effect of the entry of branded generic medications (Alvarez, Gonzalez and Fernandez, 2019[28]), found that sales of these HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 47 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS drugs sold rose by 148.1% after four years – an increase driven by their lower cost (on average 33%) than their branded non-generic counterparts. Governance waste Health system fragmentation is a key source of waste in LAC Most health systems in LAC are organised as several parallel subsystems. Usually, these subsystems represent a public component (e.g. managed by the Ministry of Health and funded by general taxes); a social security sector (e.g. public and/or private insurers funded through social contributions and, in some cases, partly by general taxes); and a private sector (e.g. funded directly by users, pre-paid or out-of-pocket). The mix of these three subsystems varies, but they are present in almost all countries, especially since the 1990s, when government-financed insurance schemes and health-service provision to cover poor people and informal workers were introduced or expanded, reinforcing the vertically articulated subsystems with fragmentation of financing and service delivery. This has led to segregation of population segments according to employment and socio-economic status and, often, left the poorest segments without effective coverage in many countries (Atun et al., 2015[29]). Figure 2.9 provides a comparative picture of selected LAC countries where institutional fragmentation leads to duplication of financing and delivery functions (Vermeersch and Mohpal, 2017[30]). In one group, Brazil shows one of the lowest national level of fragmentation, by covering all its citizens with a national health system (SUS); however, around 26% of the population purchases supplementary private insurance. In a second group, Costa Rica, Chile, Colombia, the Dominican Republic, and Uruguay have close to or more than 70% of their population covered by contributory and/or subsidised social security schemes. In a third group, Mexico and Peru have more than 40% of their population affiliated to institutions dependent on the Ministry of Health (Seguro Popular and Seguro Integral de Salud, respectively), along with others covered by social insurance, private insurance, or directly by the ministry. In a fourth group, El Salvador, Nicaragua, Guatemala, Honduras, and Nicaragua have more than 75% of their population served directly by the Ministry of Health, with social insurance covering most of the remainder of the population. From a governance point of view, the sources of waste mainly derive from the stewardship and management of resources and services, and the health-financing functions (OECD, 2017[2]). Table 2.4 provides an overview of the governance functions where waste can be identified in relation to fragmentation, along with examples from selected LAC countries. In practice, the existence of multiple subsystems and actors leads to duplication of tasks, such as enrolment, collection of contributions, claims processing, benefits management, sales and marketing, purchasing and contracting, and compliance with government and non-government regulations. Findings from analyses in OECD countries (OECD, 2017[2]) specifically related to the consequences of fragmentation in administrative spending within health systems provide key insights that can be useful for LAC. First, little difference arises in governments’ administrative costs between tax-based systems with residence-based entitlement and single-payer, insurance-based systems. In LAC, this would be the case when comparing Brazil with Costa Rica and Uruguay. Second, single-payer systems have lower administrative costs than multi-payer systems. In LAC, this could be applied when comparing a single-payer system in Costa Rica and Uruguay with countries having multi-payer schemes, such as Argentina, Chile, Colombia, Mexico, and Peru. Third, multi-payer systems with free choice of insurer tend to have higher administrative costs than multi-payer systems with automatic affiliation. This can be applied to compare multi-insurer countries with automatic affiliation, such as Bolivia, Dominican Republic, Mexico, Panama, and Peru with countries implementing multi-insurer schemes with choice of insurer, such as Argentina, Chile, Colombia, Guatemala, and Surinam. Fourth, private insurance schemes have much higher administrative costs than public schemes. This HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 48 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.9. Fragmentation leading to duplication of financing and provision functions in selected Latin American and Caribbean health systems, 2015 SUS Private+SUS Social security Subsidised Soc. Sec. MOH Plus MOH only Private Other % 110 100 90 80 70 60 50 40 30 20 10 0 Brazil 2015 Costa Rica Chile 2015 Uruguay Colombia Dominican Mexico 2014 Peru 2015 El Salvador Nicaragua Guatemala Honduras 2015 2016 2015 Republic 2015 2014 2015 2015 2016 Note: Countries can appear to have more than 100% of the population covered because of double or even triple health service affiliations. SUS – National Health System in Brazil; Private+SUS – double coverage of SUS plus a private insurance in Brazil; Social Security – Costa Rica (Caja del Seguro Social), Chile (FONASA), Uruguay (FONASA), Colombia (Regimen Contributivo), and Dominican Republic (Regimen Contributivo); Subsidised Social Security – Regimen Subsidiado in Colombia and Dominican Republic; MoH Plus – Mexico (Seguro Popular), Peru (Seguro Integral de Salud), Uruguay (free affiliation to AUSSA); MoH only – Ministry of Health. Source: Vermeersch and Mohpal (2017[30]), Latin America and the Caribbean: A Narrative for the Health Sector. StatLink 2 https://stat.link/uhxb9m finding implicates almost all LAC countries, since private insurance has been established with different characteristics and regulations. For instance, private insurance in Brazil is complementary or supplementary to the coverage provided by the national health system (SUS), while in Chile private insurers (ISAPREs) can receive and manage the mandatory health contribution from their affiliates, but regulation still allows them to ‘cherry-pick’ low-risk and higher-income segments of the population, and gives plenty of freedom to define premiums, benefits, and coverage for a large component of their services. Fragmentation in health care coverage creates silos of the population, in most cases dividing them by social conditions, and undermines efforts aimed at reducing inequalities and achieving efficient health systems. Although some LAC countries have introduced reforms and organisational changes that emphasise the intrinsic value of health for citizens, they have not been able to eliminate the inequities in access, financial protection, and outcomes produced by fragmentation – this remains one of the key challenges in LAC. Measuring expenditure to identify the most efficient disaggregation by function and level of care Data on functional expenditure indicates the share of spending by health systems’ functions and type of care. This can illustrate potential sources of waste. For example, an efficient health system offers an optimal mix of curative care (generally less cost-effective, treats patients as they become sick) and preventative care (generally more cost-effective, targets patients before they become sick). Efficient systems should also aim to reach the appropriate administrative expenditure, avoiding duplications and unnecessary or low-value governance actions. Collecting this data is an effective way to identify administrative and allocative inefficiencies, which account for a significant share of waste in all health systems. Current data availability is limited, with only eight LAC countries reporting this information as of 2019. As data for more countries HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 49 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Table 2.4. Examples of fragmentation-induced waste in the governance structure of selected LAC health systems. Governance area Governance functions Examples of waste sources in selected LAC countries In El Salvador, insurers can freely determine benefits and level of coverage, meaning that services for the population and their co-payments are not the same between the Salvadorian Institute of Social Planning and benefit Security (ISSS), the Salvadorian Institute of Magisterial Welfare (ISBM), the Armed Forces Social basket design Prevision Institute, and the Ministry of Health (which covers around 77% of the population) (Lorenzoni et al., 2019[5]). Chile has several laws regulating the management of human resources in the public sector: one for health workers in primary care administered by municipalities; three laws for doctors, dentists, and Human resources pharmacists working in secondary care and hospitals; and one for all other health workers of Differences in secondary care and hospitals. In addition, the general Labour Code is applied to some health workers stewardship and in the public sector and to all in the private sector (Sugg, Galleguillos and Caravantes, 2018[31]). management of Paraguay collects health information separately from the three subsystems of the health sector, each resources with its own rules and infrastructure. The Ministry of Health collects information by different Health information programmes directly from its providers (e.g. family health units); the Social Security Institute (IPS) and ICT development gathers data from its providers network; and the Superintendence of Health assembles information from private providers (OECD, 2018[32]). In Peru, each of the Institutions for the Administration of Health Insurance Funds (EAFAS) and the Executive Ministry of Health has its own executive management and oversight structure and machinery. management, Therefore, managerial functions such as planning, control and enforcement in the Social Health regulation and Insurance (EsSalud), the Integral Health Insurance (SIS), the Police and Armed Forces Insurances, monitoring and the private sector run mostly in parallel (OECD, 2017[33]). The Dominican Republic collects funds separately for four subsystems having their own accounting and managerial arrangements: the MoH and the National Health Service through general taxes; Resource social contributions from employers and employees for the Contributory Regime of the social mobilisation security fund; general taxes for the Subsidised Regime of the social security fund; and direct pre- paid premiums for private insurers (Rathe, 2018[34]). Argentina has more than 500 private health care insurers, national social insurance organisations, and provincial health insurance organisations; each of them can be considered as a single pooling fund. Only for the insurers of social security (‘Obras Sociales’), which cover 60% of the population, Duplication of Pool funds there is a Solidary Redistribution Fund, where currently only 15 to 20% of social contributions can be health financing distributed across insurers aiming to equalise some of the risks and cover some specific services functions and costs (Cetrángolo and Goldschmit, 2018[35]). Mexican operating institutions – Seguro Popular and State Health Services, social security institutes (IMSS, ISSSTE, PEMEX, SEDENA, and SEMAR), the private sector, as well as the Ministry of Health in a few cases – own and administer their facilities, integrating the functions of purchasing and Purchasing delivering services and pharmaceuticals mostly within their own networks. Duplication occurs for functions such as setting priorities regarding infrastructure needs and services offered, hiring workers, procurement of goods (e.g. pharmaceuticals), and defining payment mechanisms (OECD, 2016[36]). Source: Author’s review and adapted from OECD (2017[2]), Tackling Wasteful Spending on Health, https://dx.doi.org/ 10.1787/9789264266414-en. becomes available, a more precise optimal mix of functional expenditure can be identified to further guide countries to minimise waste. Figure 2.10 shows that the disaggregation of current health expenditure (CHE) by function varies substantially across LAC. Spending on curative care is the largest share in all countries, although it is relatively smaller in Haiti (conversely, Haiti spends a disproportionate amount on medical goods), while the Dominican Republic spends very little on preventive care. The available data suggest that some LAC countries (particularly Costa Rica, Haiti, and Trinidad and Tobago) spend a higher share of CHE on preventative care than OECD countries. OECD countries expenditure on prevention most often falls between 1% and 6%. Although an optimal share of prevention spending has not been established, prevention interventions have been defined as highly cost-effective, which suggests that OECD countries’ limited prevention share leads them to miss opportunities to capitalise on such investments. However, evidence from OECD countries also suggests that a large proportion of prevention spending is used for less cost-effective interventions, HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 50 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.10. Current health expenditure by health care function Inpatient care Long-term care Ancillary services Medical goods Preventative care Governance Other % 100 90 80 70 60 50 40 30 20 10 0 Haiti Guatemala Costa Rica Dominican OECD31 Trinidad and Mexico Suriname Barbados Saint Kitts and Republic Tobago Nevis Source: WHO (2019), Global Health Expenditure Database. StatLink 2 https://stat.link/lud2g1 such as check-ups. Activities such as vaccinations and screening campaigns have been proved to be more cost-effective, suggesting that all countries should examine the composition of their prevention spending to minimise waste. The budget constraints posed by recessions also tend to particularly affect prevention activities, which are often the first function to be scaled down. Maintaining adequate spending in a context of limited funds is a challenge for all countries, but it is critical that cost- effectiveness is considered when making budget reduction decisions. Improving health information systems to reduce waste Good quality data on inputs, outputs, outcomes, processes, and feedback mechanisms are needed to identify sources of inefficiency and areas of potential improvement. In parallel to the necessary data for efficiency-specific interventions, countries should invest in health infrastructure and IT systems that inform policy and clinical processes in an agile and useful way. Figure 2.11 displays the current gap in reporting of vital statistics of mortality data in LAC, the challenge in many countries of adequately tracking life events and clinical information throughout the life of a patient, and his or her interactions with the health system. Unregistered deaths are exceptionally common in Peru, while also high (in descending order, from above 21% to above 15%) in Colombia, Ecuador, Nicaragua, and Antigua and Barbuda. Information technologies can be used both directly and indirectly to reduce waste. Firstly, efficient process in all areas of the health system are dependent on effective information systems. This includes systems to adequately refer patients between facilities and levels of care, to share information in real time to inform decisions at the operational and governance levels, amongst other uses. Secondly, they are fundamental in detecting wasteful practices and unwarranted variations, which can then be addressed more rapidly and precisely. Fragmentation across providers, regions, and levels of care and a divide between policy-makers and health workers on the ground are particularly significant challenges for health information systems in LAC. For example, Peru has invested in an information system capable of producing large amounts of information; however, limited interoperability among different providers and regions challenges the quality, utility, and comprehensiveness of this data. In addition, health information collection is often a HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 51 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.11. Under-reporting of deaths in 22 Latin American and Caribbean countries, 2016 (or latest year available) % of unregistered deaths 50 43.9 40 30 21.6 19.7 20.2 20 14.5 15.7 12.6 8.9 9.4 10.1 10.9 11.1 10 6.7 7.4 0.7 2.4 0.0 0.0 0.0 0.0 0.0 0.0 0.6 0 Source: PAHO (2019[37]), Core Indicators 2019: Health Trends in the Americas, http://www.paho.org/data/index.php/en/indicators.html. StatLink 2 https://stat.link/3yg5k2 burden for front-line health workers, particularly in contexts with limited infrastructure (use of paper records or irregular connectivity). This can lead to reducing both the quality of information and of care provision. In some cases, even when information is adequately collected at the point of care and shared with institutions responsible for its processing, it is often not used in a meaningful way to make evidence-based decisions or to provide feedback to providers (OECD, 2017[38]). The collection of information that has no real purpose or value for the improvement of the system represents a clear example of waste that countries should address as a priority. Another priority for countries looking to build information systems that help reduce waste is developing capacity to track and inform decisions on quality of care. The data collection exercise implemented by the World Bank and OECD in the context of this publication found that very few LAC countries collect quality indicators at the national level, rendering it impossible to perform a comparable and comprehensive assessment of quality of care. Since quality is a key dimension of UHC, countries should aim to better measure it in order to drive its development, parallel to efforts to improve access and financial protection. Improving governance and institutions in LAC health systems Ineffective governance and institutions are an important driver of inefficiency. In some cases, miscarried governance processes take the form of corruption, where actors deliberately divert resources from the health care system in their own self-interest or in the interest of a group they support. These integrity violations prevail in all countries around the world and can take place in the context of a vast array of transactions involving providers of health services, payers of these services, and/or recipients/consumers. In addition, they can occur in the procurement and distribution of medical goods and services, and the promotion of corporate/industrial interests in the health sector (OECD, 2017[2]). Corruption in health can affect the financial arena, with waste developing in direct (money is diverted from the system) and indirect ways (the risk of corruption requires additional investments in prevention or detection activities). Furthermore, integrity violations can impact the quality of goods and services (e.g. provision of substandard quality of medicines or equipment or of unnecessary HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 52 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS service), access to care and equity (e.g. informal payments can discourage access), allocative efficiency across sectors (e.g. spending less on health), and public trust and welfare (OECD, 2017[2]). Integrity violations in health are difficult to measure, including because the understanding of what may constitute fraud, abuse, and corruption is not uniform. However, surveys to assess people’s perceptions of such incidences are at least suggestive as proxies and allow cross-country comparisons. Figure 2.12 displays the percentage of the population that believes the health sector to be corrupt or very corrupt for 12 LAC countries with available data, the OECD average for 28 countries, and the global average for 103 countries. The level of perceived corruption in health within LAC countries varies between 63% in Colombia and 22% in Jamaica, with an average of 42%, higher than the OECD28 average of 34% and lower than the global average of 45%. Figure 2.12. Percentage of the population that considers the health sector to be corrupt or very corrupt in LAC countries with data % 70 60 50 40 30 20 10 0 Jamaica Argentina Uruguay OECD28 Bolivia El Paraguay LAC12 Mexico Global Peru Chile Venezuela Brazil Colombia Salvador average Note: The global average includes 103 countries. The OECD and LAC average includes 28 and 12 countries, respectively. Source: Transparency International (2013[39]), Global Corruption Barometer 2013, https://www.transparency.org/gcb2013/report. StatLink 2 https://stat.link/if2xvk Figure 2.13 shows the rates of people who stated that they had given bribes in their encounters with public clinics and health centres in 18 LAC countries. Venezuela stands out, with 34% of people declaring to given bribes, followed by Peru (19%), Mexico (16%), and Honduras (15%). At the other end of the spectrum, less than 5% of the populations of Costa Rica, Brazil, and Barbados stated that they had given bribes to health institutions. The main stakeholders to be addressed by policies and actions to tackle corruption-related waste include providers of medical goods and services, suppliers or manufacturers of medical goods and services, payers of such goods and services, the regulatory sector, and individuals. All of these actors can either resist/respond or be the victim of corruption. Integrity violations by these stakeholders can occur in health service delivery, payment, and coverage decisions; in procurement and distribution; and through inappropriate business practices (Transparency International, 2006[41]). Some OECD countries have developed policies related to the active detection of integrity violations in service delivery and financing, using data mining and review campaigns. In addition, other countries have regulated the relationship between public and private actors, mainly by increasing transparency, for instance, mandating the disclosure of financial relationships and HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 53 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS Figure 2.13. Bribery rates in public clinics and health centres based on people who used these public services in the previous 12 months, 2019 % 40 34 35 30 25 19 20 16 15 14 15 12 11 11 10 10 8 8 8 8 7 7 6 5 5 4 5 0 Source: Transparency International (2019[40]), Global Corruption Barometer, Latin America & the Caribbean 2019. Citizens’ views and experiences of corruption, https://www.transparency.org/files/content/pages/2019_GCB_LatinAmerica_Caribbean_Full_Report.pdf. StatLink 2 https://stat.link/5zxkd2 transfers of value (e.g. Sunshine Acts). In particular with respect to the pharmaceutical sector, codes of conduct have been developed and implemented, mostly as self-regulation initiatives (OECD, 2017[2]). These actions align with policy recommendations, such as ensuring people can safely report corruption, guaranteeing that punishments are fairly given, enabling NGOs to operate freely, and empowering citizens to hold governments to account (Transparency International, 2019[40]). In LAC, several countries have put in place regulations to control corruption. For instance, with the exception of Bolivia, Costa Rica, Cuba, and Venezuela, most countries in the region have laws that guarantee access to official information, including from the health sector (UNESCO, 2017[42]). Conclusion This chapter has discussed the importance of identifying and reducing wasteful health spending for countries in LAC, in a context of a necessary expansion of health financing and a shift toward less reliance on private health expenditures as paths to high-quality universal health coverage. As countries face recurrent limitation of public funds, technological innovation, and changing epidemiological and demographic profiles, they should invest in their capacity to keep waste at minimum levels in all dimensions and areas of health systems. This will help free up existing resources and increase the willingness of key stakeholders for the mobilisation of additional resources for health. Furthermore, it will contribute to ensure the long-term sustainability of health systems and its resilience against current or future lack of funds or emerging challenges. The chapter has identified specific areas of waste and has recognised tools that LAC countries can use to reduce it in three areas of the health system: • Clinical-level care: Waste at the clinical level can be tackled by first investing in the capacity to identify unwarranted variations, which helps decision-makers understand where waste is more prevalent and what factors are influencing it. Clinical-level waste can also be addressed by reducing procedures that add little or no value to the system and the patient and in some cases may even increase harm to them. In addition, promoting rational use of medicines through incentives to only prescribe and consume antibiotics when necessary helps curtail expenditure and the threat posed by antimicrobial resistance. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 54 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS • Operational waste: Countries should develop their prioritisation mechanisms further, such as the capacity to establish what technologies bring the best value through Health Technology Assessments and the use of such findings for decision-making. They can tackle the overuse of hospital resources by reducing admissions for conditions that can be more efficiently treated at the primary-care level and by ensuring that patients can be discharged as quickly (but not prematurely) and safely as possible. The use of generics should be incentivised to ensure that resources are not wasted in more expensive branded alternatives. • Governance waste: Waste can also be addressed at the governance dimension. First, the fragmented structure of the majority of LAC health systems is a major source of waste, which will require further revision and reforms. Moreover, establishing an efficient balance in a country’s functional expenditure is key to reduce wasteful resources in a functional category while underfunding another one. Countries should ensure that their information systems are able to track performance and produce useful data, while investing in their capacity to analyse such information and use it to inform decisions at all levels. Finally, there is evidence that LAC health systems are not free of intentional efforts to take financial advantage of institutional weaknesses for personal profit – highlighting the need to enhance system integrity in both the public and private components of the health sector. Any successful effort to reduce waste must proceed in a comprehensive and holistic manner. It must also be based on the engagement of all health system actors and on effective communication and transparency. Ensuring that both patients and providers are well-informed and understand how their choices play a role in the larger picture of the health system is key. Evidence shows that several LAC countries have been undertaking well-targeted efforts to reduce waste but additional improvements are within reach for all health systems in the region. Without cutting health budgets and even considering the needs to increase government health expenditure, being more efficient and achieving better results for people who need it the most are not mutually exclusive. When policies are properly designed and implemented, these objectives can be synergic. References [16] ABIM Foundation (2020), Choosing Wisely | Promoting conversations between providers and patients, http:// www.choosingwisely.org/ (accessed on 29 January 2020). [28] Alvarez, R., A. Gonzalez and S. Fernandez (2019), “The Competitvie Impact of Branded Generic Medicine in a Developing Country”, Universdiad de Chile, Departamento de Economía. [29] Atun, R. et al. (2015), Health-system reform and universal health coverage in Latin America, Lancet Publishing Group, http://dx.doi.org/10.1016/S0140-6736(14)61646-9. [35] Cetrángolo, O. and A. Goldschmit (2018), Las obras sociales y otras instituciones de la seguridad social para la salud en Argentina. Origen y situación actual de un sistema altamente desigual, CECE, http:// fcece.org.ar/wp-content/uploads/informes/obras-sociales-argentina.pdf (accessed on 15 November 2019). [26] FNE (2019), Estudio de Mercado sobre Medicamentos (EM03-2018) : Informe_preliminar, Fiscalía Nacional Económica de Chile, Santiago, https://www.fne.gob.cl/wp-content/uploads/2019/11/Informe_preliminar.pdf. [3] Guanais, F., R. Gómez-Suárez and L. Pinzón (2012), “Series of Avoidable Hospitalizations and Strenghening Primary Health Care: Primary Care Effectivenss and the Extent of Avoidable Hospitalizations in Latin America”, Inter-American Development Bank Discussion Paper, https://publications.iadb.org/en/publication/11805/ series-avoidable-hospitalizations-and-strengthening-primary-health-care-primary. [20] Hernández-Gómez, C. et al. (2016), “Economic Impact of an Antimicrobial Stewardship Program Implementation in Three High-Complexity Hospitals in Colombia”, Open Forum Infectious Diseases, Vol. 3/ suppl_1, http://dx.doi.org/10.1093/ofid/ofw172.726. [25] IQVIA (2019), Precio de los Medicamentos en América Latina, Análisis Comparativo, https:// www.cepal.org/es/publicaciones/45423-analisis-comparativo-precios-medicamentos-america-latina. [10] Izquierdo, A., C. Pessino and G. Vuletin (2018), Better Spending for Better Lives: How Latin America and the Caribbean Can Do More with Less, InterAmerican Development Bank, https://publications.iadb.org/ HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 55 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS publications/english/document/Better-Spending-for-Better-Lives-How-Latin-America-and-the-Caribbean- Can-Do-More-with-Less.pdf. [8] Kim (2014), Atlas de variaciones geográficas en salud de Colombia, Ministerio de Salud y Protección Social, Gobierno de Colombia. [23] Leppin, A. et al. (2014), Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials, American Medical Association, http://dx.doi.org/10.1001/jamainternmed.2014.1608. [5] Lorenzoni, L. et al. (2019), “Health systems characteristics: A survey of 21 Latin American and Caribbean countries”, OECD Health Working Papers, OECD Publishing, Paris, https://doi.org/10.1787/0e8da4bd-en. [27] Maceira, D. and A. Palacios (2016), “Percepciones, Actitudes y Patrones en el Consumo de Medicamentos”, Centro de Estudios de Estado y Sociedad. [11] Magne, F. et al. (2017), “The Elevated Rate of Cesarean Section and Its Contribution to Non-Communicable Chronic Diseases in Latin America: The Growing Involvement of the Microbiota”, Frontiers in Pediatrics, Vol. 5, http://dx.doi.org/10.3389/fped.2017.00192. [9] MINSALUD (2019), Colombian Atlas of Geographical Variations SISPRO, Sistema Integrado de Información de la Protección Social, Colombia, https://sig.sispro.gov.co/sigmsp/index.html (accessed on 4 October 2019). [14] OECD (2019), OECD Health Statistics 2019, https://doi.org/10.1787/health-data-en. [32] OECD (2018), Multi-dimensional Review of Paraguay : Volume 2. In-depth Analysis and Recommendations., OECD Publishing, http://dx.doi.org/doi.org/10.1787/23087358. [19] OECD (2018), Stemming the Superbug Tide: Just A Few Dollars More, OECD Health Policy Studies, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264307599-en. [38] OECD (2017), Monitoring Health System Performance in Peru: Data and Statistics, OECD Reviews of Health Systems, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264282988-en. [33] OECD (2017), OECD Reviews of Health Systems: Peru 2017, OECD Reviews of Health Systems, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264282735-en. [2] OECD (2017), Tackling Wasteful Spending on Health, OECD Publishing, Paris, https://dx.doi.org/ 10.1787/9789264266414-en. [36] OECD (2016), OECD Reviews of Health Systems: Mexico 2016, OECD Reviews of Health Systems, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264230491-en. [7] OECD (2014), Geographic Variations in Health Care: What Do We Know and What Can Be Done to Improve Health System Performance?, OECD Health Policy Studies, OECD Publishing, Paris, https://dx.doi.org/ 10.1787/9789264216594-en. [1] OECD et al. (2019), Latin American Economic Outlook 2019: Development in Transition, OECD Publishing, Paris, https://dx.doi.org/10.1787/g2g9ff18-en. [21] PAHO (2019), Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA), Health Technology Assessments Network for the Americas (RedETSA), http://sites.bvsalud.org/redetsa/brisa/ (accessed on 5 October 2019). [37] PAHO (2019), Core Indicators 2019: Health Trends in the Americas, PLISA Database, http://www.paho.org/ data/index.php/en/indicators.html. [17] PAHO and FIU (2018), Recommendations for Implementing Antimicrobial Stewardship Programs in Latin America and the Caribbean: Manual for Public Health Decision-Makers, Pan American Health Organization. Florida International University, Washington, D.C., http://iris.paho.org/xmlui/handle/123456789/49645. [4] Pinto, D. et al. (2018), More efficiency for healthier lives, Inter-American Development Bank. [34] Rathe, M. (2018), “Dominican Republic: Implementing a health protection system that leaves no one behind”, Universal Health Coverage Study Series, No. 30, World Bank Group, Washington DC, http://dx.doi.org/ 10.1596/29182. [24] Renaudin, P. et al. (2016), “Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis”, British Journal of Clinical Pharmacology, Vol. 82/6, pp. 1660-1673, http://dx.doi.org/10.1111/bcp.13085. [22] Rojas-García, A. et al. (2017), “Impact and experiences of delayed discharge: A mixed-studies systematic review”, Health Expectations, Vol. 21/1, pp. 41-56, http://dx.doi.org/10.1111/hex.12619. [12] Stordeur, S. et al. (2016), Elective Caesarean Section in Low-Risk Women at Term: Consequences for Mother and Offspring, Belgian Health Care Knowledge Centre. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 56 2. IDENTIFYING AND TACKLING WASTEFUL SPENDING IN LATIN AMERICAN AND CARIBBEAN HEALTH SYSTEMS [31] Sugg, D., P. Galleguillos and R. Caravantes (2018), Caracterización del Gasto en Personal de los Servicios de Salud, Dirección de Presupuestos, Ministerio de Hacienda, https://www.dipres.gob.cl/598/ articles-171767_doc_pdf.pdf. [40] Transparency International (2019), Global Corruption Barometer, Latin America & the Caribbean 2019. Citizens’ views and experiences of corruption, Transparency International, https://www.transparency.org/files/ content/pages/2019_GCB_LatinAmerica_Caribbean_Full_Report.pdf. [39] Transparency International (2013), Global Corruption Barometer 2013, https://www.transparency.org/ gcb2013/report. [41] Transparency International (2006), Global Corruption Report 2006: Corruption and health, https:// www.transparency.org/whatwedo/publication/global_corruption_report_2006_corruption_and_health. [42] UNESCO (2017), Access to information: lesson from Latin America, UNESCO Office Montevideo and Regional Bureau for Science in Latin America and the Caribbean, https://unesdoc.unesco.org/ark:/48223/ pf0000249837. [30] Vermeersch, C. and A. Mohpal (2017), Latin America and the Caribbean: A Narrative for the Health Sector, The World Bank. [6] Wennberg, J. (2011), “Time to tackle unwarranted variations in practice”, BMJ, Vol. 342/mar17 3, pp. d1513- d1513, http://dx.doi.org/10.1136/bmj.d1513. [13] WHO (2019), Global Health Observatory data, https://www.who.int/gho/en/ (accessed on 5 October 2019). [18] WHO (2018), WHO Report on Surveillance of Antibiotic Consumption: 2016 - 2018 Early implementation, World Health Organisation, Geneva, https://apps.who.int/iris/bitstream/handle/ 10665/277359/9789241514880-eng.pdf?ua=1. [15] WHO (2015), WHO statement on caesarean section rates, World Health Organisation, Geneva, https:// apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf?sequence=1. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 57 Health at a Glance: Latin America and the Caribbean 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 Chapter 3 Health status 59 3. LIFE EXPECTANCY AT BIRTH Life expectancy at birth continues to rise in the Latin American and fertility rate, increased smoking by men, and the reduction of Caribbean (LAC) region, driven by the steady reduction of mortality infectious diseases that disproportionately benefited women at all ages, and particularly of infant and child mortality in all (Goldin and Lleras-Muney, 2018[2]). In addition, in LAC the gender countries (see indicators “Infant mortality” and “Under age 5 gap can also be understood because of the prevalence of violence mortality”). These gains in longevity can be attributed to a number in many countries that affects more men than women (see section of factors, including rising living standards, better nutrition and on “Mortality from injuries”). improved drinking water and sanitation facilities (see indicator Socioeconomic status and education play an important role in life “Water and sanitation” in Chapter 4). Improved lifestyles, increased expectancy as seen in the case of a diverse range of LAC countries education and greater access to quality health services also play an such as Colombia, Dominican Republic, Guatemala and Haiti, important role (Raleigh, 2019[1]). where the higher educational background of mothers and Life expectancy at birth for the whole population across the LAC31 household wealth are associated with better infant and child region reached 74.5 years on average in 2017, a gain of almost survival (see indicators “Infant mortality” and “Under age 5 4 years since 2000. In comparison, OECD countries gained mortality”). 3.6 years during the same period (Figure 3.1, left panel). However, a large regional divide persists in life expectancy at birth. The countries with the longest life expectancy in 2017 were Costa Rica Definition and comparability and Chile just over 80 years old, closely followed by Cuba just below that number. In contrast, three countries in the LAC region Life expectancy at birth is the best-known measure of had total life expectancies of less than 70 years (Haiti, Guyana and population health status and is often used to gauge a Bolivia). In Haiti, a child born in 2017 can expect to live an average country’s health development. It measures how long, on of less than 64 years. average, a new-born infant can expect to live if current death Women live longer than men do (Figure 3.1, right panel), but the rates do not change. Since the factors affecting life degree of disparity also varies across countries. The gender gap in expectancy often change slowly, variations are best life expectancy stood at 5.7 years on average across assessed over long periods of time. Age-specific mortality LAC31 countries in 2017, higher than the OECD countries average rates are used to construct life tables from which life of 5.3 years. The gender difference was particularly large in expectancies are derived. The methodologies that countries Venezuela and El Salvador with more than eight and more than use to calculate life expectancy can vary somewhat, and nine years gap, respectively. Women also have greater rates of these can lead to differences of fractions of a year. Some survival to age 65 (Figure 3.2), regardless of the economic status of countries base their life expectancies on estimates derived the country. On average across LAC countries, 83.2% of a cohort of from censuses and surveys, and not on accurate registration new-born infant women would live to age 65, while only 73.8% of of deaths. Survival to age 65 refers to the percentage of a males would live to age 65. Only in Costa Rica more than 90% of cohort of new-born infants that would survive to age 65, if new-born infant women are expected to live to age 65, still below subject to current age-specific mortality rates. the OECD average of 90.9%. Higher national income – as measured by GDP per capita – is generally associated with higher life expectancy at birth (Figure 3.3). There were, however, some notable differences in life References expectancy between countries with similar income per capita. For [2] Goldin, C. and A. Lleras-Muney (2018), “XX>XY?: The Changing instance, Costa Rica had higher, and Trinidad and Tobago had Female Advantage in Life Expectancy”, No. 24716, NBER, lower life expectancies than predicted by their GDP per capita Cambridge, MA, https://www.nber.org/papers/w24716.pdf. alone. [1] Raleigh, V. (2019), “Trends in life expectancy in EU and other OECD Regarding gender-based differences in life expectancy, it can be countries : Why are improvements slowing?”, OECD Health explained by changes occurred in the past century such as Working Papers, No. 108, OECD Publishing, Paris, https:// reductions in maternal mortality as well as the decrease in the total dx.doi.org/10.1787/223159ab-en. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD and World Bank Group 2020 60 3. LIFE EXPECTANCY AT BIRTH Figure 3.1. Life expectancy at birth, by sex, 2000 and 2017 (or nearest year) 2017 2000 Females Males Haiti 63.6 57.7 61.4 65.8 Guyana 66.8 64.9 64.5 69.2 Bolivia 67.0 69.5 60.7 72.1 Belize 67.9 73.6 70.6 68.3 Trinidad and Tobago 67.4 74.4 70.8 68.5 Suriname 68.4 74.9 71.5 67.8 Paraguay 71.1 75.5 73.2 70.1 70.6 Saint Vincent and the Grenadines 71.2 75.6 73.3 73.7 67.8 Guatemala 70.4 76.8 73.8 68.8 El Salvador 69.1 78.1 73.8 70.5 Honduras 71.2 76.3 73.8 70.3 Grenada 71.4 76.3 74.0 70.6 Dominican Republic 71.0 77.3 74.5 70.8 LAC31 71.6 77.4 74.6 71.0 Colombia 71 78.2 74.7 72.3 Venezuela 70.8 78.9 75.2 70.5 Peru 72.6 77.9 75.4 74.4 Mexico 72.9 77.9 75.7 69.7 Nicaragua 72.6 78.6 75.7 71.5 Saint Lucia 73.0 78.4 75.7 70.1 Brazil 72.1 79.3 75.8 72.4 Bahamas 72.7 78.8 76.1 73.4 Barbados 73.6 78.4 76.1 72.3 Jamaica 73.7 78.5 76.5 73.5 Antigua and Barbuda 74.0 78.9 76.6 72.9 Ecuador 73.9 79.3 76.7 73.8 Argentina 73.0 80.4 77.6 74.8 Uruguay 74.0 81.0 78.2 75.1 Panama 75.3 81.3 79.9 76.7 Cuba 78.0 81.9 80.2 76.8 Chile 77.4 83.1 80.3 77.4 Costa Rica 77.8 82.9 80.7 77.1 OECD36 78.1 83.3 90 80 70 60 50 50 60 70 80 90 Years Years Source: The World Bank World Development Indicators Online 2019, Ministry of Health for Costa Rica. StatLink 2 https://stat.link/k5bf8t Figure 3.2. Survival rate to age 65, 2017 (or nearest year) Figure 3.3. Life expectancy at birth and GDP per capita, 2017 (or nearest year) Females Males Life expectancy in years Haiti Guyana 59.0 62.3 67.1 72.1 83 Bolivia 66.6 74.3 CRI CHL OECD Trinidad and Tobago 66.9 79.8 81 Paraguay 73.8 80.2 PAN Belize 67.6 80.3 Suriname 67.6 80.7 URY Saint Vincent and the Grenadines 74.1 80.8 79 MEX Honduras 73.7 81.2 ECU ARG Dominican Republic 71.1 81.5 Guatemala LAC31 71.1 73.8 82.1 83.2 77 NIC JAM BRA BRB BHS Nicaragua 73.9 83.6 PER ATG Bahamas 73.7 83.7 LCA Saint Lucia 75.1 83.7 75 HND LAC29 Grenada 72.6 84.2 SLV El Salvador 67.1 84.3 COL DOM Peru 76.3 84.6 73 GTM VCT GRD Venezuela 72.6 84.9 PRY TTO Colombia 73.3 85.0 BLZ R² = ,0.47 Jamaica 77.4 85.0 71 Antigua and Barbuda 78.6 85.1 SUR Brazil 73.4 85.2 BOL Ecuador 77.4 85.9 Mexico 78.8 86.4 69 Panama 78.6 87.3 GUY Uruguay 79.0 87.4 Argentina Barbados 76.8 79.9 87.8 88.0 67 Cuba 83.8 88.7 Chile 83.5 89.0 65 HTI Costa Rica 83.6 90.1 OECD 84.1 90.9 40 50 60 70 80 90 100 63 % of cohort 0 10 20 30 40 50 GDP per capita (PPP USD, thousands) Source: The World Bank World Development Indicators Online 2019. StatLink 2 https://stat.link/o583lx Source: The World Bank World Development Indicators Online 2019, Ministry of Health for Costa Rica. StatLink 2 https://stat.link/0slp4z HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 61 3. INFANT MORTALITY Infant mortality, deaths in children aged less than one year, reflects infections, pneumonia, diarrhoea and malaria is also critical. Oral the effect of economic, social and environmental conditions on the rehydration therapy is a cheap and effective means to offset the health of mothers and infants, as well as the effectiveness of health debilitating effects of diarrhoea, and countries could also implement systems. Factors such as the education of the mother, quality of relatively inexpensive public health interventions including antenatal and childbirth care, preterm birth and birth weight, immunisation, and provide clean water and sanitation (see indicator immediate new-born care and infant feeding practices are “Water and sanitation” in Chapter 4 and “Childhood vaccination important determinants of infant mortality (see sections “Preterm programmes” in Chapter 7). Reductions in infant mortality will birth and low birthweight” and “Pregnancy and birth” in Chapter 4). require not only the aforementioned strategies, but also ensuring Diarrhoea, pneumonia, infection and undernutrition continue to be that all segments of the population benefit from these among the leading causes of death in both mothers and infants see improvements (Gordillo-Tobar, Quinlan-Davidson and Mills, sections “Child malnutrition (including undernutrition and 2017[4]). overweight)” and “Overweight or obese adults” in Chapter 4]. In the LAC region, around one third of the deaths in the first year of life occur during the neonatal period (i.e. during the first four weeks of life or days 0‑27) (Black et al., 2016[3]). Definition and comparability In 2017, the infant mortality average in LAC was 15.7 deaths per Infant mortality rate is defined as the number of children 1 000 live births. Infant mortality was lower in countries such as who die before reaching their first birthday in a given year, Cuba, Antigua and Barbuda, The Bahamas and Chile (under 7 expressed per 1 000 live births. Some countries base their deaths per 1 000 live births), while higher in Guyana, Bolivia and infant mortality rates on estimates derived from censuses, particularly Haiti (26, 28 and 54 per 1 000 live births, respectively) surveys and sample registration systems, and not on (Figure 3.4). Between 2000 and 2017, the average infant mortality accurate and complete registration of births and deaths. rate has fallen by 35% in the LAC region, with the majority of Differences among countries in registering practices for countries experiencing declines between 25% and 45% premature infants may also add slightly to international (Figure 3.4). Antigua and Barbuda, Bahamas, Brazil and Peru saw variations in rates. Infant mortality rates are generated by declines of over 55%. Both Grenada and Venezuela experienced either applying a statistical model or transforming under increases in infant mortality rate, particularly the latter, with a nearly age 5 mortality rates based on model life tables. 40% increase. Data on mortality by socio-economic conditions is from Across countries, important determinants of infant mortality rates DHS surveys and MICS. These surveys allow for the are income status and mother education. For instance, in disaggregation of household data by education level (no Colombia, infant mortality is more than four times higher in the education and primary vs secondary and tertiary), income poorest quintile compared to the richest quintile, and almost (lowest and highest quintiles of income) and rural and urban five times higher when mothers have low education than higher (no residency. education or primary vs secondary or tertiary). Geographical location (urban or rural) is another determinant of infant mortality in the region, though relatively less important in comparison to income or mother’s education. For example, infant mortality rate in rural areas of Peru reaches 25 deaths per 1 000 live births, compared to References 16 deaths per 1 000 live births in urban areas (Figure 3.5). [3] Black, R. et al. (2016), Reproductive, Maternal, Newborn, and Child Infant mortality can be reduced through cost-effective and Health, The International Bank for Reconstruction and appropriate interventions. These include immediate skin-to-skin Development / The World Bank, http://dx.doi.org/ contact between mothers and new-borns after delivery, early and 10.1596/978-1-4648-0348-2. exclusive breastfeeding for the first six months of life, and kangaroo [4] Gordillo-Tobar, A., M. Quinlan-Davidson and S. Mills (2017), mother care for babies weighing 2 000g or less. Postnatal care for Maternal and child health : the World Bank Group’s response to mothers and new-borns within 48 hours of birth, delayed bathing sutainable development goal 3 : Target 3.1 and 3.2, The World until after 24 hours of childbirth and dry cord care are important to Bank, http://documents.worldbank.org/curated/en/9964615112552 reducing infant deaths. Management and treatment of neonatal 44233/Target-3-1-and-3-2. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 62 3. INFANT MORTALITY Figure 3.4. Infant mortality rates, 2000 and 2017 (or nearest year) 2000 2017 Per 1 000 live births 80 70 60 54 50 40 26 26 28 30 23 23 25 16 16 17 18 18 20 9 12 12 12 12 12 13 13 13 13 14 15 15 15 15 4 5 6 7 7 8 10 4 0 Source: The World Bank World Development Indicators Online 2019, Ministry of Health for Costa Rica. StatLink 2 https://stat.link/k4gt81 Figure 3.5. Infant mortality rate ratios by socio-economic and geographic factor, selected countries and latest year available Lowest education Highest education Rural Urban Infant deaths per 1 000 live births Infant deaths per 1 000 live births 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Lowest wealth quintile (poorest) Highest wealth quintile (richest) Infant deaths per 1 000 live births 100 90 80 70 60 50 40 30 20 10 0 Haiti (2016-17) Colombia (2015) Guatemala (2014-15) Dominican Republic Honduras (2011-12) Peru (2012) (2013) Source: Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) 2005‑14. StatLink 2 https://stat.link/9p7dt2 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 63 3. UNDER AGE 5 MORTALITY The under age 5 mortality rate is an indicator of child health as well In order to achieve the SDG target, countries can accelerate their as the overall development and well-being of a population. In 2017, efforts, for example by scaling effective preventive and curative 5.4 million children died worldwide before their fifth birthday and interventions including early essential new-born care, vitamin A 3.5% of these deaths (188 000) occurred in the LAC region supplementation, vaccines for rotavirus and measles, safe water (UNICEF et al., 2018[5]). As part of their Sustainable Development and improved sanitation, breastfeeding and adequate Goals (SDG), the United Nations has set a target of reducing under complementary food, hand-washing with soap, and improved case age 5 mortality to at least as low as 25 per 1 000 live births by 2030. management. An integrated approach targeting the main causes of The main causes of death among children under five include post-neonatal deaths, namely pneumonia, diarrhoea, malaria and preterm birth complications (18%), pneumonia (12%), intrapartum- undernutrition, and reaching the most vulnerable new-born babies related complications (8%) and sepsis (7%). Undernutrition, and children, could produce a 14% reduction in the under‑5 suboptimal breastfeeding and zinc deficiency are overlapping risk mortality rate (PAHO, 2017[6]). The benefits would be two‑fold: a factors of childhood diarrhoea and pneumonia – the leading decrease in the short-term mortality rates, and healthier survivors infectious causes of childhood morbidity and mortality (PAHO, with better outcomes in the long-run. 2017[6]). In this context, the UN General Assembly has also proclaimed the UN Decade of Action on Nutrition (2016‑25). The global under-five mortality rate was estimated by the World Definition and comparability Bank at 39 per 1 000 live births, while the average under-five Under age 5 mortality is defined as the probability of a child mortality rate across LAC33 countries was 19 deaths per 1 000 live born in a given year dying before reaching their fifth birthday, births (Figure 3.6). Cuba, Bahamas, Antigua and Barbuda, Chile, and is expressed per 1 000 live births. Since under age 5 Uruguay and Costa Rica achieved rates of less than 10 deaths per mortality is derived from a life table, it is, strictly speaking, not 1 000 live births. Mortality rates in Bolivia, Dominica, Guyana and a rate but a probability of death. Age-specific mortality rates Venezuela were high, between 31 and 35 deaths per 1 000 live are used to construct life tables from which under age 5 births, while rates in Haiti were very high, reaching 71.7 deaths per mortality is derived. Some countries base their estimates on 1 000 live births. These countries also had the highest infant censuses, surveys and sample registration systems, and not mortality in the region as seen in the previous section. on accurate and complete registration of deaths. See Whilst under age 5 mortality has declined by an average of 46% in indicator “Infant mortality” for definition of rate ratios. LAC countries between 2000 and 2017, progress varies Data on mortality by socio-economic conditions is from significantly among countries. Countries such as Bolivia, El DHS surveys and MICS. These surveys allow for the Salvador, Peru and Brazil reported a drop of over 55%, while in disaggregation of household data by education level (no Dominica increased by 121%, in Venezuela by 42%, and in education and primary vs secondary and tertiary), income Grenada by 6%. Haiti saw a reduction of 31% in the period, which is (lowest and highest quintiles of income) and rural and urban still below the improvement in the region. residency. As is the case for infant mortality (see indicator “Infant mortality” in Chapter 3), inequalities in under age 5 mortality rates also exist within countries. Across countries, under age 5 mortality rates consistently vary based on household income and mother’s education, and to a certain extent by geographical location. For References example, in Haiti under age 5 mortality was around three times [6] PAHO (2017), Health in the Americas+, 2017 Edition. Summary: higher among children whose mother had no o little education Regional Outlook and Country Profiles, Pan American Health compared to those whose mother had more than secondary Organization, Washington, D.C., https://www.paho.org/salud-en- education. Inequality by education level was also large in Guyana las-americas-2017/wp-content/uploads/2017/09/Print-Version- and Peru. In Peru, Honduras and Haiti, disparities in under age 5 English.pdf. mortality according to income were also large with children in the [5] UNICEF et al. (2018), Levels and Trends in Child Mortality Report poorest 20% of the population above or around two times more 2018, UNICEF Publications, https://www.unicef.org/publications/ likely to die before their fifth birthday than those in the richest 20%. index_103264.html. Inequalities in mortality rates based on geographic locations were relatively small (Figure 3.7). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 64 3. UNDER AGE 5 MORTALITY Figure 3.6. Under age 5 mortality rates, 2000 and 2017 (or nearest year) 2000 2017 Per 1 000 live births 120 100 80 72 60 31 34 35 40 26 28 30 31 13 14 14 15 15 15 15 15 15 16 16 17 17 17 18 19 20 21 20 7 7 7 8 9 10 12 5 5 0 Source: UN IGME 2019. StatLink 2 https://stat.link/04ub2r Figure 3.7. Under age 5 mortality rate ratios by socio-economic and geographic factor, selected countries and years Lowest education Highest education Rural Urban Under age 5 deaths per 1 000 live births Under age 5 deaths per 1 000 live births 125 125 100 100 75 75 50 50 25 25 0 0 Lowest wealth quintile (poorest) Highest wealth quintile (richest) Under age 5 deaths per 1 000 live births 125 100 75 50 25 0 Colombia (2010) Dominican Republic Guyana (2009) Haiti (2012) Honduras (2011-12) Peru (2012) (2014) Source: Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) 2005‑14. StatLink 2 https://stat.link/p01qr2 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 65 3. MORTALITY FROM ALL CAUSES Cumulative development in countries is bringing an countries in the LAC region, accounting for 10% of deaths in 2017. “epidemiological transition”, whereby early deaths are replaced by The remaining 8% of deaths are attributed to injuries and violence. late deaths, and communicable diseases are substituted by non- The level of all-cause mortality and the causes of death are communicable diseases (Omran, 2005[7]). This is also the case in important for identifying the country’s public health priorities and LAC, where the burden from non-communicable diseases among assessing the effectiveness of a country’s health system. This can adults – the most economically productive age group – is rapidly be complemented with multiple data to understand the increasing. relationships with other factors and also forecast future health There are wide disparities in adult mortality in the LAC region. For scenarios, which can guide decision making about funding and men in 2016, the probability of dying between ages 15 and 60 actions in health systems (Foreman et al., 2018[8]). ranged from a low of 114 per 100 000 population in Chile to 311 per 100 000 in Guyana (Figure 3.8). It also exceeded 260 per 100 000 population in Haiti and El Salvador. Among women, the probability ranged from 60 per 100 000 population in Chile to 211 in Haiti. Definition and comparability Mortality was higher among men than women across all countries, and the ratio was higher in countries with overall lower mortality Mortality rates are calculated by dividing annual numbers rates. Mortality rates for men were two times the rates for women or of deaths by mid-year population estimates. Rates have higher in most countries. Across LAC31, the average probability of been age-standardised to the UN World Population dying was 184 per 100 000 population for adult men and 108 per Prospects to remove variations arising from differences in 100 000 population for adult women, still much higher than the age structures across countries. Complete vital registration average adult mortality in OECD countries (104 per 100 000 systems do not exist in many developing countries, and population for men and 53 per 1 000 population for women). about one‑third of countries in the region do not have recent All-cause mortality for the entire population ranged from less than data. Misclassification of causes of death is also an issue. 700 per 100 000 population in The Bahamas, Chile and Barbados, The WHO Global Health Estimates (GHE) project draws on a to over 1 000 in Honduras and Haiti (Figure 3.9). The average all- wide range of data sources to quantify global and regional cause mortality rate in the LAC region was nearly double the effects of diseases, injuries and risk factors on population average among OECD-countries. Nonetheless, mortality for the health. WHO has also developed life tables for all member entire population declined by an average of 13% in the LAC region states, based on a systematic review of all available between 2000 and 2017. The largest declines were in Guatemala, evidence on mortality levels and trends. The probability of Honduras, El Salvador, Nicaragua, Chile and Dominican Republic dying between 15 and 60 years of age (adult mortality rate) (over 15% decrease). Overall mortality for all populations is highly derive from these life tables. related with adult mortality across countries in the region; Haiti having the highest adult mortality for both men and women, as well as the highest all-cause mortality. The share of deaths due to non-communicable diseases is References increasing in LAC countries. Non-communicable diseases such as [8] Foreman, K. et al. (2018), “Forecasting life expectancy, years of life cardiovascular diseases and cancers were the most common lost, and all-cause and cause-specific mortality for 250 causes of causes of death, being responsible for over 82% of all deaths, on death: reference and alternative scenarios for 2016-40 for 195 average, across 32 LAC countries (Figure 3.10; see also section countries and territories.”, Lancet (London, England), “Mortality from cardiovascular diseases” and section “Mortality from Vol. 392/10159, pp. 2052-2090, http://dx.doi.org/10.1016/ cancer” in Chapter 3). In OECD countries, the average was higher S0140-6736(18)31694-5. at 85% and the share was also increasing. However, [7] Omran, A. (2005), “The epidemiologic transition: a theory of the communicable diseases such as respiratory infections, diarrhoeal epidemiology of population change”, The Milbank quarterly, diseases and tuberculosis, along with maternal and perinatal Vol. 83/4, pp. 731-57, http://dx.doi.org/10.1111/ conditions, also remained major causes of death among many j.1468-0009.2005.00398.x. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 66 3. MORTALITY FROM ALL CAUSES Figure 3.8. Adult mortality rate (probability of dying between 15 Figure 3.9. All cause-mortality rates for all populations, 2000 and 60 years per 1 000 population), 2016 and 2017 (or nearest year) Females Males 2000 2017 OECD36 OECD32 Chile Bahamas Costa Rica Chile Cuba Barbados Barbados Antigua and Barbuda Panama Argentina Uruguay Uruguay Argentina Trinidad and Tobago Ecuador Cuba Mexico Dominica Brazil Jamaica Colombia Panama Venezuela Brazil Peru Costa Rica Grenada Venezuela Jamaica Saint Lucia Nicaragua LAC32 Grenada El Salvador Suriname Antigua and Barbuda Peru LAC31 Ecuador Saint Lucia Colombia Dominican Republic Mexico Trinidad and Tobago Paraguay Honduras Saint Vincent and the Grenadines Guatemala Belize Bahamas Dominican Republic Paraguay El Salvador Saint Vincent and the Grenadines Guyana Belize Bolivia Suriname Nicaragua Bolivia Guatemala Guyana Honduras Haiti Haiti 0 100 200 300 400 0 500 1000 1500 Per 1 000 population Age-standardised rates per 100 000 population Source: WHO GHO 2018. Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/bkuzwt StatLink 2 https://stat.link/yeku1g Figure 3.10. Proportions of all cause deaths, 2015 (or nearest year) Communicable, maternal, perinatal and nutritional conditions Noncommunicable diseases Injuries % 100 80 60 40 20 0 Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/wto79j HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 67 3. MORTALITY FROM CARDIOVASCULAR DISEASES Cardiovascular diseases (CVD) are the number one cause of death countries, but hypertensive deaths in LAC are almost double than in globally and were estimated to have caused 1.8 million annual the OECD (8% versus 5%) (Figure 3.13). IHD deaths represent deaths in the WHO Region of the Americas (PAHO, 2017[6]). CVD over 60% of all CVD deaths in El Salvador, Honduras and Mexico, covers a range of diseases related to the circulatory system, while less than 35% in Saint Lucia, Jamaica and Dominica. In including ischaemic heart disease (IHD) and cerebrovascular Jamaica, stroke deaths take 45% of all CVD deaths while is less disease. Ischemic heart disease is caused by the accumulation of than 23% in El Salvador, Costa Rica, Mexico and Argentina. an atherosclerotic plaque in the inner wall of a coronary artery, Success of reducing the mortality rates from CVD in OECD restricting blood flow to the heart. Cerebrovascular diseases refer countries owes to a decline in smoking rates, expanded health to a group of diseases that relate to problems with the blood vessels system’s capacity to control high cholesterol and blood pressure, that supply the brain. Common types of cerebrovascular disease and greater access to effective care in the event of an acute include ischemic stroke, which develops when the brain’s blood episode such as a stroke or heart attack (see indicator “In-hospital supply is blocked or interrupted, and haemorrhagic stroke which mortality following acute myocardial infarction and stroke” in occurs when blood leaks from blood vessels onto the subarachnoid Chapter 7) (OECD, 2015[9]). As the proportion of older people space (subarachnoid haemorrhage) or within the brain increases in the LAC region (see section “Ageing” in Chapter 3), (intracerebral haemorrhage). demand for health care will increase and the complexity and type of The majority of CVD is caused by risk factors that can be controlled, care that CVD patients require will change, for instance, due treated or modified, such as high blood pressure, high blood mounting multi-morbidity. Increases in total cholesterol and blood glucose (see section “Blood glucose and high blood pressure” in pressure, along with smoking, overweight/obesity and high blood Chapter 5), high blood cholesterol, obesity (see section glucose highlight the need for management of risk factors to “Overweight or obese adults” in Chapter 4), lack of physical activity prevent further development of CVD. In addition to efforts to (see section “Physical activity” in Chapter 4), tobacco use (see improve lifestyles, primary care needs to be strengthened and section “Tobacco” in Chapter 4) and excessive alcohol quality of acute care also needs to improve through better consumption (see section “Alcohol” in Chapter 4). emergency care and improved professional skills and training CVD is the leading cause of death in the LAC region (see section on capacity (OECD, 2015[9]). “Mortality from all causes”). Average mortality from CVD decreased both in LAC and OECD between 2000 and 2017, although the reduction was considerably smaller in LAC (‑18% versus ‑35%) Definition and comparability (Figure 3.11). Countries like Peru, Belize and Colombia have experienced the largest decreases in CVD mortality rates of over See indicator “Mortality from all causes” in Chapter 1 for ‑35% in the period, being the only LAC countries above the OECD definition, source and methodology underlying mortality average reduction. Notably, Dominican Republic is the only country rates. that has increased CVD mortality from 211 to 267 deaths per 100 000 population in the period. Mortality from CVD exceeded 300 deaths per 100 000 population among men in Suriname, Dominican Republic, Haiti and Guyana in References 2017 (Figure 3.12). Peru, Nicaragua, Colombia, Panama, Chile and Ecuador were the countries below the OECD average of 162 male [9] OECD (2015), Cardiovascular Disease and Diabetes: Policies for Better Health and Quality of Care, OECD Health Policy Studies, deaths per 100 000 population. For women, the highest rates were OECD Publishing, Paris, https://dx.doi.org/ observed in Haiti and Guyana, with 473 and 340 deaths per 10.1787/9789264233010-en. 100 000 population, respectively. In contrast, Peru had the lowest figures for women in the region, with 78 deaths per 100 000 [6] PAHO (2017), Health in the Americas+, 2017 Edition. Summary: Regional Outlook and Country Profiles, Pan American Health population being the only country below the OECD average of 103. Organization, Washington, D.C., https://www.paho.org/salud-en- Together, IHD and stroke comprise 78% of all CVD deaths in all las-americas-2017/wp-content/uploads/2017/09/Print-Version- LAC countries combined, very similar to the 77% in OECD English.pdf. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 68 3. MORTALITY FROM CARDIOVASCULAR DISEASES Figure 3.11. Cardiovascular disease, estimated mortality rates, Figure 3.12. Cardiovascular disease, estimated mortality rates, 2000 and 2017 (or nearest year) by sex, 2017 (or nearest year) 2000 2017 Male Female Haiti Haiti Guyana Guyana Honduras Dominican Republic Grenada Suriname Saint Vincent and the Grenadines Saint Vincent and the Grenadines Dominican Republic Grenada Honduras Suriname Bahamas Dominica Trinidad and Tobago Bahamas Dominica Saint Lucia Jamaica Antigua and Barbuda Venezuela Trinidad and Tobago Saint Lucia Bolivia Bolivia LAC32 LAC32 Jamaica Paraguay Paraguay Antigua and Barbuda Cuba Argentina Venezuela Cuba Barbados Brazil Argentina Belize Belize Barbados Brazil El Salvador El Salvador Uruguay Nicaragua Guatemala Guatemala Mexico Mexico Ecuador Uruguay Costa Rica Ecuador Nicaragua Colombia Panama Panama OECD36 Chile Chile Costa Rica Colombia OECD36 Peru Peru 0 200 400 600 0 200 400 600 Age-standardised rates per 100 000 population Age-standardised rates per 100 000 population Source: Global Burden of Disease (2019), IHME. Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/9nxvgk StatLink 2 https://stat.link/4dhot5 Figure 3.13. Proportions of deaths per type of cardiovascular disease, 2017 (or nearest year) Ischaemic heart disease Ischaemic stroke Haemorrhagic stroke Others % 100% 67 11 11 9 7 8 11 57 7 11 5 11 8 8 6 8 13 12 9 12 20 5 9 5 12 6 9 7 12 9 13 4 13 7 9 8 13 12 13 5 13 8 13 16 9 16 10 17 6 17 8 18 90% 5 18 12 18 5 19 6 21 21 22 25 80% 24 7 23 20 28 9 25 29 25 70% 26 29 23 30 15 28 22 34 24 33 30 23 34 40 28 60% 36 32 30 33 28 32 34 45 31 35 50% 26 36 26 40% 66 64 63 30% 59 59 59 57 57 56 56 55 53 53 53 51 50 49 48 47 45 45 45 45 43 43 42 20% 42 41 39 38 37 34 34 32 10% 0% Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/oxk94a HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 69 3. MORTALITY FROM CANCER Cancer is the second leading cause of death after CVD among LAC Cuba and Trinidad and Tobago (below 5%). Colorectal cancer is countries, producing over 670 000 deaths in 2018 in the region more prominent in some higher income countries such as (Bray et al., 2018[10]). Cancer occurs when abnormal cells divide Barbados, Argentina and Uruguay, although variations within the without control and are able to invade other tissues. There are more region are not as significant. Breast cancer represents a higher than 100 different types of cancers, with most named after the proportion of deaths in Bahamas, Barbados, Trinidad and Tobago, organ in which they start. Only about 5% to 10% of all cancers are and Antigua y Barbuda, all with more than 10%, and a lower share inherited, meaning that modifiable risk factors such as smoking, in Guatemala, Belize, Ecuador, Bolivia, Chile and Peru (below 6%). obesity, exercise, and excess sun exposure, as well as Finally, cervical cancer is responsible for over 8% of cancer deaths environmental exposures, explain as much as 90‑95% of all cancer in Nicaragua and Honduras, significantly higher that the LAC32 cases (Whiteman and Wilson, 2016[11]). Prevention, early average of 4.5%. This might be contributing to the overall higher detection and treatment remain at the forefront of the tools to cancer death rates amongst women in both countries. Cervical reduce the burden of cancer. cancer is attributed a much smaller share of cancer mortality in The regional average cancer mortality rate in LAC32 was 120 per OECD (1.4%). 100 000 population in 2017, less than the average among OECD As with cardiovascular disease, the ageing of the population will countries of 125 (Figure 3.14). Cancer deaths were less common in lead to many more cases of cancer in coming decades, taxing Nicaragua, Mexico, Colombia, Panama and Honduras with rates of underprepared health systems. Since resources needed to treat less than 90 deaths per 100 000, and the highest in Uruguay, cancer are large (e.g. skilled health workforce, expensive Dominica and Haiti being over 150 deaths per 100 000 population. medicines and technologies), cancer control planning in the LAC Cancer mortality has decreased overall in the LAC region by 4.45% region will be more effective and efficient by targeting risk factors since 2000, although well below the reduction of 17% observed in such as smoking, physical activity and overweight/obesity. Early OECD countries. However, ten countries increased its cancer diagnosis is also a key to reducing mortality, so access to cancer mortality rate between 2000 and 2017, with Dominican Republic diagnosis and care needs to be promoted through public health and Grenada showing the largest increases with 18% and 13%, interventions and wider health coverage (OECD, 2013[13]). respectively. On the other hand, Colombia and Peru experienced the largest decrease in the region of 20%, over the OECD average reduction. Definition and comparability Cancer mortality rate was higher in men than in women in almost all LAC countries, with the exception of Honduras and Nicaragua See indicator “Mortality from all causes” in Chapter 1 for (Figure 3.15). Dominica and Uruguay are the only LAC countries definition, source and methodology underlying mortality with a higher male/female ratio of cancer than OECD countries. rates. Men’s higher cancer mortality rates can be explained by sex hormones differences and genes on the X chromosome that can affect the function of the immune system; better health literacy or awareness of cancer symptoms by women and greater willingness References to uptake screening or seek medical help; and a higher historical [12] Afshar, N. et al. (2018), “Differences in cancer survival by sex: a exposure to risk factors, such as smoking and alcohol use (Afshar population-based study using cancer registry data”, Cancer Causes et al., 2018[12]). & Control, Vol. 29/11, pp. 1059-1069, http://dx.doi.org/10.1007/ Respiratory system (trachea, bronchus and lung), stomach and s10552-018-1079-z. colorectal cancer were the three most common cancer mortality [10] Bray, F. et al. (2018), “Global cancer statistics 2018: GLOBOCAN sites in the LAC region in 2017, accounting for 10.6%, 9.4% and estimates of incidence and mortality worldwide for 36 cancers in 9.35% of cancer deaths, respectively (Figure 3.16). This is different 185 countries”, CA: A Cancer Journal for Clinicians, Vol. 68/6, from OECD countries, where respiratory system, colorectal and pp. 394-424, http://dx.doi.org/10.3322/caac.21492. breast are three most common cancer death sites with 22.1%, [13] OECD (2013), Cancer Care: Assuring Quality to Improve Survival, 11.6% and 6.8%, respectively. Respiratory system cancer was OECD Health Policy Studies, OECD Publishing, Paris, https:// responsible for more than 15% of cancer deaths in Cuba, Uruguay, dx.doi.org/10.1787/9789264181052-en. Venezuela and Argentina. Low-income countries tend to show a [11] Whiteman, D. and L. Wilson (2016), “The fractions of cancer lower share of respiratory system cancer deaths, below 10%. attributable to modifiable factors: A global review”, Cancer Stomach cancer deaths have higher shares in Guatemala, Bolivia, Epidemiology, Vol. 44, pp. 203-221, http://dx.doi.org/10.1016/ Ecuador and Peru (over 15% of all cancer deaths) and the lowest in j.canep.2016.06.013. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 70 3. MORTALITY FROM CANCER Figure 3.14. All cancers, estimated mortality rates, 2000 and Figure 3.15. All cancers, estimated mortality rates, by sex, 2017 2017 (or nearest year) (or nearest year) 2000 2017 Female Male Uruguay Uruguay Dominica Dominica Haiti Haiti Bahamas Bahamas Bolivia Cuba Grenada Argentina Saint Vincent and the Grenadines Barbados Barbados Saint Vincent and the Grenadines Cuba Jamaica Argentina Saint Lucia Jamaica Grenada Saint Lucia OECD36 Chile Bolivia OECD36 Chile Antigua and Barbuda Costa Rica LAC32 Antigua and Barbuda Suriname Suriname Costa Rica LAC32 Ecuador Brazil Venezuela Dominican Republic Brazil Trinidad and Tobago Trinidad and Tobago Venezuela Dominican Republic Paraguay Paraguay Belize Belize Ecuador Guyana Guyana Guatemala Guatemala El Salvador El Salvador Peru Panama Honduras Colombia Panama Peru Colombia Mexico Mexico Honduras Nicaragua Nicaragua 0 50 100 150 200 0 100 200 300 Age-standardised rates per 100 000 population Age-standardised rates per 100 000 population Source: Global Burden of Disease (2019), IHME. Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/1olhtu StatLink 2 https://stat.link/fm02jb Figure 3.16. Proportions of cancer deaths, 2017 (or nearest year) Others Stomach Colorectal Liver Respiratory system neoplasms Breast Cervical Dominica Saint Vincent and the Grenadines Saint Lucia Grenada Antigua and Barbuda Barbados Trinidad and Tobago Haiti Guyana Honduras Bahamas Belize LAC32 Jamaica Dominican Republic Chile Brazil Paraguay Suriname Mexico Uruguay Venezuela Panama Argentina Ecuador Bolivia Cuba Costa Rica El Salvador Colombia Peru OECD36 Nicaragua Guatemala 0 20 40 60 80 100 % Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/z20dkn HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 71 3. MORTALITY FROM INJURIES Injuries are a leading cause of death and disability for all age groups also increased in LAC by 5%, opposed to the reduction of 9% in the and took over 635 000 lives in 2015 in the WHO Region of the OECD. Jamaica shows the largest increase by 132% and Chile Americas, accounting for 9.7% of all deaths. Injuries can result from exhibits the most pronounced decrease of ‑56%. Road traffic traffic collisions, drowning, poisoning, falls, burns, violence from injuries deaths in LAC and the OECD experienced a decrease of assault, self-inflicted or acts of war, exposure to mechanical forces, 22% and 38% between 1990 and 2017, respectively. Only as well as natural disasters. The magnitude of the problem varies Jamaica, Dominican Republic, Paraguay and Argentina saw an considerably across countries by cause, age, sex, and income increase, while the largest reduction was observed in Cuba, Bolivia group, but injury deaths, both intentional and unintentional, are and Nicaragua (over ‑50%). largely preventable events. OECD countries improved a safe systems approach to road safety, Men had far higher mortality rates than women in the LAC region in which includes education and prevention campaigns as well as 2017, with 104 deaths per 100 000 for men and 28 deaths per vehicle design and safety, and also adopted new laws and 100 000 for women, compared to 58 and 20 deaths per 100 000 regulations and the enforcement of these laws to improve respectively among OECD countries (Figure 3.17). Venezuela compliance with drink-driving regulation, speed limits and the shows the largest gender difference with an injuries mortality wearing of seat belts and motorcycle helmets (ITF, 2017[15]). On almost six and a half times higher among men compared to women, 11 May 2011, the first ever Decade of Action for Road Safety followed by El Salvador and Colombia with rates more than five 2011‑20 was launched across the world. Mandated by the United times higher. Conversely, Cuba and Bolivia show the lowest gender Nations General Assembly, the Decade represents an historic differences with injuries death gender ratios of 2.2 and 2.5, opportunity for countries to stop and reverse the trend which – respectively. without action – would lead to the loss of around 1.9 million lives on Violent deaths were the most common cause of death due to the roads each year by 2020. injuries in the LAC region in 2017 and accounted in average for 27% of injury deaths, followed by road traffic deaths with 25% and self-inflicted injuries with 13% (Figure 3.18). A different trend was Definition and comparability observed in OECD countries where 28% of injury deaths were self- inflicted, 22% were due to road traffic crashes and violent deaths See indicator “Mortality from all causes” in Chapter 1 for represented 15%. However, the figure should be considered in the definition, source and methodology underlying mortality context of a corresponding global increase in the number of rates. registered vehicles, suggesting that interventions to improve global Injury deaths where the intent is not determined are road safety have mitigated the expected rise in the number of distributed proportionately to all causes below the group level deaths (WHO, 2018[14]). Over half of all injury deaths could be for injuries. attributed to interpersonal violence in Honduras, Jamaica and El Estimates for road injury deaths drew on death registration Salvador, and the lowest proportion was observed in Peru, data, reported road traffic deaths from official road traffic Uruguay, Bolivia and Chile, all below 11% of all injury deaths. In surveillance systems and revised regression model for Haiti, Paraguay, Ecuador and Dominican Republic, road traffic countries without usable death registration data (WHO, accidents represented over 37% of injury deaths and below 17% in 2014[16]). Saint Vincent and the Grenadines, Guyana, Jamaica and Cuba. In Suriname, Uruguay, Guyana and Chile, self-inflicted deaths were over 25% of all injury deaths, and below 6% in Honduras and The Bahamas. Mortality from injuries due to violence shows an increase of 33% in References LAC between 1990 and 2017, lower than the 50% increase in the [15] ITF (2017), Road Safety Annual Report 2017, OECD Publishing, OECD (Figure 3.19). The highest growth was observed in Paris, https://dx.doi.org/10.1787/irtad-2017-en. Venezuela, Jamaica and Belize of more than 150%, while the [14] WHO (2018), Global status report on road safety 2018, World largest decrease occurred in Colombia (‑62%), Bolivia (‑48%) and Health Organization, Geneva, https://apps.who.int/iris/bitstream/ Nicaragua (‑43%). Mortality due to self-harm injuries in the period handle/10665/277370/WHO-NMH-NVI-18.20-eng.pdf?ua=1. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 72 3. MORTALITY FROM INJURIES Figure 3.17. Injuries, mortality rates, male and female, 2017 (or Figure 3.18. Proportions of injury deaths, 2017 (or nearest year) nearest year) Violence Road traffic Self-inflicted Falls Female Male Drownings Others El Salvador Honduras Venezuela Jamaica Haiti El Salvador Guatemala Colombia Guyana Venezuela Belize Mexico Dominican Republic Guatemala Honduras Brazil Brazil Bahamas Mexico Trinidad and Tobago Suriname Panama Ecuador Saint Vincent and the Grenadines Bahamas Belize LAC32 Saint Lucia Colombia Barbados Trinidad and Tobago LAC32 Saint Vincent and the Grenadines Dominican Republic Uruguay Paraguay Jamaica Dominica Saint Lucia Nicaragua Paraguay Costa Rica Bolivia Ecuador Dominica Guyana Costa Rica Haiti Panama OECD36 Argentina Antigua and Barbuda Grenada Argentina Cuba Cuba Chile Grenada Nicaragua Suriname Peru Chile OECD36 Bolivia Barbados Uruguay Antigua and Barbuda Peru 0 50 100 150 200 0 20 40 60 80 % 100 Age-standardised rates per 100 000 population Source: Global Burden of Disease (2019), IHME. Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/pot5d4 StatLink 2 https://stat.link/ky9lsu Figure 3.19. Growth rates of road traffic accidents, self-harm and violence mortality, 1990‑2017 (or nearest year) Road traffic Self harm Violence % 250 200 150 100 50 0 -50 -100 Source: Global Burden of Disease (2019), IHME. StatLink 2 https://stat.link/2zi7uy HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 73 3. MATERNAL MORTALITY Maternal mortality – the death of a woman during pregnancy, postnatal care by skilled health professionals. Addressing childbirth, or within 42 days of the termination of pregnancy – is an disparities in the provision of these essential reproductive health important indicator of a woman’s health status and also to assess services to underserved populations must be included in any health system’s performance. The Sustainable Development Goals strategy. Furthermore, the broad health systems strengthening and set a target of reducing the global maternal mortality ratio to less universal health coverage agenda, along with multisectoral action than 70 per 100 000 live births by 2030. In LAC, around 7 600 (e.g. women’s education, tackling violence) are collaborative efforts maternal deaths occurred in 2015, most of them preventable. The that are crucial to reduce maternal deaths in the LAC region (WHO main causes of maternal death were haemorrhage after birth and et al., 2018[18]). gestational hypertension, and were concentrated in countries with higher fertility rates, more poverty and less access to high-quality health care services (GTR, 2017[17]). Definition and comparability In 31 LAC countries, maternal mortality ratio (MMR) averaged 83 deaths per 100 000 live births in 2017, substantially higher than the Maternal mortality is defined as the death of a woman while 8 deaths per 100 000 live births in OECD countries (Figure 3.20). pregnant or during childbirth or within 42 days of termination Estimates show Chile and Uruguay with low MMRs of less than 17, of pregnancy, irrespective of the duration and site of the but others such as Haiti have 480, followed by Guyana and Bolivia pregnancy, from any cause related to or aggravated by the with 169 and 155, respectively. pregnancy or its management but not from unintentional or incidental causes. This includes direct deaths from obstetric Despite high rates in certain countries, a reduction of 26% in complications of pregnancy, interventions, omissions or maternal mortality have been achieved in the LAC region between incorrect treatment. It also includes indirect deaths due to 2000 and 2017, however below the reduction in OECD countries of previously existing diseases, or diseases that developed ‑40% in the same period. Belize, Chile, Bolivia and Ecuador during pregnancy, where these were aggravated by the decreased MMR by over 50%. Nevertheless, during the same effects of pregnancy. Maternal mortality is here measured period MMR increased in five countries: Saint Lucia (36%), using the maternal mortality ratio (MMR). It is the number of Dominican Republic (19%), Haiti (10%), Venezuela (5%) and maternal deaths during a given time period per 100 000 live Jamaica (4%). births during the same time period. There are difficulties in Across 16 LAC countries, maternal mortality is inversely related to identifying maternal deaths precisely. Many countries in the the coverage of skilled births attendance (Figure 3.21). Although region do not have accurate or complete vital registration most countries (11) had more than 95% of births attended by skilled systems, and so the MMR is derived from other sources health professionals, the country with the highest MMR, Haiti, was including censuses, household surveys, sibling histories, also the country with the lowest proportion of births attended by a verbal autopsies and statistical studies. Because of this, skilled health professional (42%). On the other side, countries like estimates should be treated cautiously. Guyana, Venezuela and Suriname show high skilled birth attendance coverage (96% or more) but relatively high MMR (all over 120), probably evidencing quality of care problems. Higher coverage of antenatal care (at least four times) is associated References with lower MMR, indicating the effectiveness of antenatal care across countries (Figure 3.22). Grenada moves away from the [17] GTR (2017), Panorama de la Situación de la Morbilidad y trend by having a low coverage of antenatal care (only 67% of Mortalidad Maternas: América Latina y el Caribe, Grupo de Trabajo para la Reducción de la Mortalidad Materna. Naciones Unidas, pregnant women receives at least four visits) but a relatively low https://lac.unfpa.org/sites/default/files/pub-pdf/MSH-GTR-Report- MMR of 25. Oppositely, Bolivia and Guyana show antenatal care Esp.pdf. coverage above 85% but MMR over 150 deaths per 100 000 live births, which might be linked with lower rates of skilled birth [18] WHO et al. (2018), Survive, Thrive, Transform. Global Strategy for Women’s, Children’s and Adolescents’ Health: 2018 report on attendance but also with quality of care issues. progress towards 2030 targets, World Health Organization, Risk of maternal death can be reduced through family planning, Geneva, https://www.everywomaneverychild.org/wp-content/ better access to high-quality antenatal care, and delivery and uploads/2018/05/EWECGSMonitoringReport2018.pdf. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 74 3. MATERNAL MORTALITY Figure 3.20. Estimated maternal mortality ratio, 2017, and percentage change since 2000 8 OECD36 -40.0 13 Chile -58.1 17 Uruguay -34.6 25 Grenada -34.2 27 Barbados -46.0 27 Costa Rica -32.5 33 Mexico -40.0 36 Belize -59.6 36 Cuba -21.7 39 Argentina -40.9 42 Antigua and Barbuda -4.5 46 El Salvador -37.0 52 Panama -42.9 59 Ecuador -51.6 60 Brazil -13.0 65 Honduras -23.5 67 Trinidad and Tobago -17.3 68 Saint Vincent and the Grenadines -15.0 70 Bahamas -6.7 80 Jamaica 3.9 83 LAC31 -25.9 83 Colombia -11.7 84 Paraguay -49.1 88 Peru -38.9 95 Dominican Republic 18.8 95 Guatemala -41.0 98 Nicaragua -39.5 117 Saint Lucia 36.0 120 Suriname -45.7 125 Venezuela 5.0 155 Bolivia -53.2 169 Guyana -26.8 480 Haiti 9.8 600 500 400 300 200 100 0 -80 -60 -40 -20 0 20 40 60 Deaths per 100 000 live births % change over period Source: WHO GHO 2019. StatLink 2 https://stat.link/t01xry Figure 3.21. Skilled birth attendant coverage and estimated Figure 3.22. Antenatal care coverage and maternal mortality, maternal mortality ratios, latest year available latest year available Skilled birth attendance coverage (%) At least four antenatal care visits 110 100 CRI TTO PAN DOM BRB CUB DOM CHL BRA VEN URY PER 100 CRI MEX GUY SUR GUY BLZ OECD COL PRY 90 BRA COL MEX PER GTM LAC16 BOL ARG ARG VEN 90 PAN R² = 0.3204 LAC24 80 80 ECU PRY R² = 0.1108 BOL SLV GTM 70 VCT 70 HTI HTI GRD (67, 480) SUR (42, 480) 60 60 0 50 100 150 200 0 50 100 150 200 Maternal mortality ratio Maternal mortality ratio Source: WHO GHO 2019, Ministry of Health for Costa Rica. Source: WHO GHO 2019. StatLink 2 https://stat.link/k3jz8n StatLink 2 https://stat.link/ku5pio HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 75 3. TUBERCULOSIS Globally in 2016, the total number of new cases of tuberculosis (TB) 60% reduction, while in Grenada incidence increased by 282%, was estimated at 10.42 million, of which over 160 000 are observed however, the baseline was low at 0.7 cases per 100 000 population in LAC. The number of TB deaths was estimated at 1.45 million, of (Figure 3.25). which more than 15 000 occurred in LAC. Most of these TB cases The LAC region still faces important challenges in TB control, and deaths occur disproportionately among men, except in the first including providing services to those in greatest need, especially 15 years of life were the situation is similar to both genders (GBD the poor and vulnerable. The most relevant strategies to develop in Tuberculosis Collaborators et al., 2018[19]). Most cases of TB are LAC countries include the implementation and expansion of early preventable if diagnosed and the right treatment is provided. TB diagnosis with new rapid molecular tests, the epidemiological study was declared a global health emergency by WHO in 1993 and the of contacts, the use of shortened multi-drug resistance TB WHO-coordinated Stop TB Partnership set targets of halving TB treatment regimens, the reduction of funding gaps and the need for prevalence and deaths by 2015, compared with a baseline of 1990. greater technical expertise (PAHO, 2018[20]). The Sustainable Development Goals foresee the end of the epidemic of tuberculosis by 2030. The highest incidence rate was seen in Haiti, Peru and Bolivia, with Definition and comparability 176, 123 and 108 cases per 100 000 population in 2018, respectively (Figure 3.23). Low incidence rates, below 5 cases per Tuberculosis (TB) is a contagious disease, caused by the 100 000 population, were reported in Barbados, Grenada, Jamaica Mycobacterium tuberculosis bacteria. Tuberculosis usually and Saint Lucia. Saint Kitts and Nevis reported zero new cases in attacks the lungs but can also affect other parts of the body. It 2018. is spread through the air, when people who have the disease cough, sneeze, talk or spit. Most infections in humans are The highest mortality rates due to TB (excluding HIV) were found in latent and without symptoms, with about one in ten latent Guyana and Bolivia with 15 and 11 deaths per 100 000 population infections eventually progressing to active disease. If left in 2018. The lowest mortality rates are observed in Jamaica, Cuba, untreated, active TB kills between 20% and 70% of its victims Costa Rica and Barbados, all below 1 death per 100 000 population within ten years depending on severity. (Figure 3.23). Although the average TB detection rate in the region is generally The TB incidence rate is the number of new cases of the high (83% of detection of all cases in 2016), there were a large disease estimated to occur in a year, per 100 000 population. number of undetected cases in Bolivia and Haiti, where detection The TB prevalence rate is the total number of persons with rates were 62% and 75%, respectively, the only two countries the disease at a particular time, per 100 000 population. TB below 80% (Figure 3.24). High-quality TB services have expanded mortality does not include TB/HIV as per ICD‑10. in LAC countries and many cases are treated, reaching excellent treatment success rates in Grenada, Dominica and Barbados. In contrast, treatment success rate is the lowest in Jamaica with 23% followed by Argentina with 54%, well below the LAC33 average of References 76%. [19] GBD Tuberculosis Collaborators, H. et al. (2018), “Global, regional, In general, the LAC region is rising to the challenges presented by and national burden of tuberculosis, 1990-2016: results from the TB, with incidence and mortality declining steadily since 1990, Global Burden of Diseases, Injuries, and Risk Factors 2016 Study.”, although regional disparities exist. The average reduction of The Lancet. Infectious diseases, Vol. 18/12, pp. 1329-1349, http:// incidence in the LAC region between 2000 and 2018 was 10%. The dx.doi.org/10.1016/S1473-3099(18)30625-X. strongest decline in this period was observed in Honduras, [20] PAHO (2018), Tuberculosis in the Americas 2018, http:// Barbados and Saint Vincent and the Grenadines with more than iris.paho.org/xmlui/handle/10665.2/49510. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 76 3. TUBERCULOSIS Figure 3.23. Estimate of the burden of disease caused by tuberculosis, 2018 Incidence rate Mortality rate Bahamas Jamaica Cuba Costa Rica Barbados Antigua and Barbuda El Salvador Argentina Grenada Mexico Trinidad and Tobago Guatemala Saint Vincent and the Grenadines Nicaragua Uruguay Chile Saint Kitts and Nevis Saint Lucia Belize Brazil Dominican Republic Venezuela Colombia Ecuador Suriname LAC33 Paraguay Dominica Honduras Panama Peru Haiti Bolivia Guyana 200 150 100 50 0 0 5 10 15 20 Per 100 000 population Per 100 000 population Source: WHO GHO 2019. StatLink 2 https://stat.link/h0j4uz Figure 3.24. Tuberculosis treatment success for new TB cases Figure 3.25. Change in tuberculosis incidence rate, 2000‑18 (or and case detection, 2017 (or nearest year) nearest year) Case detection rate for all forms of tuberculosis Grenada Treatment-success rate for new TB cases El Salvador Suriname Grenada Uruguay Dominica Venezuela Barbados Guyana El Salvador Trinidad and Tobago Honduras Dominica Guatemala Panama Bolivia Paraguay Peru Saint Kitts and Nevis Nicaragua Cuba Mexico Costa Rica Antigua and Barbuda Venezuela LAC33 Haiti Colombia Panama Brazil Mexico Guatemala Chile Chile LAC32 Argentina Trinidad and Tobago Nicaragua Dominican Republic Peru Uruguay Haiti Ecuador Ecuador Brazil Belize Guyana Cuba Suriname Saint Vincent and the Grenadines Bolivia Saint Lucia Dominican Republic Paraguay Costa Rica Bahamas Saint Lucia Belize Jamaica Colombia Bahamas Argentina Saint Vincent and the Grenadines Jamaica Barbados Antigua and Barbuda Honduras 25 50 75 100 -100 0 100 200 300 % % Source: WHO GHO 2019. Source: WHO GHO 2019. StatLink 2 https://stat.link/yrz9vc StatLink 2 https://stat.link/nazbfi HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 77 3. HIV/AIDS HIV/AIDS reached the LAC region in the early 80s and spread for prevention and treatment, but also to integrate with other key heterogeneously. The Caribbean has been and continues to be the services related to sexual and reproductive health and rights, one of the most affected regions in terms of prevalence, second hepatitis C virus, tuberculosis, provision of clean needles and only to some African regions (UNAIDS, 2019[21]). The UN has set syringes, medication-assisted therapy and non-communicable the goal of eliminating the epidemic of AIDS as a public threat as an diseases. The benefits of antiretroviral therapy and integrated SDG for 2030, which has been defined as reducing the number of services can be fully realised only if people living with HIV are new HIV infections and AIDS-related deaths by 90% relative to diagnosed and successfully linked to care. This will require targets 2010 (UNAIDS, 2014[22]). efforts and removing barriers especially among key affected In LAC27, the prevalence in adults between 14 and 49 years old populations, for instance, sex workers, their clients, men who have ranges from 0.2% in Mexico and Nicaragua to 2% in Haiti in 2018 sex with men, transgender persons and injection drug users, along (Figure 3.26, left panel). Although overall prevalence in the region is with active stakeholder’s collaboration, including civil society in not very high, the number of people living with HIV is over 2 million each country (Bekker et al., 2018[23]). in reporting countries, most of which live in Brazil with more than 900 000 people, followed by Mexico with 230 000 and Colombia and Haiti with 160 000 each. Definition and comparability Expanded access to antiretroviral therapy has increased the Human immunodeficiency virus (HIV) is a retrovirus that survival rates of people living with HIV, but about half of the people destroys or impairs the cells of the immune system. As HIV eligible for HIV treatment do not receive it worldwide. In LAC26, the infection progresses, a person becomes more susceptible to estimated coverage was particularly low (<40%) in Belize and infections. The most advanced stage of HIV infection is Jamaica while it is over 70% in Peru, Colombia, Cuba and Mexico acquired immunodeficiency syndrome (AIDS). It can take (Figure 3.27). This indicates that some countries with high 10‑15 years for an HIV-infected person to develop AIDS, prevalence (e.g. Mexico) are addressing the issue of treatment although antiretroviral drugs can slow down the process. coverage, but the region remains substantially far from the goal of treating 90% of people living with HIV/AIDS. The HIV prevalence among adults aged 15 to 49 is the number of persons aged 15‑49 estimated to be living with The trend is positive in recent years however, with most LAC HIV divided by the total number of persons aged 15‑49 at a countries reducing incidence rates. Between 2010 and 2018, El particular time. Salvador, Bahamas and Nicaragua reduced incidence rates by 50%, 33% and 30%, respectively, followed by Colombia, Haiti and Cuba that have all reduced the number of new cases of HIV infection by more than 25% (Figure 3.28). Among the five countries that show an increase, Chile has the largest HIV incidence growth References of 23%, followed by Brazil with 13% and Costa Rica with 11%, but [23] Bekker, L. et al. (2018), “Advancing global health and strengthening these three countries remain below the LAC average for HIV the HIV response in the era of the Sustainable Development Goals: prevalence. the International AIDS Society-Lancet Commission.”, Lancet Strengthening the agenda on HIV prevention and treatment could (London, England), Vol. 392/10144, pp. 312-358, http://dx.doi.org/ further tackle the AIDS public health threat in the region. The 10.1016/S0140-6736(18)31070-5. UNAIDS 90‑90‑90 approach is central, stating that by 2020, 90% of [21] UNAIDS (2019), AIDSinfo, Joint United Nations Programme on HIV all people living with HIV will know their HIV status, 90% of people and AIDS, http://aidsinfo.unaids.org/. with an HIV diagnosis will receive ART, and 90% of people [22] UNAIDS (2014), 90–90–90: an ambitious treatment target to help receiving ART will achieve viral suppression. The rapid scale-up end the AIDS epidemic, Joint United Nations Programme on HIV/ antiretroviral therapy in LAC provides unprecedented opportunity to AIDS, Geneva, https://www.unaids.org/sites/default/files/ successfully implement not only antiretroviral-based interventions media_asset/90-90-90_en.pdf. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 78 3. HIV/AIDS Figure 3.26. HIV Prevalence rate, % of adults aged 15‑49, and people living with HIV, absolute number, 2018 (or nearest year) HIV prevalence rate People living with HIV n.a. Venezuela 120 0.2 Mexico 230 0.2 Nicaragua 9 0.3 Bolivia 22 0.3 Honduras 23 0.3 Peru 79 0.4 Argentina 140 0.4 Colombia 160 0.4 Costa Rica 15 0.4 Cuba 31 0.4 Ecuador 44 0.4 Guatemala 47 0.5 Brazil 0.5 Chile 71 900 0.5 Paraguay 21 0.6 El Salvador 25 0.6 Uruguay 14 0.8 LAC27 85 0.9 Dominican Republic 70 0.9 Panama 26 1.1 Trinidad and Tobago 11 1.4 Guyana 8 1.4 Suriname 6 1.5 Barbados 3 1.8 Bahamas 6 1.9 Belize 5 1.9 Jamaica 40 2.0 Haiti 160 3 2 1 0 0 200 400 600 800 1000 % Population (thousands) Source: WHO 2019. StatLink 2 https://stat.link/dl26jo Figure 3.27. Antiretroviral therapy coverage among people Figure 3.28. New HIV infections per 1 000 uninfected living with HIV, 2018 (or nearest year) population, 2010 and 2018 (or nearest year) Peru 73 2010 2018 Colombia 73 Cuba 72 Mexico 70 Jamaica 0.8 Guyana 68 Belize 0.8 Brazil 66 Haiti 0.7 Chile 63 Barbados 0.6 Trinidad and Tobago Bahamas 0.6 62 Guyana Argentina 61 0.5 Uruguay Suriname 0.5 58 Trinidad and Tobago Haiti 58 0.4 Panama 0.3 Ecuador 57 LAC26 Dominican Republic 56 0.3 Chile 0.3 LAC26 55 Uruguay Panama 54 0.3 Dominican Republic 0.3 Nicaragua 53 Brazil Suriname 52 0.3 Costa Rica 0.2 Bahamas 52 Paraguay Honduras 50 0.2 Cuba 0.2 Barbados 50 Argentina Costa Rica 49 0.2 Guatemala 0.1 El Salvador 47 Colombia Bolivia 44 0.1 Ecuador 0.1 Guatemala 43 Bolivia 0.1 Paraguay 40 El Salvador 0.1 Jamaica 31 Peru 0.1 Belize 28 Honduras 0.1 0 20 40 60 80 Mexico 0.1 % 100 Nicaragua 0.1 Source: WHO 2019. 0 0.2 0.4 0.6 0.8 1 StatLink 2 https://stat.link/ofijz4 New HIV infections per 1 000 uninfected population Source: UNAIDS 2019. StatLink 2 https://stat.link/aen6od HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 79 3. MOSQUITO BORNE DISEASES Malaria, dengue and Zika are three diseases that are transmittable affected the disease is usually mild with symptoms that can last by the bites of infected mosquitoes. They are present in LAC with between two and seven days. There is no specific treatment for varying degrees of incidence. Malaria is a tropical disease caused Zika virus disease (PAHO, 2019[26]). by a parasite transmitted by the female Anopheles mosquitoes. Incidence of Zika is very high in Panama with 66 cases per 100 000 After a period spent in the liver, malaria parasites multiply within red population in 2018. Belize, Guatemala and Bolivia follow with 33, 16 blood cells, causing symptoms such as fever, headache and and 13 cases per 100 00 population. There were no reported Zika vomiting. As part of the SDG targets, the UN set a goal to end the deaths in 2018 (Figure 3.31). epidemic of malaria by 2030. Between 2000 and 2017, there has Mosquito borne diseases disproportionally affect economically been a global reduction of 60% in malaria deaths, making it one of disadvantaged communities, which lack adequate prevention the biggest public health successes of the 21st century (The Global methods and modern sanitation and infrastructure. It is key that Fund, n.d.[24]). countries ensure good quality access and coverage among these In the LAC region, country efforts have greatly reduced new cases communities to protect them from transmittable diseases like of malaria to the point where it has been nearly or completely malaria, dengue and zika. Outbreaks preparedness and control is eradicated in Argentina, Belize, Costa Rica, Belize, El Salvador and crucial for a proper prevention and response, for which countries Paraguay, plus several countries no longer report incidence data. should develop their capacities and resources. For instance, the However, the region remains vulnerable to outbreaks. The biggest use of insecticide-treated nets and indoor residual spraying with incidence in the region can be found in Venezuela with 48 cases per insecticides are important preventive measures for at-risk 1 000 risk population in 2017, nearly tripled in the last three years, populations to avoid mosquito bites. after having been almost eradicated (Figure 3.29, left panel). Moreover, Venezuela also shows the largest number of estimated malaria deaths with 456 people dying in the country, followed by Definition and comparability Haiti, Guyana and Brazil with 81, 33 and 30 deaths, respectively. Dengue is a viral infection caused by the mosquito Aedes aegypti Underreporting of mosquito borne diseases cases and and remains a public health problem in the Americas despite the deaths remain a major challenge in countries with efforts countries to stop and mitigate it. Dengue causes a severe inadequate and limited access to health services and weak flu-like illness (e.g. high fever, headache, pain behind the eyes, surveillance systems. The number of mosquito borne nausea, vomiting, swollen glands, muscle and joint pains, rash) diseases caused deaths were estimated by adjusting the and, sometimes can cause a potentially lethal complication called number of reported cases for completeness of reporting, the severe dengue. Once infected, humans become the main carriers likelihood that cases are parasite positive, and the extent of and multipliers of the virus, serving as a source of the virus for health service use. uninfected mosquitoes. There is no specific treatment for dengue fever (WHO, 2019[25]). Incidence of dengue in the region is heterogeneous, and is particularly high in Nicaragua with 934 cases per 100 000 References population in 2018, followed by Belize with 564, Paraguay with 469 [26] PAHO (2019), Zika virus infection, Pan American Health and Granada with 428 (Figure 3.30). Lethality of the disease also Organization, https://www.paho.org/hq/index.php? varies, reaching a percentage of over 1% of cases resulting in option=com_topics&view=article&id=427&Itemid=414&lang=en. deaths only in Jamaica. The diseases did not cause any deaths [24] The Global Fund (n.d.), Malaria. The Global Fund to Fight AIDS, during 2018 in the majority of countries in the region. Tuberculosis and Malaria, 2019, https://www.theglobalfund.org/en/ Zika fever is a viral disease caused by Zika virus transmitted by the malaria/. mosquito Aedes aegypti, consisting of mild fever, rash, headaches, [25] WHO (2019), Dengue and severe dengue, World Health arthralgia, myalgia, asthenia, and non-purulent conjunctivitis. One Organization, https://www.who.int/news-room/fact-sheets/detail/ out of four people may develop symptoms, but in those who are dengue-and-severe-dengue. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 80 3. MOSQUITO BORNE DISEASES Figure 3.29. Confirmed malaria cases and estimated deaths, 2018 (or nearest year) Malaria incidence Malaria deaths 0.0 Argentina 0 0.0 Belize 0 1.4 Bolivia 2 5.1 Brazil 30 8.5 Colombia 0 0.0 Costa Rica 0 0.1 Dominican Republic 1 3.3 Ecuador 0 0.0 El Salvador 0 0.3 Guatemala 1 44.4 Guyana 33 1.6 Haiti 81 0.1 Honduras 1 5.5 LAC20 31 0.3 Mexico 0 7.1 Nicaragua 10 0.2 Panama 0 0.0 Paraguay 0 4.7 Peru 10 0.3 Suriname 0 32.7 Venezuela 456 50 40 30 20 10 0 0 100 200 300 400 500 Incidence per 1 000 risk population Estimated deaths Source: WHO GHO 2019. StatLink 2 https://stat.link/qiyvf5 Figure 3.30. Dengue incidence and mortality, 2018 (or nearest year) Incidence Mortality 0 Uruguay 0.0 0 Chile 0.0 0 Haiti 0.0 3 Bahamas 0.0 4 Saint Vincent and the Grenadines 0.0 4 Argentina 0.0 7 Antigua and Barbuda 0.0 9 Trinidad and Tobago 0.0 13 Saint Kitts and Nevis 0.0 14 Dominican Republic 0.1 18 Ecuador 0.0 18 Cuba 0.0 21 Peru 0.0 21 Suriname 0.0 23 Barbados 0.0 34 Jamaica 1.3 36 Guyana 0.0 39 Guatemala 0.1 50 Saint Lucia 0.0 55 Costa Rica 0.0 59 Venezuela 0.1 60 Mexico 0.1 60 Dominica 0.0 67 Bolivia 0.1 84 Honduras 0.3 90 Colombia 0.1 109 LAC33 0.1 126 Brazil 0.1 131 El Salvador 0.0 165 Panama 0.0 428 Grenada 0.0 469 Paraguay 0.0 934 564 Belize 0.0 Nicaragua 0.0 1 000 800 600 400 200 0 0 0.2 0.4 0.6 0.8 1 1.2 1.4 Incidence rate per 100 000 population Deaths (% of cases) Source: PAHO 2019. StatLink 2 https://stat.link/tn1hs4 Figure 3.31. Zika incidence, 2018 (or nearest year) Incidence rate for 100 000 population 75 60 45 30 15 0 Source: PAHO 2019. StatLink 2 https://stat.link/d8guia HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 81 3. DIABETES Diabetes is a chronic metabolic disease, characterised by high Policy initiatives can be directed towards both reducing diabetes levels of glucose in the blood. It occurs either because the pancreas prevalence and mortality. Strengthening the integral response to stops producing the hormone insulin (type 1 diabetes, insulting NCDs, including diabetes, particularly at primary-care level is a key dependent diabetes, genetic predisposition), which regulates blood action. In general, countries with strong primary care systems sugar, or through a reduced ability to produce insulin (type 2 obtain better diabetes results (e.g. Costa Rica, Cuba). For diabetes, diabetes, non-insulin dependent in most cases, lifestyle related), or this includes the implementation of guidelines and protocols to through reduced ability to respond to insulin (insulin resistance). improve diagnosis and management, ensuring equitable access to People with diabetes are at a greater risk of developing essential technologies for all population groups (e.g. insulin). Most cardiovascular diseases such as heart attack and stroke. They also of countries in LAC have programmes devoted to diabetes, which is have elevated risks for vision loss, foot and leg amputation due to a relevant step toward its control (WHO, 2016[27]). Prevalence damage to nerves and blood vessels, and renal failure requiring must be addressed by targeting risky behaviours (e.g. unhealthy dialysis or transplantation. Globally, an estimated 422 million adults diet and sedentarism are the main ones, as well as alcohol and were living with diabetes in 2014, compared to 108 million in 1980. tobacco consumption). The global prevalence of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population, and caused 1.5 million deaths in 2012, with an additional 2.2 million deaths due Definition and comparability to higher-than-optimal blood glucose (WHO, 2016[27]). In LAC, about 41 million adults (over 20 years old) live with diabetes and Diabetes prevalence refers to the percentage of people about half of them are undiagnosed and unaware of developing ages 20‑79 who have type 1 or type 2 diabetes. Accurate long-term complications. diabetes estimates at the national and global levels rely heavily on the quality and availability of data sources. Data Among LAC countries, the prevalence of diabetes in adults in 2019 sources were searched and selected according to ranged from under 6% in Ecuador and Argentina to 17% in Belize established criteria, and the standardised, age-specific (Figure 3.32). On average, prevalence in LAC countries was 9.7%, prevalence of both diabetes and impaired glucose tolerance an increase from 7.4% in 2010. Belize is the country that has (IGT) were estimated. For countries where data sources experienced the largest increase, 10 percentage points, while were not available, prevalence was extrapolated based on prevalence in both Venezuela and Uruguay has decreased around data sources from similar countries. Mortality rates per 6 percentage points in the 2010‑19 period. 100 000 population were calculated based on data on In the 2010‑19 period, mortality attributable to high blood glucose in number of deaths attributable to high blood glucose in the the 20 to 79 years age group increased in countries such as 20‑79 age group from the International Diabetes Federation, Paraguay (+72%), Antigua and Barbuda (+65%), and Saint Lucia and total population in the 20‑79 age group from the United (+55%). In average, it increased in LAC by 8%, in opposition to the Nations Population Prospects. OECD average reduction of 14% (Figure 3.33). Several countries experienced significant decreases, such as Honduras (‑47%), Haiti (‑37%), and Guyana (‑30%). In 2019, the country with the highest mortality was Guyana with 188 deaths per 100 000 population, followed by Suriname and Saint Vincent and the Grenadines, with References 155 and 153, respectively. These three countries are the only ones [27] WHO (2016), Global report on diabetes, World Health above the OECD average of 151 deaths per 100 000 population. Organization, https://apps.who.int/iris/handle/10665/204871. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 82 3. DIABETES Figure 3.32. Diabetes among adults aged 20‑79 years, age-adjusted prevalence, 2010 and 2019 2010 2019 % of the population 18 16 14 12 10 8 6 4 2 0 Source: International Diabetes Federation. Diabetes Atlas 2020. StatLink 2 https://stat.link/ucgm73 Figure 3.33. Deaths attributable to high blood glucose for adults aged 20‑69 years per 100 000 population, by country, 2010 and 2019 2010 2019 Per 100 000 population 300 250 200 150 100 50 0 Source: International Diabetes Federation. Diabetes Atlas 2020. StatLink 2 https://stat.link/kefnxj HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 83 3. AGEING Population ageing naturally occurs when life expectancy extends Such demographic changes will challenge the financial (see indicator “Life expectancy at birth” in Chapter 1) and fertility sustainability of not only health systems but also social protection declines. In LAC, life expectancy has increased around 4 years systems and the economy as a whole. Moreover, older age often since 2000 (see section “Life expectancy at birth”) and fertility has exacerbates pre-existing inequities based on income, education, decreased from 2.6 to 2 births per woman, below the replacement gender and urban/rural residence, highlighting the importance of rate of 2.1, necessary to maintaining the current population equity-focuses policy-making in future (OECD, 2017[29]). Many number. The latter has occurred due to better and more widespread LAC countries who are arriving at the demographic transition in fast access to reproductive health, primarily to different contraceptive pace are facing much shorter timeframes to prepare before methods (see indicator “Reproductive health” in Chapter 4), and reaching very high shares of elderly populations. Population ageing more access to the labor market. Population ageing is a calls for an equity-focused, gender-responsive and human rights- consequence of successful health and development policies over based action across several sectors, and will likely lead to greater last decades, but it is not exempt from placing challenges of its own demand for labour-intensive long-term care. Therefore, countries in (ECLAC, 2019[28]). LAC could think forward to plan ahead the vast arrange of policies The share of the population above 65 years old is expected to more that other OECD countries have already put in place, for instance, than double by 2050, reaching over 18% in LAC31 (Figure 3.34, left in the areas of long-term care workforce, financial coverage and panel). This will still be lower than the 27% expected among OECD social protection systems (Muir, 2017[30]). countries, which are deeper in the population ageing process. In LAC, the share of older people will be particularly large in Barbados and Cuba, both above 25%. In the lower end, Belize will have less Definition and comparability than 10% of its population aged over 65 years old. Women tend to Population projections are based on the most recent live longer than men do and therefore the proportion of elderly “medium-variant” projections from the United Nations, World women will likely be even higher. The speed to which this process is Population Prospects – 2019 revision. already occurring will be unprecedented and will have significant consequences. The share of the population over 65 will increase by three‑fold in Nicaragua, a country that was still relatively young in 2015. The growth of the share of population over 80 years will be even References more drastic (Figure 3.34, right panel). On average, the share of [28] ECLAC (2019), Latin America and the Caribbean: Population this population is expected to triple by 2050 in LAC31, reaching an estimates and projections, Economic Commission for Latin average of 5.2%. The largest rise will be in Guyana, Bahamas, America and the Caribbean, https://www.cepal.org/en/topics/ Brazil, Antigua and Barbuda and Cuba, countries that will more demographic-projections/latin-america-and-caribbean-population- than quadruple their population over 80 years old. estimates-and-projections. Another important consideration is the fact that population ageing [30] Muir, T. (2017), “Measuring social protection for long-term care”, implies a decrease in the share of working age population OECD Health Working Papers, No. 93, OECD Publishing, Paris, https://dx.doi.org/10.1787/a411500a-en. (aged 15‑64). The ratio of working age population to people over 65 will be four times in 2050 compared to nine times in 2015 [29] OECD (2017), Preventing Ageing Unequally, OECD Publishing, (Figure 3.35). The situation will be particularly severe in Uruguay, Paris, https://dx.doi.org/10.1787/9789264279087-en. Cuba, Barbados and Chile where there will only be two working age adults per each person over 65 by 2050. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 84 3. AGEING Figure 3.34. Share of the population aged over 65 and 80 years, 2015 and 2050 Population aged 65 years and over Population aged 80 years and over 2015 2050 2015 2050 OECD36 Uruguay Barbados Cuba Argentina Chile Trinidad and Tobago Jamaica Saint Lucia Brazil Bahamas El Salvador Colombia Costa Rica LAC31 Panama Saint Vincent and the Grenadines Antigua and Barbuda Grenada Mexico Suriname Peru Dominican Republic Ecuador Bolivia Venezuela Paraguay Nicaragua Guyana Honduras Guatemala Haiti Belize 35 30 25 20 15 10 5 0 0 5 10 15 % % Source: UN World Population Prospects 2019. StatLink 2 https://stat.link/kxzn30 Figure 3.35. Ratio of people aged 15‑64 to people aged over 65 years, 2015 and 2050 2015 2050 Ratio 25 16.8 20 13.4 13.2 12.9 12.7 12.2 15 10.6 10.4 10.1 9.8 9.6 9.6 9.6 9.5 9.5 9.4 9.3 9.2 9.2 8.9 8.6 8.5 7.9 7.7 7.5 7.4 7.4 7.0 10 6.5 6.5 6.5 6.3 5.9 5.3 5.2 5.0 4.9 4.7 4.2 4.1 4.0 4.0 3.9 3.8 3.8 3.8 3.7 3.6 3.5 3.5 3.4 3.3 3.2 3.5 3.0 3.0 3.0 3.0 3.0 2.7 2.6 2.3 2.2 2.3 5 1.7 2.0 0 Source: UN World Population Prospects 2019. StatLink 2 https://stat.link/ch0f2y HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 85 Health at a Glance: Latin America and the Caribbean 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 Chapter 4 Determinants of health 87 4. FAMILY PLANNING The WHO estimates that 214 million women of reproductive age in accessible and affordable to all individuals. Modern family planning developing countries who want to avoid pregnancy are not using a interventions can be further incorporated in the essential services modern contraceptive method (WHO, 2018[1]). The SDG targeting package to provide universal coverage, paying special attention to reproductive health care services aims to provide universal access the poorest and most vulnerable people. In addition, countries must by 2030, and to integrate reproductive and sexual health into also take actions beyond the health sector to change social norms, national agendas, strategies and programs. The global agenda for laws, and policies to uphold human rights and promote gender sexual and reproductive health and rights is linked to gender equality (Starrs et al., 2018[2]; WHO, 2018[1]). equality and women’s wellbeing, affecting newborn, child, adolescent and maternal health, and their roles in shaping future economic development and environmental sustainability (Starrs Definition and comparability et al., 2018[2]). Family planning is a key component of any essential Contraceptive prevalence is the percentage of women who package of reproductive and sexual health services, and it is one of are currently using, or whose sexual partner is currently the most cost-effective public health interventions, contributing to using, at least one method of contraception, regardless of the significant reductions in child and maternal mortality and morbidity method used. It is usually reported as a percentage of (UNFPA, 2018[3]). married or in union women aged 15‑49. Modern methods of Reproductive health involves having a responsible, satisfying and contraception include combined oral contraceptives (“the safe sexual life, along with the freedom to make decisions about pill”), progestogen-only pills (“the minipill”), implants, reproduction. This includes accessing methods of fertility regulation injectables, patches, vaginal ring, intrauterine device (cooper and appropriate health care through pregnancy and childbirth, and levonorgestrel), male and female condoms, vasectomy, providing parents with the best chance of having a healthy, happy tubal ligation, lactational amenorrhea method, emergency and prosperous baby when they are ready to start or extend their contraception pills, standard days method, basal body family. Women who have access to contraception can protect temperature method, two‑day method and symptom-thermal themselves from unwanted pregnancy and some methods double method. Traditional methods considers the calendar or as protection against sexually transmitted diseases as well rhythm method, and the withdrawal or coitus interruptus. (e.g. condoms). Spacing births can also have positive benefits on both the reproductive health of the mother and the overall health Women with a demand for family planning satisfied are and well-being of the child, well beyond the pregnancy period and those who are fecund and sexually active, are using a birth. method of contraception, and report wanting more children. It is also reported as a percentage of married or in union The prevalence of contraceptive use varies widely in the LAC women aged 15‑49. Information on contraceptive use and region. In Costa Rica, Colombia, Nicaragua and Brazil, over three unmet need for family planning is generally collected through quarters of married or in union women of reproductive age report nationally representative household surveys. The most using any contraceptive method (Figure 4.1). However, both Haiti commonly used survey formats are the Demographic and and Guyana report that less than 35% of married women or in union Health Surveys (DHS) and the Multiple Indicator Cluster of reproductive age use any contraceptive methods. Regarding Surveys (MICS). modern methods of contraception, less than 50% of women are using them in Haiti, Guyana, Trinidad and Tobago, Bolivia, Suriname, Belize and Guatemala. In eight LAC countries with data, demand for family planning is generally satisfied at higher rates among women living in urban References areas, with higher income and education levels (Figure 4.2). These [2] Starrs, A. et al. (2018), “Accelerate progress-sexual and differences are particularly stark in Haiti and Guatemala, between reproductive health and rights for all: report of the Guttmacher- six to more than 20% lower access in the least advantaged groups. Lancet Commission.”, Lancet (London, England), Vol. 391/10140, Some countries such as Paraguay report less significant pp. 2642‑2692, http://dx.doi.org/10.1016/S0140-6736(18)30293-9. differences with similar access in the three categories. In most [3] UNFPA (2018), Strategic plan 2018‑2021, United Nations cases where both least and more socially advantaged women Population Fund, https://www.unfpa.org/resources/strategic- report high access to family planning (over 80‑85%), the rates tends plan-2018-2021. to be similar between both groups. This supports the fact that [1] WHO (2018), Family planning / Contraception, World Health providing wide availability to family planning services contributes Organization, https://www.who.int/news-room/fact-sheets/detail/ not only to more access but also to reduced social inequalities in the family- planning-contraception. utilisation of these services. LAC countries can continue improving the information and services related to sexual and reproductive health, which should be HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 88 4. FAMILY PLANNING Figure 4.1. Contraceptive prevalence, married or in-union women, 2015 or latest available estimate Any method Any modern method % 100 75 50 25 0 Note: Data for Haiti is 2016 and for Surinam is 2010. Source: World Contraceptive use 2019, UNDP. Ministry of Health for Costa Rica. StatLink 2 https://stat.link/0vgc4h Figure 4.2. Demand for family planning satisfied by socio-economic characteristics, any method, selected countries, latest available estimate Lowest education Highest education Rural Urban % % 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Lowest wealth quintile (poorest) Highest wealth quintile (richest) % 100 90 80 70 60 50 40 30 20 10 0 Haiti Belize Guatemala LAC8 Mexico Paraguay Honduras Dominican Peru Republic Source: DHS and MICS surveys, various years. StatLink 2 https://stat.link/1oi5ws HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 89 4. PRETERM BIRTH AND LOW BIRTH WEIGHT Globally, preterm birth (i.e. birth before 37 completed weeks of care facilities. Current cost-effective interventions include kangaroo gestation) is the leading cause of death in children under 5 years of mother care (continuous skin-to-skin contact initiated within the first age, responsible for approximately 1 million deaths in 2015 (see minute of birth), early initiation and exclusive breastfeeding indicator “Under age 5 mortality” in Chapter 3). In almost all (initiated within the first hour of birth) and basic care for infections countries with reliable data, preterm birth rates are increasing. and breathing difficulties (WHO, 2018[4]), all of which can also be Many survivors of preterm births also face a lifetime of disability, scaled up in LAC countries. including learning disabilities and visual and hearing problems as well as long-term development (WHO, 2018[4]). In LAC, most countries are near the regional average of 9.5% of births being preterm. Colombia is the only country significantly Definition and comparability above average with near 15% of preterm births, followed by Brazil Preterm birth is defined as babies born alive before with 11%. The lowest rates were observed in Cuba (6%) and 37 weeks of pregnancy are completed. There are sub- Mexico (7%) (Figure 4.3, left panel). Most LAC countries rates are categories of preterm birth based on gestational age: lower than the global rate, but there are opportunities for further extremely preterm (less than 28 weeks); very preterm improvements through interventions such as a national focus on (28‑32 weeks); moderate to late preterm (32‑37 weeks). Low improved obstetric and neonatal care, and the systematic birthweight is defined by the World Health Organization as establishment of referral systems with higher capacity of neonatal the weight of an infant at birth of less than 2 500 grammes care units and staff and equipment (Howson, Kinney and Lawn, (5.5 pounds) irrespective of the gestational age of the infant. 2012[5]). On average, 10 new-borns out of 100 had low weight at This figure is based on epidemiological observations birth across LAC countries (Figure 4.3, right panel). There are very regarding the increased risk of death to the infant and serves significant differences between countries in the region, ranging for international comparative health statistics. In developed from a low 5% in Cuba and 6% in Chile, to the highest rate of 23% in countries, the main information sources are national birth Haiti, followed by Guyana with 16%. registers. For developing countries, low birthweight Low birth weight has decreased an average of 0.4 percentage estimates are primarily derived from mothers participating in points in LAC26 countries in the 2000‑15 period, suggesting that, national household surveys, as well as routine reporting overall, the region still has room for improvement in regards to this systems (WHO and UNICEF, 2004[7]). indicator. Chile, Brazil, Venezuela and Costa Rica are the only LAC Antenatal care (ANC) is defined as the care provided by countries to have increased low birth weight new-borns, while the skilled health-care professionals to pregnant women and largest reduction happened in Surinam, Guatemala and Honduras adolescent girls in order to ensure the best health conditions with more than 1 percentage point of decrease between 2000 and for both mother and baby during pregnancy. The 2015 (Figure 4.4). recommendation is to provide at least four visits during Antenatal care can help women prepare for delivery and pregnancy (WHO, 2016[8]). understand warning signs during pregnancy and childbirth. Higher coverage of antenatal care is associated with higher birth weight in LAC countries, suggesting the significance of antenatal care over infant health status across countries (Figure 4.5). However, the correlation does not apply equally in all countries. For instance, References Trinidad and Tobago and Barbados report to have 100% and 98% [5] Howson, C., M. Kinney and J. Lawn (eds.) (2012), Born Too Soon: of at least four antenatal care visits, but their low birth weight The Global Action Report on Preterm Birth, World Health prevalence is 12%, over the LAC average of 10%. This might be Organization, Geneva, https://www.who.int/ explained partly by a low quality of care in their antenatal care visits. maternal_child_adolescent/documents/born_too_soon/en/. On the other hand, countries like Grenada, Paraguay and Bolivia [6] Osman, R., L. Manikam and K. Watters (2018), “Interventions to show an antenatal care coverage below the LAC24 average of reduce premature births: a review of the evidence”, The Lancet, 87%, but also a low birth weight prevalence of 7‑9%. Some of the Vol. 392, p. S69, http://dx.doi.org/10.1016/ differences between countries can be attributed to cultural s0140-6736(18)32188-3. practices and preferences, such as different approaches to privacy [7] WHO and UNICEF (2004), Low birthweight: country, regional and or perceptions about what antenatal and postnatal care entail. global estimates, World Health Organization, https://apps.who.int/ Preterm birth can be largely prevented. Effective interventions to iris/handle/10665/43184. reduce preterm births include smoking cessation, progesterone [8] WHO (2016), WHO recommendations on antenatal care for a supplementation, cervical cerclage, preterm surveillance clinics positive pregnancy experience, World Health Organization, https:// and screening, diagnosis and preparation, corticosteroids, www.who.int/reproductivehealth/publications/ magnesium sulphate, and tocolysis (Osman, Manikam and maternal_perinatal_health/anc-positive-pregnancy- Watters, 2018[6]). Most of these exist in several LAC countries and experience/en/. could be further developed. In addition, three‑quarters of deaths [4] WHO (2018), Preterm birth, World Health Organization, https:// associated with preterm birth can be saved even without intensive www.who.int/news-room/fact-sheets/detail/preterm-birth. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 90 4. PRETERM BIRTH AND LOW BIRTH WEIGHT Figure 4.3. Preterm birth and low birth weight infant rates, 2015 (or latest year available) Preterm births Low birth weight infants Cuba OECD36 Chile Bolivia Argentina Costa Rica Uruguay Mexico Paraguay Brazil Belize Grenada Antigua and Barbuda Venezuela Peru Colombia Saint Kitts and Nevis Saint Lucia Panama El Salvador LAC32 Nicaragua Honduras Saint Vincent and the Grenadines Guatemala Ecuador Dominican Republic Barbados Trinidad and Tobago Bahamas Jamaica Suriname Guyana Haiti 16 14 12 10 8 6 4 2 0 0 5 10 15 20 25 Per 100 live births Per 100 live births Source: UNICEF, 2019. StatLink 2 https://stat.link/5mlgp8 Figure 4.4. Low birth weight increase or decrease, 2000‑15 (or Figure 4.5. Antenatal care coverage and low birth weight, 2016 nearest year) or latest year available 2000 2015 Low birth weight infants (per 100 live births) 25 Per 1 000 live births 18 23 HTI 16 21 14 R² = 0.2252 19 12 10 17 GUY 8 15 SUR 6 13 TTO BRB ECU GTM DOM 4 11 VCT LAC 2 SLV COL PER 9 GRD VEN PAN 0 PRY BRA BLZ URY 7 BOL ARG MEX CRI CUB 5 60 70 80 90 100 Antenatal care coverage, at least four visits (%) Source: UNICEF-WHO Low birthweight estimates, 2019. Source: WHO GHO 2018. StatLink 2 https://stat.link/y5zb86 StatLink 2 https://stat.link/w0iuyz HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 91 4. INFANT AND YOUNG CHILD FEEDING Feeding practices of infants and young children heavily influence Paraguay, women living in urban areas breastfeed exclusively their chances of short-term survival and their capacity to realise more than women in rural areas. Argentina is the only country with their long-term potential. They contribute to healthy growth, data where more educated and wealthier women show higher rates decrease rates of stunting and obesity and lead to higher of exclusivity in LAC. intellectual development (Victora et al., 2016[9]). Starting at the Key factors that can lead to inadequate breastfeeding rates are beginning of a woman’s pregnancy to the second birthday of her broad and encompass several dimensions of society. They include child, the first 1 000 days represent a key opportunity to ensure unsupportive hospital and health care practices and policies, lack of wellness and create the foundations of a productive and healthy adequate skilled support for breastfeeding, specifically in health life. Breastfeeding is often the best way to provide nutrition for facilities and the community, aggressive marketing of breast milk infants. Breast milk provides infants with nutrients they need for substitutes and inadequate maternity and paternity leave legislation healthy development, including the antibodies that help protect and unsupportive workplace policies. In conclusion, considering them from common childhood illnesses such as diarrhoea and persisting high levels of children malnutrition, infant and young child pneumonia, the two primary causes of child mortality worldwide feeding practices must be further improved to tackle current and (see Chapter 3. Child mortality). Breastfeeding is also linked with forthcoming challenges (Rollins et al., 2016[10]). better health outcomes as children grow older (Rollins et al., 2016[10]). Adults who were breastfed as babies often have lower blood pressure and lower cholesterol, as well as lower rates of Definition and comparability overweight, obesity and type 2 diabetes. Breastfeeding also improves IW, school attendance and is linked to higher income Exclusive breastfeeding is defined as no other food or levels in adult life. More than 800 000 deaths among children under drink, not even water, other than breast milk (including milk five could be saved every year globally, if all children 0‑23 months expressed or from a wet nurse) for the first six months of life, were optimally breasted (Victora et al., 2016[9]). Breastfeeding also with the exception of oral rehydration salts, drops and syrups benefits mothers through its effect in fertility control, reducing the (vitamins, minerals and medicines). Thereafter, to meet their risk of breast and ovarian cancer later in life and lowering rates of evolving nutritional requirements, infants should receive obesity. adequate and safe complementary foods while continued In LAC19, most of the countries reporting data have exclusive breastfeeding up to two years of age or beyond. breastfeeding lower than the WHO goal with an average of 35% of The usual sources of information on the infant and young children exclusively breastfed in the first 6 months of life child feeding practices are household surveys. They also (Figure 4.6). Over half of infants are exclusively breastfed in Peru, measure other indicators of infant and young child feeding Bolivia and Guatemala, while the rate is lower than one in five in practices such as minimal meal frequency, minimal diet Barbados and less the one in ten in Dominican Republic. diversity and minimum acceptable diet. The most commonly After the first six months of life, an infant needs additional used survey formats are the Demographic and Health nutritionally adequate and safe complementary foods, while Surveys (DHS) and the Multiple Indicator Cluster Surveys continuing breastfeeding. In 24 LAC countries with data, 83% of (MICS). children receive any solid, semi-solid and soft foods in their diet, with Jamaica and Ecuador below 75%, and Argentina, Brazil, Cuba and El Salvador above 90%. Moreover, in average, 43% of children in LAC continued breastfeeding until having 2 years old, a rate References below 30% in Saint Lucia and Brazil, and above 60% in Peru, El [10] Rollins, N. et al. (2016), “Why invest, and what it will take to improve Salvador and Guatemala (Figure 4.7). breastfeeding practices?”, The Lancet, Vol. 387/10017, Exclusive breastfeeding is more common in lower and lower-middle pp. 491‑504, http://dx.doi.org/10.1016/s0140-6736(15)01044-2. income countries rather than higher income in LAC, as well as [9] Victora, C. et al. (2016), “Breastfeeding in the 21st century: among poorer rural women with lower education than richer women epidemiology, mechanisms, and lifelong effect”, The Lancet, with higher education living in cities (Figure 4.8). However, in Vol. 387/10017, pp. 475‑490, http://dx.doi.org/10.1016/ countries such as Costa Rica, Dominican Republic, Jamaica and s0140-6736(15)01024-7. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 92 4. INFANT AND YOUNG CHILD FEEDING Figure 4.6. Infants exclusively breastfed – first 6 months of life, 2016 or nearest year % 80 70 60 50 40 30 20 10 0 Source: UNICEF World Children Report 2017. StatLink 2 https://stat.link/cn87jk Figure 4.7. Feeding practices after six months of age, selected countries (2006‑17) Introduced to any solid, semi-solid and soft foods Continued breastfeeding at age 2 % 100 90 80 70 60 50 40 30 20 10 n.a. n.a. 0 Source: DHS and MICS surveys 2006‑17; UNICEF Infant and young child feeding. StatLink 2 https://stat.link/h0ql1a Figure 4.8. Infants exclusively breastfed in the first six months of life, by select socio-economic and geographic factors Lowest education Highest education Rural Urban % % 100 100 80 80 60 60 40 40 20 20 0 0 Lowest wealth quintile (poorest) Highest wealth quintile (richest) % 100 80 60 40 20 0 Argentina Belize Bolivia Costa Cuba Dominican El Guatemala Guyana Honduras Jamaica Mexico Panama Paraguay Suriname LAC15 Rica Republic Salvador Source: DHS and MICS surveys 2006‑17; UNICEF Infant and young child feeding. StatLink 2 https://stat.link/0xvak7 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 93 4. CHILD MALNUTRITION A key component of human capital is healthy and well-nourished (Figure 4.11). The highest rates are observed in Paraguay and people throughout their lives, but many children are not able to Barbados having over 12%, followed by Trinidad and Tobago, access sufficient, safe nutritious food and a balanced diet that Bolivia, Panama and Argentina, where more than one child out of meets their needs for optimal growth and development, to enable 10 is overweight. In turn, rates are lower than 5% in Haiti, Suriname an active and healthy life. Globally, it is estimated that 150.8 million and Guatemala. children are stunted, 50.5 million are wasted, and 38.3 million are The identification, promotion and implementation of actions that overweight (Development Initiatives, 2018[11]). Hence, many simultaneously and synergistically address undernutrition as well countries are facing a double burden of malnutrition – characterised as overweight, obesity and diet related NCDs are important by the coexistence of undernutrition along with overweight, obesity opportunities and immediate priorities. They include: food systems or diet related NCDs – a health challenge on the rise in many LAC for healthy, sustainable diets, aligned health systems providing countries. Child malnutrition also contributes to poorer cognitive universal coverage of essential nutrition actions, social protection and educational outcomes in later childhood and adolescence, and nutrition related education, trade and investment for improved which in turn affect lifelong potential and heavily determines the nutrition, safe and supportive environments for nutrition at all ages, socio-economic status of the individual. and strengthening and promotion of nutrition governance and The UN SDG target 2.2 sets that by 2030 end all forms of accountability (WHO, 2017[14]). malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age, and also includes an indicator on childhood overweight. Subsequently, in April 2016, the United Nations General Assembly Definition and comparability proclaimed 2016‑2025 the UN Decade of Action on Nutrition to The WHO definition of children overweight is weight for eradicate hunger, and malnutrition in all its forms (undernutrition, height greater than 2 standard deviations above WHO child micronutrient deficiencies, overweight or obesity) and reduce the growth standard median. The WHO definition of children burden of diet-related NCDs in all age groups (UN, 2019[12]). obesity is weight for height greater than 3 standard Stunting rates in LAC are generally lower than in other world deviations above the WHO Child Growth Standard median. regions but it is still a significant problem in several countries. In Stunted growth (low height for age) reflects failure to reach average, 13% of children below five years of age are stunted in linear growth potential as a result of long-term suboptimal LAC27 (Figure 4.9). The rate is nearly 47% in Guatemala and health and/or nutritional conditions. over 20% in Haiti, Ecuador and Honduras, while is lowest in Chile Wasting usually indicates recent and severe weight loss, and Saint Lucia below 3%. Wasting rates are also lower than in because a person has not had enough food to eats and or other regions with an average of 2.5% among children below they have had an infectious disease such as diarrhea which five years of age, but Barbados, Guyana and Uruguay have as cause d them to lose weight. significantly higher rates than average being over 6%. The lowest rates are observed in Chile, Peru, Guatemala and Colombia, all below 1%. Countries with higher stunting prevalence tend to have higher than average under‑5 mortality, reflecting the fact that about half of all References deaths before the age of 5 can be attributed to malnutrition [11] Development Initiatives (2018), Global Nutrition Report: shining a (Figure 4.10). Guatemala deviates significantly from the trend by light to spur action on nutrition, Development Initiatives Poverty having a stunting rate almost four times the LAC average and an Research Ltd, Bristol, https://globalnutritionreport.org/ under‑5 mortality rate eight points over the LAC average. This is documents/344/2018_Global_Nutrition_Report_Executive_Summ mainly due to the high poverty rate and large inequality in the ary.pdf. country, which causes that half the population cannot afford the [12] UN (2019), United Nations Decade of Action on Nutrition cost of the basic food basket. This adds to the effects of natural 2016‑2025, https://www.un.org/nutrition/home. disasters and climate change that damages food production (WFP, [13] WFP (2019), Guatemala | World Food Programme, https:// 2019[13]). www.wfp.org/countries/guatemala. Childhood overweight and obesity is shaping up to be one of the [14] WHO (2017), The double burden of malnutrition, World Health most significant challenges of the century. In LAC26, the average Organization, https://www.who.int/nutrition/publications/ prevalence of overweight among children under age 5 is almost 8% doubleburdenmalnutrition-policybrief/en/. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 94 4. CHILD MALNUTRITION Figure 4.9. Prevalence of stunting and wasting among children under age 5, latest year available Stunting Wasting % of prevalence 50 46.7 45 40 35 23.9 22.6 30 21.9 19.0 25 17.3 16.1 15.0 13.6 13.4 12.9 12.7 20 12.6 11.3 10.7 10.0 15 9.2 8.8 8.2 7.7 7.1 7.0 7.0 6.4 6.4 6.0 6.8 5.6 5.6 5.8 10 4.1 3.7 3.7 3.6 2.5 2.5 2.4 2.4 2.2 2.1 2.0 2.0 1.8 1.8 1.8 1.6 1.4 1.3 1.2 1.2 1.0 1.0 0.9 0.8 0.5 0.3 5 0 Source: WHO GHO 2018. StatLink 2 https://stat.link/m9u12g Figure 4.10. Under age 5 mortality and stunting prevalence, latest year available Under age 5 mortality (per 1 000 live births) 80 70 HTI R² = 0.1263 60 50 40 BOL DOM GUY VEN 30 TTO PRY LAC27 GTM LCA HND 20 PER PAN BRA MEX NIC ECU 10 CHL JAM BRB ARG COL SLV CRI CUB URY BLZ 0 0 5 10 15 20 25 30 35 40 45 50 Stunting among children under 5 (%) Source: WHO GHO 2018. StatLink 2 https://stat.link/y6mxlk Figure 4.11. Prevalence of overweight among children under age 5, latest year available 14 % 12.4 12.2 11.4 12 10.1 10.0 9.7 9.3 10 8.6 8.3 8.3 8.1 8.0 7.6 7.6 7.3 7.2 8 6.4 6.4 6.4 6.3 5.7 5.3 5.3 5.2 4.9 6 4.0 3.4 4 2 0 Source: WHO GHO 2018. StatLink 2 https://stat.link/irfc27 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 95 4. ADOLESCENT HEALTH Adolescence is a fundamental transitional phase in human The Global Strategy for Women’s, Children’s and Adolescent’s development as it represents a change from childhood to physical, Health 2016‑2030 fosters a world in which “every woman, child and psychological and social maturity. During this period, adolescents adolescent in every setting realizes their rights to physical and learn and develop knowledge and skills to deal with critical aspects mental health and well-being, has social and economic of their health and development while their bodies mature. opportunities, and is able to participate fully in shaping prosperous Adolescent girls, especially younger girls, are particularly and sustainable societies”. Aiming to end preventable deaths, vulnerable because they face the risks of premature pregnancy and ensure health and well-being, and expand enabling environment, it childbirth (UNICEF, 2017[15]). In the present, there are two clear calls for action in several areas: country leadership, financing for transitions regarding adolescent population: demographic health, health system resilience, individual potential, community transition, with an increase in the number of adolescents engagement, multisector action, humanitarian and fragile states, (aged 10‑24 years) from 1.53 billion in 1990 to 1.8 billion in 2016; research and innovation, and accountability (United Nations, and epidemiological transition, which has seen a decrease in the 2015[17]). LAC countries are taking this agenda in many ways and number of countries classified as multi-burden moving to be adapting it to their national context, with the opportunity to gather classified as NCDs predominant (Weiss and Ferrand, 2019[16]). the international momentum to take a big step in improving Risk factors for NCDs, the leading cause of premature adult deaths, adolescent health from a multifaceted perspective. are often acquired in adolescence. Overweight and obesity are one these key risk factors. In LAC, over 38% of both male and female adolescents were overweight or obese in 2016 (Figure 4.12). Definition and comparability Among male adolescents, Argentina and Chile led the group with The WHO definition of adolescent overweight is a body more than half of their adolescent population living with overweight mass index greater than 1 standard deviation above the or obesity, while Colombia and Saint Lucia were at the other end median, according to the WHO child growth standards. with less than 29%. Among female adolescents, Bahamas, Mexico and Venezuela stand over 45% of overweight and obesity, while The WHO definition of adolescent obesity is a body mass Haiti is the only country in the region with less than 30%. index greater than 2 standard deviation above the median, according to the WHO Child Growth Standards. Between 2010 and 2016, obesity in the LAC region increased in all countries, with an average of more than 34% growth among male Adolescent birth rate is defined as the annual number of adolescents and almost 30% among female adolescents births to women aged 15‑19 years per 1 000 women in that (Figure 4.13). The largest increase among male adolescents age group. It is also referred to as the age specific fertility rate occurred in Trinidad and Tobago, Haiti, Saint Lucia and Guyana for women aged 15‑19 years. with more than 50% increase, whereas in Venezuela, Mexico, Argentina, Uruguay and Bahamas the surge was below 20%. Similarly, the highest increase among female adolescents happened in Trinidad and Tobago with 57%, followed by Saint References Lucia, Haiti and Guyana just over 45%. The lowest increases in [15] UNICEF (2017), Adolescent Health, http://data.unicef.org/topic/ Uruguay and Bahamas, both below 15% growth. maternal-health/adolescent-health/. Another key issue for adolescents worldwide is the high prevalence of pregnancies during youth. In LAC25, the average adolescent [17] United Nations (2015), The Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016‑2030, Every Woman birth rate is 62 births per 1 000 adolescent women, which is almost Every Child, Geneva, https://www.who.int/life-course/partners/ the triple as in OECD countries that stand in 21 births per 1 000 global-strategy/en/. adolescent women (Figure 4.14). Notably, all LAC countries are situated above the OECD average. The highest adolescent birth [16] Weiss, H. and R. Ferrand (2019), Improving adolescent health: an evidence-based call to action, Lancet Publishing Group, http:// rate is found in Honduras with 101 births per 1 000 adolescent dx.doi.org/10.1016/S0140-6736(18)32996-9. women (1 out of 10 teenage girls will give birth), followed by Nicaragua and Guatemala with 92 births. On the other hand, Bahamas and Trinidad and Tobago have the lowest adolescent birth rates in the region with 32 and 38, respectively. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 96 4. ADOLESCENT HEALTH Figure 4.12. Adolescents who are overweight or obese, 2016 Male Female Obese Overweight Obese Overweight Mexico Bahamas Venezuela Chile El Salvador Dominica Costa Rica Dominican Republic Nicaragua Panama Uruguay Jamaica Guatemala Argentina Bolivia Suriname LAC33 Honduras Ecuador Saint Vincent and the Grenadines Cuba Peru Belize Saint Kitts and Nevis Barbados Antigua and Barbuda Colombia Paraguay Grenada Guyana Brazil Trinidad and Tobago Saint Lucia Haiti 40 30 20 10 0 0 10 20 30 40 Source: WHO GHO 2019. StatLink 2 https://stat.link/24yjcb Figure 4.13. Change in obesity prevalence, 2010‑16 Male Female % 70 60 50 40 30 20 10 0 Source: WHO GHO 2019. StatLink 2 https://stat.link/gkh3jl Figure 4.14. Adolescent birth rate, latest year available Adolescent birth rate (per 1 000 women aged 15-19 years) 120 92.0 92.0 84.3 100 74.0 71.6 71.0 69.2 101.0 66.2 65.5 63.7 62.8 61.9 60.8 57.7 80 56.5 55.6 50.0 49.7 49.4 49.0 45.7 45.3 44.7 38.0 60 32.0 20.6 40 20 0 Source: WHO GHO 2019. StatLink 2 https://stat.link/ybgfup HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 97 4. OVERWEIGHT AND OBESE ADULTS Overweight and obesity are major public health concerns as the leads growth the increase with 39% increase followed by global epidemic has far-reaching consequences for individuals, Dominican Republic and Guyana (30%). Venezuela and Argentina society and the economy. Obesity is an established risk factor for show the lowest increase of 13% (Figure 4.17). numerous health conditions, including hypertension, high Social determinants of health such as poverty, inadequate water cholesterol, diabetes, cardiovascular disease, respiratory and sanitation, and inequitable access to education and health problems, skeletal diseases and some forms of cancer, and services underlie malnutrition. A key driver of the increasing obesity mortality also increases progressively once the overweight epidemic is a changing food environment, in which nutrient poor threshold is crossed. Therefore, obesity and overweight reduces and energy dense processed foods are aggressively marketed, life expectancy, increases health care costs, decreases workers’ readily available and often cheaper than healthier alternatives. productivity and lowers countries’ GDP (OECD, 2019[18]). Countries such as Mexico, Chile, Peru, Uruguay and Ecuador, have Worldwide, 39% of men and 39% of women in 2016 were managed to develop some policies related to taxing sugar overweight, and 11% of men and 15% of women were obese. Thus, sweetened beverages and front-of-package labelling, along with nearly 2 billion adults worldwide were overweight and, of these, regulating food advertising to children. These efforts can be more than half a billion were obese. Forty-one million children complemented with policies such as menu labelling, workplace under the age of five were overweight or obese in 2016; while anti-sedentary interventions and mass media campaigns, as not over 340 million children and adolescents aged 5‑19 were only they are effective but also have a positive return on investment overweight or obese. Both overweight and obesity have shown a (OECD, 2019[18]). marked increase over the las four decades (WHO, 2018[19]). In OECD countries, 63% of men and 52% of women are overweight (pre-obesity + obesity). In LAC countries, 61% of women are overweight (Figure 4.15). In Mexico and Chile over 75% of their Definition and comparability female population is overweight, while the lowest rates are The most frequently used measure of underweight, observed in Paraguay and Trinidad and Tobago with less than overweight and obesity for adults is the Body Mass Index 55%. Similarly, 53% of men in LAC countries are overweight. Chile (BMI). This is a single number that evaluates an individual’s leads the region with 74% of its male population being overweight weight in relation to height, and is defined as weight in followed by Mexico (70%) and Argentina (66%). Saint Lucia and kilograms divided by the square of height in metres. Trinidad and Tobago are below 40% with the lowest rate in the Based on the WHO classification, adults with a BMI region. below 18.5 are considered to be underweight/thinness and Women’s overweight population increased in all LAC countries 25 or over are overweight. Adults who have BMI between 20 between 2010 and 2016 but the average growth rate was more than and 30 are considered to have pre-obesity. A BMI 30 or over half below the average increase in OECD countries (6% vs 13%). are defined as obese. Haiti and Trinidad and Tobago show the largest increases of 10% In many countries, self-reported estimates of height and each (Figure 4.16), while the lowest growth was registered in weight are collected through population-based health Venezuela (3%) followed by Chile, Uruguay and Bahamas (4%). surveys while other countries actually take measurements Among men, the LAC region increased by 9% while in the OECD amongst the population. These differences limit data was close to 16%. The largest increase happened in Haiti (17%) comparability. BMI estimates from health examinations are followed by Dominica (13%), Jamaica (12%) and Guyana (12%), more reliable, and generally result in higher values than whereas Venezuela and Argentina have the lowest rate of increase those from self-reported surveys. below 6%. In LAC countries, obesity is higher among women (29%) than men (18%) (Figure 4.15). Among women, Bahamas and Dominica have over 35% of obese female population, while Paraguay, Peru and Ecuador are below 25%. The largest increase in women’s obesity References between 2010 and 2016 occurred in Haiti (22%) and Trinidad and [18] OECD (2019), The Heavy Burden of Obesity: The Economics of Tobago (20%), whereas the smallest growth was in Venezuela and Prevention, OECD Health Policy Studies, OECD Publishing, Paris, Bahamas (8%) (Figure 4.17). Among men, Argentina has the https://dx.doi.org/10.1787/67450d67-en. highest obesity rate (27%) followed by Chile and Uruguay (25%), [19] WHO (2018), Obesity and overweight, World Health Organization, while Trinidad and Tobago (11%), Antigua and Barbuda (12%) and https://www.who.int/news-room/fact-sheets/detail/obesity-and- Saint Lucia (12%) stands in the other end (Figure 4.15). Haiti again overweight. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 98 4. OVERWEIGHT AND OBESE ADULTS Figure 4.15. Adults who are overweight or obese, 2016 Female Male Pre-Obesity Obesity Pre-Obesity Obesity Mexico Chile Bahamas Dominica Dominican Republic Suriname Venezuela Costa Rica Jamaica Cuba El Salvador Nicaragua Panama LAC33 Colombia Belize Saint Vincent and the Grenadines Uruguay Peru Guatemala Barbados Bolivia Honduras Argentina Saint Kitts and Nevis Ecuador Grenada Haiti Guyana Saint Lucia Antigua and Barbuda Brazil Trinidad and Tobago Paraguay OECD36 80 60 40 20 0 0 20 40 60 80 % % Note: OECD and LAC average includes both measured and self-reported data. Source: WHO GHO, 2018; OECD Health Statistics 2019 for Mexico, Chile, Colombia, Brazil and Costa Rica. StatLink 2 https://stat.link/672l8z Figure 4.16. Change in overweight prevalence, 2010‑16 Figure 4.17. Change in obesity prevalence, 2010‑16 Female Male Female Male Venezuela Venezuela Argentina Argentina Mexico Chile Chile Uruguay Uruguay Mexico Bahamas OECD36 Panama Bahamas Colombia Suriname Peru Peru Suriname Brazil Ecuador Colombia Nicaragua Ecuador El Salvador Panama Belize Cuba Antigua and Barbuda Nicaragua Brazil El Salvador Cuba Paraguay Paraguay Belize Bolivia Dominica LAC33 Bolivia Guatemala Antigua and Barbuda Barbados LAC33 Dominica Grenada Costa Rica Barbados Saint Lucia Guatemala Honduras Honduras Grenada Saint Lucia Trinidad and Tobago Costa Rica Saint Kitts and Nevis Saint Kitts and Nevis Saint Vincent and the Grenadines Jamaica Guyana Saint Vincent and the Grenadines Jamaica Trinidad and Tobago Dominican Republic Guyana OECD36 Dominican Republic Haiti Haiti 0 5 10 15 20 0 10 20 30 40 % % Note: OECD and LAC average includes both measured and self-reported data. Note: OECD and LAC average includes both measured and self-reported data. Source: WHO GHO, 2018; OECD Health Statistics 2019 for Mexico, Chile, Source: WHO GHO, 2018; OECD Health Statistics 2019 for Mexico, Chile, Colombia, Brazil and Costa Rica. Colombia, Brazil and Costa Rica. StatLink 2 https://stat.link/suljdm StatLink 2 https://stat.link/c4ag0m HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 99 4. WATER AND SANITATION Exposure to inadequate drinking water, sanitation and hygiene for all and end open defecation by 2030. Furthermore, UNICEF behaviours (WASH) are vital to individual health, livelihood and strategy for WASH seeks to ensure that every child lives in a clean well-being. Diarrhoea, respiratory infections, malnutrition, and safe environment, gains access to basic sanitation and safe schistosomiasis, malaria, soil-transmitted helminth infections and drinking water in early childhood development centres, school, trachoma are some of the diseases associated to inadequate health centres and in humanitarian situations. Tax-based public WASH. In 132 low and middle-income countries, an estimated subsidies, well-designed water tariffs and strategic use of aid flows 829 000 WASH-attributable deaths and 49.8 million DALYs to the water sector can assist in ensuring that poor and vulnerable occurred from diarrhoeal diseases in 2016, equivalent to 60% of all groups have access to sustainable and affordable water services diarrhoeal deaths (Prüss-Ustün et al., 2019[20]). Over half a million (WHO, 2012[22]). children under the age of five die every year due to diarrhoeal disease. The estimation is that 88% of that burden is attributable to WASH and is mostly concentrated on children in developing countries. Better access to water and sanitation is fundamental to Definition and comparability better health but it also contributes to social and economic People that use improved sources of drinking water that progress, one of the many links to human capital described in this required no more than 30 minutes per trip to collect water are publication. It helps drive higher educational enrolment rates, classified as having at least basic drinking water services. An improves the standard of living and lower health care costs improved drinking-water source is constructed so that is necessary to maintain a productive workforce (UNICEF and WHO, protected from outside contact, especially from fecal matter, 2017[21]). improved sources include piped water, public taps, Access to basic sanitary facilities has grown in LAC over recent boreholes, and protected dug wells or springs (UNICEF and years (Figure 4.18, left panel). In 2017, almost three out of four WHO, 2017[21]). people living in rural areas and almost seven out of eight people living in urban areas in LAC countries have access to basic People that use an improved sanitation facility that was not sanitation. However, in Haiti and Bolivia only around 24% and 36% shared with other households are classified as having at of people living in rural areas have access to basic sanitation for least basic sanitation services. Improved sanitation facilities adequate excreta disposal, respectively, meaning that open hygienically separate excreta from human contact, through defecation is still common. Urban basic sanitation in these two the use of flushing to piped sewer systems, septic tanks or pit countries increases to 44% and 72%, respectively, but still latrines, along with improved pit latrines or composting toilets substantially below the LAC average. Progress has been (UNICEF and WHO, 2017[21]). particularly rapid in Paraguay and Chile, with an increase of more The WHO/UNICEF Joint Monitoring Program for Water than 30 percentage points in the proportion of the population living Supply and Sanitation (JMP) database includes nationally in rural areas with access to basic sanitation between 2010‑17. representative household surveys and censuses that ask Bolivia and Panama reported the largest increases of 25 and questions on water and sanitation, mostly conducted in 21 percentage points in the population living in urban areas with developing countries. Generally, developed countries supply access to basic sanitation during the same period. Guatemala and administrative data. Saint Lucia were the only countries in LAC reporting a decrease in Countries showing 100% not included in figure. the percentage of the population having access to basic sanitation in urban areas from 2010‑17. Between 2010 and 2017, most countries in LAC improved access to basic drinking water (Figure 4.19, right panel). Only Antigua and References Barbuda, Barbados and Venezuela experienced small decreases. On average, nearly nine in ten persons in rural areas and nearly all [20] Prüss-Ustün, A. et al. (2019), “Burden of disease from inadequate persons in urban areas have access to improved water sources in water, sanitation and hygiene for selected adverse health LAC. Only Nicaragua, Peru and Haiti lagged behind with outcomes: An updated analysis with a focus on low- and middle- income countries”, International Journal of Hygiene and three‑quarters or less of the population living in rural areas having Environmental Health, Vol. 222/5, pp. 765‑777, http://dx.doi.org/ access to basic water sources. In Haiti, the rate was 40%, meaning 10.1016/j.ijheh.2019.05.004. that less than half of the rural population had access to drinking water. Access was significantly improved in Bolivia, Chile, El [21] UNICEF and WHO (2017), Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG, WHO/UNICEF Joint Salvador and specially Paraguay reported an increase in the Monitoring Programme for Water Supply, Sanitation and Hygiene, population living in rural areas having access to basic drinking https://www.unicef.org/publications/index_96611.html. water of more than 25 percentage points between 2010‑17 (Figure 4.19, left panel). [22] WHO (2012), UN-Water Global Annual Assessment of Sanitation and Drinking-Water. Report: The Challenge of Extending and The United Nations set a target of achieving universal and equitable Sustaining Services, World Health Organization, https:// access to safe and affordable drinking water for all, as well as www.who.int/water_sanitation_health/publications/ achieving access to adequate and equitable sanitation and hygiene glaas_report_2012/en/. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 100 4. WATER AND SANITATION Figure 4.18. Access to basic sanitation, 2017 and change between 2010‑17 2017 Change between 2010-17 Urban Rural Urban Rural Haiti Bolivia Saint Lucia Guatemala Peru Nicaragua Honduras LAC24 Jamaica Dominican Republic Suriname Ecuador El Salvador Panama Guyana Cuba Colombia Brazil Mexico Belize Paraguay Argentina Uruguay Costa Rica Chile 100 80 60 40 20 0 -20 0 20 40 60 80 100 % % Source: WHO GHO 2019. StatLink 2 https://stat.link/1twid9 Figure 4.19. Access to basic drinking water, 2017 and change between 2010‑17 2017 Change between 2010-17 Urban Rural Urban Rural Argentina Brazil Chile Colombia Costa Rica Ecuador Guyana Mexico Paraguay Uruguay Belize Bolivia El Salvador Honduras LAC24 Dominican Republic Guatemala Nicaragua Panama Saint Lucia Suriname Cuba Jamaica Peru Haiti 100 80 60 40 20 0 0 20 40 60 % % Source: WHO GHO 2019. StatLink 2 https://stat.link/n90xz4 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 101 4. TOBACCO Tobacco use is the second leading risk factor for early death and cigarettes (Figure 4.22). The countries with the highest taxation on disability worldwide, claiming more than 5 million lives every year tobacco are Chile and Argentina with over 80%, but these are not since 1990. The negative effects of smoking spread out beyond the countries with the highest prices. The most expensive tobacco individual and population health affecting the economy as well. can be found in Jamaica with a price of USD 14.3, while the Worldwide in 2015, the age-standardised prevalence of daily cheapest one is observed in Paraguay, Colombia, Cuba, Dominica smoking was 25% for men and 5.4% for women, representing and Guyana, all below USD 3 dollars. 28.4% and 34.4% reductions, respectively, since 1990. It is LAC countries can strengthen its regulations to reduce tobacco use estimated that in 2015 there were between 5.7 to 7 million deaths by fully implementing the WHO Framework Convention on Tobacco due to smoking, equivalent to 11.5% of all global deaths (Reitsma Control. For this, WHO’s strategy MPOWER can be followed to et al., 2017[23]). Currently, 1.1 billion people are estimated to be Monitor tobacco use and prevention policies; Protect people from active smokers, 84% of which were males and 80% of which live in tobacco use; Offer help to quit tobacco use; Warn about the low- and middle-income countries. Moreover, second-hand smoke dangers of tobacco; Enforce bans on tobacco advertising, causes more than 1.2 million premature deaths per year, of which promotion and sponsorship; and Raise taxes on tobacco (WHO, 65 000 are children (WHO, 2019[24]). The UN SDGs call for 2019[24]). strengthening the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate. Definition and comparability The proportion of daily tobacco smokers varies greatly across countries but close to one in four men aged 15 and above in the Adults smoking daily is defined as the percentage of the LAC18 smokes daily, a very similar rate to the OECD (Figure 4.20). population aged 15 years and over who reported smoking Rates are particularly high in Cuba, where over half of all men every day. Estimates for 2015 were based on data obtained smoke, followed by Surinam where 43% men smoke. The lowest from a broad range of health and household surveys, rates among men are observed in Costa Rica, Panama and including the Global Adult Tobacco Survey (GATS). Results Mexico, all below 10%. Rates are lower among women with 7% were age-standardised OECD standard population for smoking daily, lower than the OECD average. Chile is at the top OECD countries and to the WHO Standard Population for with over one women of every five smoking, followed closely by non-OECD countries. Cuba and Argentina. Cuban women smoke three times less than Current tobacco use among youth is derived from the men do. The lowest rates for women are found in Barbados and Global Youth Tobacco Survey 2010‑17. It is defined as the Ecuador with 2% or less, followed by El Salvador, Costa Rica, Haiti percentage of young people aged 13‑15 years who and Panama, all below 2%. consumed any tobacco product at least once during the last Among adolescents aged between 13 and 15 years old in 29 LAC 30 days prior to the survey. countries, tobacco use prevalence for men was 15% and almost 12% for women. Chile shows the highest tobacco use among women (26%) followed by Argentina (25%) and Mexico (18%), while the lowest rates are found in Dominican Republic (6%) and References Honduras (6%). Among men, Saint Vincent and the Grenadines [25] Guindon, G., G. Paraje and F. Chaloupka (2018), “The Impact of has the highest tobacco use (24%) followed by Argentina (23%) Prices and Taxes on the Use of Tobacco Products in Latin America and Mexico (22%). Paraguay has the lowest rate among men of 7% and the Caribbean”, American Journal of Public Health, (Figure 4.21). Vol. 108/S6, pp. S492‑S502, http://dx.doi.org/10.2105/ Increasing tobacco prices through higher taxes is one of the most ajph.2014.302396r. effective interventions to reduce tobacco use, by discouraging [23] Reitsma, M. et al. (2017), “Smoking prevalence and attributable youth from beginning cigarette smoking and encouraging smokers disease burden in 195 countries and territories, 1990‑2015: a to quit. A recent review of studies conducted in LAC countries found systematic analysis from the Global Burden of Disease Study that tax increases effectively reduce cigarette use and can also be 2015”, The Lancet, Vol. 389/10082, pp. 1885‑1906, http:// expected to increase cigarette tax revenue (Guindon, Paraje and dx.doi.org/10.1016/s0140-6736(17)30819-x. Chaloupka, 2018[25]), which can be used in complementary [24] WHO (2019), Tobacco, World Health Organization, https:// interventions. The average taxation in LAC is 48% for a pack of 20 www.who.int/news-room/fact-sheets/detail/tobacco. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 102 4. TOBACCO Figure 4.20. Age standardised prevalence estimates for daily tobacco smoking among persons aged 15 and above, 2016 Male Female Cuba Suriname Jamaica Chile Argentina Haiti OECD36 LAC18 Paraguay Bahamas Uruguay Dominican Republic Colombia El Salvador Barbados Brazil Ecuador Mexico Panama Costa Rica 60 50 40 30 20 10 0 0 5 10 15 20 % 25 % Source: WHO GHO 2018. OECD Health Statistics 2019 for Mexico, Chile, Colombia, Costa Rica and Brazil. StatLink 2 https://stat.link/bsx47w Figure 4.21. Prevalence of current tobacco use among youth Figure 4.22. National taxes and retail price for a pack of 20 aged 13 and 15, latest estimate available cigarettes of the most sold brand, 2016 Female Male Price excluding taxes Taxes Dominica Saint Vincent and the Grenadines Jamaica Argentina Ecuador Mexico Peru Bolivia Dominican Republic Nicaragua Trinidad and Tobago Colombia Suriname Haiti Panama Chile Barbados Guatemala Guyana Chile Barbados Uruguay Trinidad and Tobago El Salvador Suriname Saint Vincent and the Grenadines Belize LAC30 Bahamas Mexico Jamaica Saint Lucia LAC33 Guatemala El Salvador Costa Rica Ecuador Saint Kitts and Nevis Cuba Grenada Uruguay Antigua and Barbuda Grenada Saint Lucia Honduras Venezuela Argentina Peru Nicaragua Saint Kitts and Nevis Bolivia Costa Rica Belize Honduras Guyana Dominican Republic Colombia Panama Venezuela Antigua and Barbuda Brazil Paraguay Dominica Brazil Paraguay 0 10 20 30 40 0 10 20 % USD Source: Global Youth Tobacco Surveys 2010‑17. Source: WHO report on the global tobacco epidemic 2017. StatLink 2 https://stat.link/31hqo0 StatLink 2 https://stat.link/ayoqbh HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 103 4. ALCOHOL Alcohol use is a leading risk factor for disease burden, both in terms rates are over 40% in Saint Lucia and over 30% in Barbados and of mortality and morbidity, and has been linked to numerous Trinidad and Tobago. negative health and social outcomes, including more than 200 Reduction of health, safety and socio-economic problems disease and injury conditions such as cancer, stroke, liver cirrhosis, attributable to alcohol requires broad-based strategies among others. Foetal exposure to alcohol increases the risk of birth (e.g. addressing the wider social determinants of health) and ones defects and intellectual impairment. Alcohol misuse is also that target alcohol drinkers. Policies raising awareness of public associated with a range of mental health problems, including health problems caused by harmful use of alcohol and ensuring depression and anxiety disorders, obesity and unintentional injury support for effective alcohol policies, regulating the marketing of (WHO, 2018[26]). In 2016, 2.8 million deaths were attributed to alcoholic beverages and restricting the availability of alcohol, in alcohol use globally, corresponding to 2.2% of total age- particular to younger people, can be further developed in the standardised deaths among females and 6.8% among males. In region. Drink-driving policies have proven to be effective; for terms of overall disease burden, alcohol use led to 1.6% of total instance in Chile a “zero tolerance” policy was enacted in 2012 with DALYs globally among females and 6% among males, ranking positive results. Demand can be reduced through taxation and alcohol use as the seventh leading risk factor for premature death pricing mechanisms, which in LAC countries has been less utilised and disability in 2016, compared with other risk factors in the Global as a policy tool. Finally, in relation to alcohol-use disorders, Burden of Disease studies (Griswold et al., 2018[27]). implementing screening and brief interventions programmes along Average alcohol consumption in the LAC region was more than with providing accessible and affordable treatment is an effective 6 litres per capita in 2016, lower than the 9.3 litres per capita in the strategy (WHO, 2018[26]; Sassi, 2015[28]). OECD. The lowest consumption is observed in Guatemala, Costa Rica and El Salvador, while the highest intake is in Uruguay, Saint Lucia, Argentina and Barbados (Figure 4.23, left panel). Definition and comparability Consumption is in general higher among more developed countries, consistent with trends in other world regions. The Alcohol intake is measured in terms of annual consumption evolution of alcohol consumption in the period 2010‑16 has been of litres of pure alcohol per person aged 15 years and over. very heterogeneous across countries, but the regional average has Sources are based mostly on FAO (Food and Agriculture increased by almost 3%. Countries like Guatemala and Venezuela Organization of the United Nations) data, which consist of experienced decreases of over 25%, while Dominica and Trinidad annual estimates of beverage production and trade supplied and Tobago increased their per capita intake by the same by national Ministries of Agriculture and Trade. The percentage (Figure 4.23, right panel). methodology to convert alcoholic drinks to pure alcohol may differ across countries. Data are for recorded alcohol, and Heavy and binge drinking are drinking patterns with more exclude homemade sources, cross-border shopping and associated health risks. In average in the LAC region, 43% of the other unrecorded sources. Information on drinking patterns is drinking population in 2016 had a heavy episodic drinking in the derived from surveys and academic studies. past 30 days (Figure 4.24). In Peru, Saint Lucia, Grenada, Saint Kitts and Nevis, and Trinidad and Tobago, around half of all drinkers report heavy drinking behaviour. Rates of heavy drinking are below 35% in countries such as Chile, Guatemala, El Salvador, Argentina and Uruguay, suggesting a different drinking culture in References some of the countries with higher population intakes. Regarding [27] Griswold, M. et al. (2018), “Alcohol use and burden for gender patterns, in average men have more than 2.5 times heavy 195 countries and territories, 1990‑2016: a systematic analysis for episodic drinking than women, with Peru, Saint Lucia, Grenada, the Global Burden of Disease Study 2016”, The Lancet, Saint Kitts and Nevis, and Trinidad and Tobago leading for both Vol. 392/10152, pp. 1015‑1035, http://dx.doi.org/10.1016/ genders. s0140-6736(18)31310-2. Regarding road accidents in the LAC region, between one out of [28] Sassi, F. (ed.) (2015), Tackling Harmful Alcohol Use: Economics three for men and more than one out of every five for woman can be and Public Health Policy, OECD Publishing, Paris, https:// attributed to alcohol consumption (Figure 4.25). The rates are dx.doi.org/10.1787/9789264181069-en. over 40% for male drivers in Argentina, Uruguay, Barbados, [26] WHO (2018), Alcohol, World Health Organization, https:// Grenada, Saint Lucia, Trinidad and Tobago, while among women www.who.int/news-room/fact-sheets/detail/alcohol. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 104 4. ALCOHOL Figure 4.23. Recorded alcohol consumption, population aged 15 years and older, 2016 2016 Difference in consumption 2010-16 Uruguay Saint Lucia Argentina Barbados Saint Kitts and Nevis OECD36 Grenada Trinidad and Tobago Saint Vincent and the Grenadines Dominica Chile Panama Brazil Paraguay Antigua and Barbuda Dominican Republic Belize LAC33 Peru Guyana Cuba Haiti Venezuela Nicaragua Suriname Bolivia Colombia Mexico Ecuador Bahamas Jamaica Honduras El Salvador Costa Rica Guatemala 12 10 8 6 4 2 0 -40 -30 -20 -10 0 10 20 30 Litres per capita % Source: WHO GHO 2018. OECD Health Statistics 2019 for Mexico, Chile, Colombia, Costa Rica and Brazil. StatLink 2 https://stat.link/kr2nxp Figure 4.24. Heavy episodic drinking (drinkers only), past Figure 4.25. Proportion of road traffic deaths that are 30 days (%), 2016 attributable to alcohol, 2016 Female Male Female Male Trinidad and Tobago Trinidad and Tobago Saint Kitts and Nevis Saint Lucia Grenada Grenada Saint Lucia Barbados Peru Uruguay Antigua and Barbuda Argentina Saint Vincent and the Grenadines Peru Barbados Dominican Republic Brazil Dominica Antigua and Barbuda Belize Saint Vincent and the Grenadines Paraguay Panama Bolivia Brazil Ecuador Chile Dominican Republic Paraguay Guyana Bolivia Panama Belize Suriname Ecuador Bahamas Haiti LAC30 LAC33 Suriname Cuba Cuba Mexico Bahamas Jamaica Mexico Colombia Venezuela Venezuela Haiti Nicaragua Colombia Costa Rica Costa Rica Honduras Uruguay Nicaragua Argentina Jamaica El Salvador Honduras Guatemala El Salvador Chile Guatemala 0 20 40 60 % 80 0 10 20 30 40 % 50 Source: WHO GHO 2018. Source: WHO GHO 2018. StatLink 2 https://stat.link/794qad StatLink 2 https://stat.link/q9hjx8 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 105 4. ROAD SAFETY Approximately 1.35 million people die each year as a result of road the main factor in about half of road deaths. Speed limits are traffic crashes. While the global rate for road traffic deaths is 17.4 enforced by a national law in all LAC countries except in Venezuela. per 100 000, there is great disparity by income, with rates higher in However, in several countries speed limits are not adapted at the low- and middle-income countries than in the world’s high-income local level (Table 4.1). countries (WHO, 2018[29]). The burden of road traffic injuries falls Wearing a motorcycle helmet correctly can reduce the risk of death disproportionately on vulnerable road users – pedestrians, cyclists by almost 40% and the risk of severe injury by over 70%. When and motorcyclists. Road injuries will cost the world economy motorcycle helmet laws are enforced, helmet-wearing rates can USD 1·8 trillion (constant 2010 USD) in 2015‑30, which is increase to over 90%. However, four countries does not have a equivalent to an annual tax of 0.12% on global gross domestic regulation mandating helmet use. Motorcycle helmet wearing rate product (Chen et al., 2019[30]). The SDG 3 target aims to halve the is very low in Dominican Republic, Guatemala and Jamaica, and in number of global deaths and injuries from road traffic crashes by rural areas of most countries. Only Brazil, Chile, Colombia, 2020, while SDG 11 relates to providing access to sustainable Costa Rica, Cuba and Surinam report motorcycle helmet use transport systems for all, improving road safety, and expanding over 80% in rural areas. public transport. In 2016, LAC countries reported 17 deaths per 100 000 population due to road traffic accidents (Figure 4.26). In Saint Lucia, Dominican Republic and Venezuela, there were over 30 deaths per Definition and comparability 100 000 population because of road traffic injuries in 2016, followed by Ecuador, El Salvador, Paraguay, Guyana and Belize with To calculate road injury mortality data, countries were over 20 deaths. On the other end, Barbados, Antigua and Barbuda classified into four groups: (1) Countries with death and Cuba have the lowest road traffic death rates. registration data completeness of at least 80%. For these The five key risk factors in road traffic deaths and injuries are countries’ death registration, projection of the most recent drinking and driving, speeding, and failing to use motorcycle death registration, reported death or projected reported helmets, seat belts and child restraints (Table 4.1). In addition, deaths were used. (2) Countries with other sources of distracted driving is a growing threat to road safety considering the information on cause of death. For these countries a use of mobile phone and other in-vehicle technologies. Texting regression method was used to project forward the most causes cognitive distraction and both of manual and visual recent year for which an estimate of total road traffic deaths distraction as well. Even talking on mobile phones without holding was available. (3) Countries with population less than or browsing a phone can reduce driving performance (WHO, 150 000 and which did not have eligible death registration 2018[29]). Since hands-free phone and hand-held phone are data. For these countries the death reported in the survey equally at risk of cognitive distraction, some national laws regulate were used directly, without adjustment. (4) Countries without both of the ways of using mobile phones (Table 4.1). Drinking and eligible death registration data. For these countries a driving, especially with a blood alcohol concentration level of over negative binomial regression model was used. For more 0.05g/dl (grammes per decilitre), greatly increases the risk of a information about this process, see the report Global Status crash and the possibility that it will result in death or serious injury. Report on Road Safety (WHO, 2018[31]). Furthermore, lower limit BAC limits (0.02 g/dl) for young people and novice drivers can reduce the risk of road crashes. Enforcement through random breath testing checkpoints is highly cost effective and can reduce alcohol-related crashes by approximately 20%. References Wearing a seat belt can reduce fatalities among front-seat [30] Chen, S. et al. (2019), “The global macroeconomic burden of road passengers by up to 50% and among rear seat car passengers by injuries: estimates and projections for 166 countries”, The Lancet up to 75%. A national law does not exist in Antigua and Barbuda, Planetary Health, Vol. 3/9, pp. e390‑e398, http://dx.doi.org/ while several other countries do not require that all the occupants of 10.1016/S2542-5196(19)30170-6. a car wear a seat belt. Child restraint systems, such as child seats [29] WHO (2018), Road traffic injuries, World Health Organization, for infants and booster seats for older children, decrease the risk of https://www.who.int/news-room/fact-sheets/detail/road-traffic- death in a crash by about 70% for infants and up to 80% for small injuries. children. However, mandatory child restraint national laws exist [31] WHO (2018), The Global Status Report on Road Safety, World only in 16 LAC countries. Health Organization, https://www.who.int/publications-detail/ In high-income countries, speed contributes to about 30% of road global-status-report-on-road-safety-2018. deaths, while in some low and middle-income countries speed is HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 106 4. ROAD SAFETY Figure 4.26. Road traffic death rates, 2016 Per 100 000 population 40 35 30 25 20 15 10 5 0 Source: WHO GHO 2018. StatLink 2 https://stat.link/mowfry Table 4.1. Existence of a national legislation on five main risk factors of road traffic deaths, 2016 or latest year available Drink Diving Seat-belt Child restraint Speed limit Motorcycle helmet Mobile phone use Country Motorcycle helmet National law on Road traffic Applicability to all National or local Rural Urban wearing rate (% hand-held/hand- National law deaths to National law National law National law occupants law (km/h) (km/h) drivers / % free mobile phone alcohol (%) passengers) use Antigua and Yes 17.95 No No National 64 32 No No Barbuda Argentina Yes 18.13 Yes Yes Yes Both 110 60 Yes 65/44 Yes Barbados Yes 17.06 Yes Yes Yes National 80 80 Yes Yes Belize Yes 20.70 Yes No No National 88 40 Yes No Bolivia Yes 20.84 Yes No No Both 80 40 Yes 52/3 No Brazil Yes 19.52 Yes Yes Yes Both 80 60 Yes 83/80 Yes Chile Yes 16.68 Yes Yes Yes Both 100 60 Yes 99/98 Yes Colombia Yes 20.34 Yes Yes No Both 120 80 Yes 96/80 Yes Costa Rica Yes 19.69 Yes Yes Yes National 60 50 Yes 98/92 Yes Cuba Yes 18.82 Yes Yes No National 90 50 Yes 95/90 Yes Dominica Yes 18.97 Yes Yes No None No No Dominican Yes 20.75 Yes Yes Yes National 60 60 Yes 27/2 Yes Republic Ecuador Yes 20.34 Yes Yes Yes Both 120 60 Yes 90/12‑52 Yes El Salvador Yes 20.75 Yes No Yes National 90 50 Yes Yes Grenada Yes 20.26 Yes No No National 64 32 Yes No Guatemala Yes 21.68 Yes No No Both 80 60 Yes 36/11 Yes Guyana Yes 20.84 Yes No Yes National 64 64 No 50/20 Yes Honduras Yes 21.92 Yes Yes No National Yes Yes Jamaica Yes 19.11 Yes Yes Yes National 80 48 Yes 6/2 No Mexico Yes 20.39 Yes No Both 20‑90 20‑70 No 83/55 No Panama Yes 19.23 Yes Yes No National 100 80 Yes Yes Paraguay Yes 20.49 Yes Yes Yes Both 110 50 Yes Yes Peru Yes 20.34 Yes Yes Yes Both 60 60 Yes 70/8 Yes Saint Lucia Yes 19.85 Yes No No National 24 24 Yes Yes Suriname Yes 20.26 Yes Yes Yes National 80 40 Yes 95/92 Yes Trinidad and Yes 18.49 Yes No Yes National 80 50 Yes Yes Tobago Uruguay Yes 18.32 Yes Yes Yes Both 90 45 Yes 80/71 Yes Venezuela Yes 19.85 Yes Yes Yes None Yes Yes LAC28 19.70 82.25 53.125 Note: Speed limit regulation in 2015 (Global status report on road safety, 2015). Source: WHO Global Status Report on Road Safety 2018, CONAPRA 2015 for Mexico. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 107 4. PHYSICAL ACTIVITY Physical activity (or the lack thereof) is a key determinant of health than the global average (84%) (Figure 4.28). It is particularly high in and risk factors. For instance, the higher the level of physical Ecuador and Venezuela, where around nine out of every ten activity, the lower the chance of coronary heart disease. The adolescents do not engage in enough physical activity. The only relationship between energy expenditure and incidence of stroke countries in the region under the global average are Antigua and forms a U-shaped pattern, with levels of physical activity at both Barbuda, Belize and Suriname. extremes increasing the incidence of stroke. Studies also show a Countries and communities must act to provide individuals with negative relation between physical activity and the risk of type 2 more opportunities to be active, in order to increase physical diabetes mellitus, although level of obesity and physical fitness also activity. Policies to increase physical activity aim to ensure that influence the relationship. High levels of physical activity have been physical activity is promoted through activities of daily living. found to have a protective effect on many types of cancers, Walking, cycling and other forms of active transportation are including neoplasms of the breast, colon, endometrial and prostate. accessible and safe for all. Labor and workplace policies encourage Finally, there exists a J-shaped curve where physical inactivity and physical activity, and schools have safe spaces and facilities for extreme physical inactivity increase the risk of upper respiratory students to spend their free time actively. Moreover, quality tract infections (Graf and Cecchini, 2017[32]). Therefore, engaging physical education can support children to develop behaviour in physical activity has many health benefits and it greatly patterns that will keep them physically active throughout their lives, contributes to preventing disease in the short and long run, and sports and recreation facilities provide opportunities for improving muscular and cardiorespiratory fitness along with bone everyone to participate in sports (WHO, 2018[33]). and functional health, and reducing the risk of several NCDs, depression, and the risk of falls and consequently of hip or vertebral fractures. Definition and comparability WHO defines physical activity as “any bodily movement produced by skeletal muscles that requires energy expenditure – including The estimates are based on self-reported physical activity activities undertaken while working, playing, carrying out household captured using the GPAQ (Global Physical Activity chores, travelling, and engaging in recreational pursuits” (WHO, Questionnaire), the IPAQ (International Physical Activity 2018[33]). WHO recommends that children and adolescents carry Questionnaire) or a similar questionnaire covering activity at out moderate to vigorous physical activity for at least 60 minutes a work/in the household, for transport, and during leisure time. week and adults of all ages should do at least 150 minutes of Where necessary, adjustments were made for the reported moderate intensity or 75 minutes of vigorous intensity. In order to be definition (in case it was different to the indicator definition), beneficial for cardiovascular health, activity should be performed for known over-reporting of activity of the IPAQ, for survey for at least 10 minutes at a time (WHO, 2018[33]). coverage (in case a survey only covered urban areas), and Globally, around 23% of adults aged 18 and over were not active for age coverage (in case the survey age range was narrower enough in 2010 (men 20% and women 27%). In 22 LAC countries than 18+ years). No estimates were produced for countries with data, in average, 35% of the adult population do not engage in with no data, which in this case included Cuba, Dominican enough physical activity. The rate is over 40% for several countries Republic, Haiti, Jamaica, Mexico, Nicaragua, Panama and such as Argentina, Colombia, Suriname, Brazil, Barbados, Paraguay. Costa Rica and Bahamas. On the other hand, Dominica and Uruguay have the lowest rates, under 23%. Consistent with global trends, women tend to carry out less physical activity. More than 42% of all adult women do not engage in sufficient exercise in six References countries of the region, with a regional average of 42%. Among [32] Graf, S. and M. Cecchini (2017), “Diet, physical activity and men, this average reaches 30% of insufficient physical activity sedentary behaviours: Analysis of trends, inequalities and (Figure 4.27). clustering in selected oecd countries”, OECD Health Working Globally, 81% of adolescents aged 11‑17 years were insufficiently Papers, No. 100, OECD Publishing, Paris, https://dx.doi.org/ physically active in 2010. Adolescent girls were less active than 10.1787/54464f80-en. adolescent boys, with 84% vs. 78% not meeting WHO [33] WHO (2018), Physical Activity, World Health Organization, https:// recommendations. The LAC region’s average rate is again higher www.who.int/news-room/fact-sheets/detail/physical-activity. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 108 4. PHYSICAL ACTIVITY Figure 4.27. Prevalence of insufficient physical activity among adults aged 18+ years, 2016 Male Female Brazil Colombia Paraguay Suriname Costa Rica Argentina Guatemala Dominican Republic Cuba Bahamas LAC22 Venezuela Barbados Jamaica Trinidad and Tobago Saint Lucia Mexico Ecuador Chile Saint Kitts and Nevis Grenada Uruguay Dominica 50 % 40 30 20 10 0 0 10 20 30 40 50 % 60 Source: WHO GHO 2019. StatLink 2 https://stat.link/0im9xn Figure 4.28. Prevalence of insufficient physical activity among school going adolescents, 2016 Male Female Antigua and Barbuda Belize Barbados Costa Rica Uruguay Suriname Argentina Saint Kitts and Nevis Trinidad and Tobago Chile Honduras LAC25 Guatemala Bahamas Guyana Brazil Grenada Dominica Bolivia Colombia El Salvador Peru Saint Lucia Saint Vincent and the Grenadines Ecuador Venezuela 100 % 80 60 40 20 0 75 80 85 90 95 100 % Source: WHO GHO 2019. StatLink 2 https://stat.link/5pznt3 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 109 4. DIET Diet is another key determinant that contributes to the overall health products such as honey, syrups, fruit juices, etc., but it is often and wellbeing of an individual. Adults who follow a diet rich in fruits added to foods for taste. In the LAC region, sugar consumption is and vegetables and low in fat, sugars and salt/sodium are at a estimated to be significantly higher on average than the 50‑gramme lesser risk of developing one or more cardiovascular diseases and maximum recommended amount. The data captured here refers to certain types of cancer (Graf and Cecchini, 2017[32]). In many consumption of sugar sweetened beverages, which contain a large countries, people are switching to diets more reliant on processed amount of sugar. Considering the average person in LAC foods. This together with changes in the way we interact with the consumes nearly 500 grammes of these beverages, it is likely that environment and each other is leading to a new food environment most people consume over 50 grammes of sugar per day. The and culture. Combined with the increasing lack of physical activity country with the highest consumption is St Lucia (Chapter 4. Physical activity), this poses a significant challenge in (over 1 250 grammes per person per day) followed by Saint Vincent the short and long-term (WHO, 2018[34]). and the Grenadines (952 grammes). Per capita sugary beverages A healthy diet begins early in life. Breastfeeding and child nutrition intake is lowest in Brazil and Ecuador with 154 grammes each. In (Chapter 4. Infant and Child Feeding) fosters healthy development average, sugar sweetened beverages consumption in LAC and evidence suggests it reduces the risk of risk factors such as increased by almost 4% between 2000 and 2015. Fifteen countries overweight and obesity, as well as of suffering from NCDs later in reduced their consumption led by Colombia, Argentina and Guyana life. A healthy diet must be in balance with energy expenditure and (‑32%), while the highest increases occurred in Antigua and must have variety of different food groups. It is key to include fruits Barbuda (62%), Peru (45%) and Dominican Republic (44%) and vegetables; 3.9 million deaths in 2017 were attributable to (Figure 4.31). insufficient fruit and vegetable consumption (WHO, 2019[35]). The recommendation is five pieces of fruit or vegetables every day, or at least 400 grammes. Definition and comparability Daily consumption of fruit and vegetables in the LAC region is Data on dietary consumption is extracted from the Global estimated to be under the recommended 400 grammes per person Dietary Database, from Tufts University. Draft estimates are per day in all countries, although there is ample variation between currently available for a set of dietary factors in GDD 2015. countries. The highest consumer of fruit is Jamaica with The data has been estimated by carrying out systematic over 220 grammes per person per day, followed by Saint Vincent searches of literature to identify public and private data and the Grenadines, Dominican Republic and Peru that are sources, collecting individual-level dietary data, harmonising over 160 grammes. Trinidad and Tobago and Haiti consume an and standardising the data, incorporating covariate data, and average of under 65 grammes per person per day, situating them in modelling individual-level dietary intake. the lower end in the LAC region (Figure 4.29). In average, the LAC region reduced its fruit consumption by 8% between 2000 and 2015. Only in ten countries fruit consumption was increased led by a 47% augment in Dominican Republic. The largest decreases are observed in Argentina (‑37%) and Haiti (‑36%). References Consumption of vegetables is even lower with a regional average of [32] Graf, S. and M. Cecchini (2017), “Diet, physical activity and 104 grammes per person per day. Suriname is the highest sedentary behaviours: Analysis of trends, inequalities and consumer of vegetables followed by Saint Lucia, Antigua and clustering in selected oecd countries”, OECD Health Working Papers, No. 100, OECD Publishing, Paris, https://dx.doi.org/ Barbuda and Belize, all over 140 grammes. On the other end, 10.1787/54464f80-en. adults in Honduras consume just over 30 grammes, while Haiti reaches 60 grammes (Figure 4.30). The LAC region reduced [34] WHO (2018), Healthy diet, World Health Organization, https:// vegetables consumption by an average of 7% between 2000 and www.who.int/news-room/fact-sheets/detail/healthy-diet. 2015. Only Venezuela, Trinidad and Tobago, Guatemala and [35] WHO (2019), e-Library of Evidence for Nutritions Actions, World Antigua and Barbuda increased consumption, while the largest Health Organization, https://www.who.int/elena/titles/ decreases happened in Argentina (‑27%) and Honduras (‑25%). fruit_vegetables_ncds/en/. Healthy diets are also low in sugar. The recommended maximum amount of sugar is about 50 grammes. Sugar is naturally present in HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 110 4. DIET Figure 4.29. Daily fruit consumption among adults, 2000‑15 2000 2015 Daily consumption in grams 250 221.0 168.2 164.0 200 155.0 146.1 134.9 125.8 124.5 118.2 114.7 150 178.9 146.9 153.9 100 133.7 113.4 128.7 124.4 120.6 102.3 117.4 115.5 112.4 89.0 105.9 86.9 101.5 100.1 50 93.1 92.9 80.0 83.1 62.5 65.7 0 Source: Global dietary database 2015. StatLink 2 https://stat.link/klot7y Figure 4.30. Daily vegetables consumption among adults, 2000‑15 2000 2015 Daily consumption in grams 200 142.3 180 160 101.7 140 170.1 120 77.8 79.1 145.6 140.9 139.2 137.4 100 130.8 125.6 80 112.6 111.8 110.9 110.6 110.4 106.2 106.1 105.4 104.0 103.6 102.9 102.8 60 95.5 93.1 88.1 84.9 81.3 40 76.2 59.6 73.1 71.8 30.6 20 0 Source: Global dietary database 2015. StatLink 2 https://stat.link/ktv0am Figure 4.31. Daily sugar sweetened beverages consumption among adults, 2000‑15 2000 2015 Daily consumption in grams 1400 1255.4 952.4 1200 846.5 1000 670.8 664.2 561.6 556.9 485.8 444.2 800 495.9 443.2 366.5 362.9 435.9 417.6 390.1 847.3 600 154.5 153.5 400 629.1 591.2 437.9 514.4 508.4 423.9 412.1 378.5 244.6 421.8 335.1 332.7 200 326.7 304.5 0 Source: Global dietary database 2015. StatLink 2 https://stat.link/42khvs HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 111 4. DRUG USE Drug use disorders are a growing cause of short- and long-term OECD countries average. Opioid problematic use are the leading health problems, economic cost and social burden. In 2017, an specific cause of drug-related deaths in LAC with 0.7 deaths per estimated 271 million people, or 5.5% of the global population 100 000 population, a number much lower than in OECD countries aged 15‑64, had used drugs in the previous year, while 35 million (4.4) where some countries are experiencing a so-called ‘opioids people are estimated to be suffering from drug use disorders. In crisis’ (OECD, 2019[37]). Grenada and Dominica have the highest addition, there were 585 000 deaths and 42 million years of death rate due to cocaine consumption (0.3 deaths per 100 000 “healthy” life lost as a result of the use of drugs. Around half of the population), close to the average rate in OECD countries (0.4). The drug related deaths were attributed to untreated hepatitis C share of deaths attributed to amphetamines and other drugs is (UNODC, 2019[36]). lower across the region (Figure 4.33). Substance abuse refers to the harmful or hazardous use of Intersectoral policies that influence the levels and patterns of psychoactive substances, illicit drugs. Psychoactive substance use substance use and related harm can take a public health can lead to dependence syndrome – a cluster of behavioural, perspective to reduce the health, economic and social problems cognitive, and physiological phenomena that develop after attributable to substance use, and interventions at the health care repeated substance use and that typically include a strong desire to system level can work towards the restoration of health in affected take the drug, difficulties in controlling its use, persisting in its use individuals. Policies must also reflect changing attitudes towards despite harmful consequences, a higher priority given to drug use drug abuse and contribute to the removal of the stigma associated than to other activities and obligations, increased tolerance, and with addiction, to enable the integration of current and former users sometimes a physical withdrawal state. as well as their successful treatment and recovery. Cannabis is globally the most commonly used psychoactive substance under international control. Worldwide, there were an estimated 188 million past-year users of cannabis in 2017, Definition and comparability corresponding to 3.8% of the global population aged 15‑64 (UNODC, 2019[36]). There is an increasing demand of treatment Quality of reporting is higher in more developed countries, for cannabis use disorders and associated health conditions in which suggests a certain degree of under reporting of high- and middle-income countries, and there has been increased prevalence in low- and middle-income countries. Mortality attention to the public health aspects of cannabis use and related figures are observed and not estimated, so they also do not disorders in international drug policy dialogues. Countries, such as take into account differences in reporting between countries. Uruguay, have introduced partial legalisation of cannabis under No information on the prevalence of opioids abuse was clear regulation, for instance allowing pharmacies to sell cannabis, available at the regional level. aiming to reduce the illegal market, raise revenue through taxation Data on the prevalence of cannabis and cocaine and establishing the capacity of the government to regulate the consumption was taken from household surveys and provision and consumption of the substance. In 15 LAC countries compiled by the Organization of American States (OAS). with data, in average 5% of the population uses cannabis regularly. Data on mortality due to drug use was estimated by the Prevalence of cannabis use is significantly higher in Chile and Global Burden of Disease (GBD) programme based on Jamaica (15%), followed by Uruguay (9%) and Argentina (8%). The national data. Consumption of cannabis and cocaine refers lowest consumption is found in Panama, Ecuador and Bolivia, all to at least one time use in the year previous to the survey. with 1% prevalence (Figure 4.32, left panel). Mortality included under “other drugs” covers deaths due Traditionally coca leaves have been chewed by people in the the abuse of benzodiazepines, barbiturates and other Andean countries of South America for thousands of years. The substances. Alcohol or tobacco use are not included in this main alkaloid of the coca leave, cocaine, was isolated relatively section. recently in about 1860. Cocaine was then used in patent medicines, beverages and ‘tonics’ in developed countries in Europe, North American and in Australia until the early 1900s. It is now widely available as an illicit recreational drug. Regarding cocaine, prevalence in 14 LAC countries with data is 0.65%. Argentina and References Uruguay have the highest rate in the region in 1.6%, followed by [37] OECD (2019), Addressing Problematic Opioid Use in OECD Costa Rica (1.2%) and Chile (1.1%), while cocaine use in most LAC Countries, OECD Health Policy Studies, OECD Publishing, Paris, countries is under 1% of the population (Figure 4.32, right panel). https://dx.doi.org/10.1787/a18286f0-en. Regarding mortality, Guatemala and Argentina have the highest [36] UNODC (2019), World Drug Report 2019 (United Nations drug-related death rates, but still almost three times lower than the publication, Sales No. E.19.XI.8), https://wdr.unodc.org/wdr2019/. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 112 4. DRUG USE Figure 4.32. Prevalence of cannabis and cocaine consumption, % of the population, 2017 (or nearest year available) Cannabis Cocaine Bolivia Panama n.a. Ecuador El Salvador Mexico Bahamas Brazil Colombia Suriname Guyana Costa Rica LAC15 Argentina Uruguay Chile Jamaica 16 12 8 4 0 0 0.5 1 1.5 2 % % Source: OAS 2019. StatLink 2 https://stat.link/ciakh5 Figure 4.33. Death rates due to drug use disorders, 2017 Opioid Cocaine Amphetamine Other drug Deaths per 100 000 population 7 6.6 6 5 4 3 2.1 1.8 1.5 1.5 1.5 1.5 1.4 1.3 1.3 2 1.2 1.2 1.2 1.2 1.2 1.2 1.1 1.1 1.1 1.1 1.0 1.0 1.0 0.8 0.7 0.7 0.7 0.6 0.6 0.6 0.5 0.5 0.5 0.4 1 0 Source: GBD 2019. StatLink 2 https://stat.link/12t73x HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 113 Health at a Glance: Latin America and the Caribbean 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 Chapter 5 Health care resources and activities 115 5. DOCTORS AND NURSES Health workers play a central role in providing health services to the Global Code of Practice on the International Recruitment of Health population and improving health outcomes. Access to high-quality Personnel and committing continuing efforts on self-sufficiency health services critically depends on the size, skill-mix, policies to meet their human resources needs (Carpio and competency, geographic distribution and productivity of the health Santiago, 2015[4]). workforce. Health workers, and in particular doctors and nurses, The specialisation-mix and distribution of doctors, nurses and other are the cornerstone of health systems. In most countries, the health professionals may be improved in LAC countries. For demand and supply of health workers have increased over time, instance, the expansion of task shifting can provide new to tools by and for example, in OECD countries jobs in the health and social reviewing scope-of-practice laws and/or regulations, recognising sector account for more than 10% of total employment (OECD, new professional roles by payers and the level of reimbursement of 2016[1]). these services, and through organisational-level factors such as On average across LAC countries, there are 2 doctors per 1 000 ongoing support and commitment by management (Maier, Aiken population and most of LAC countries stand below the OECD and Busse, 2017[5]). average of 3.5 (Figure 5.1). Cuba has by far the highest number of doctors per capita, with over 8 doctors per 1 000 population, more than two times higher than the OECD average. Argentina, Trinidad and Tobago and Uruguay are the only additional countries above Definition and comparability the OECD average, with a density of more than 4 doctors per 1 000 Doctors include Generalist medical doctors (including population. In contrast, Haiti, Honduras and Guatemala have the family and primary care doctors) and Specialist medical lowest number of physicians per 1 000 population at or below 0.5. doctors. For LAC non-OECD countries, “Nurses” refers to the Regarding nurses, the number is highest in Cuba with nearly number of nursing and midwifery personnel, including 8 nurses per 1 000 population, followed by Saint Vincent and the professional nurses, professional midwives, auxiliary nurses, Grenadines with 7. The supply is much lower in Haiti, Jamaica, auxiliary midwives, enrolled nurses, enrolled midwives and Venezuela, Honduras and Guatemala, where there is less than related occupations such as dental nurses and primary care 1 nurse per 1 000 population. On average, less than three nurses nurses. Data are based on head counts and there is per 1 000 population are available in LAC countries, three times considerable variability in coverage, periodicity, quality and lower than the OECD average of almost 9 (Figure 5.2). completeness for some countries. In average, nurses outnumber doctors in both the LAC region and the OECD: there are 1.4 and 2.7 nurses per doctor, respectively (Figure 5.3). However, there are some exceptions. Doctors outnumber nurses in nine LAC countries, led by Guatemala, References Uruguay and Venezuela with a ratio of nurses/doctors of 0.5 or less. On the other hand, due to very few numbers of doctors, St Lucia [4] Carpio, C. and N. Santiago (2015), The Health Workforce in Latin America and the Caribbean: An analysis of Colombia, Costa Rica, has more than 10 nurses per doctor. Jamaica, Panama, Peru and Uruguay, World Bank Group, http:// Countries in LAC need to respond to the changing demand for documents.worldbank.org/curated/en/634931468000893575/The- health services and, hence, to the need for a health professional health-workforce-in-Latin-America-and-the-Caribbean-an- skill-mix in the context of rapidly ageing populations (see indicator analysis-of-Colombia-Costa-Rica-Jamaica-Panama-Peru-and- “Ageing” in Chapter 1). The report of the (High-Level Commission Uruguay. on Health Employment and Economic Growth, 2016[2]) made the [2] High-Level Commission on Health Employment and Economic case for more and better investment in the health workforce. The Growth (2016), Working for health and growth: investing in the Commission gave recommendations that LAC countries can follow health workforce, World Health Organization, Geneva, http:// in 10 areas: job creation; gender and women´s rights; education, www.who.int. training and skills; service delivery and organisation; technology; [5] Maier, C., L. Aiken and R. Busse (2017), “Nurses in advanced roles crises and humanitarian settings; financing and fiscal space; in primary care: Policy levers for implementation”, OECD Health partnership and cooperation; data, information and accountability; Working Papers, No. 98, OECD Publishing, Paris, https:// and international migration. Regarding the latter, emigration of dx.doi.org/10.1787/a8756593-en. health professionals from LAC to OECD countries such as Spain [1] OECD (2016), Health Workforce Policies in OECD Countries: Right has been extensive, a phenomenon that further decreases density Jobs, Right Skills, Right Places, OECD Health Policy Studies, of human resources in the region (PAHO, 2013[3]). In addition, due OECD Publishing, Paris, https://dx.doi.org/ to large migration movements in recent years within the LAC 10.1787/9789264239517-en. region, countries can further cooperate to address the issues [3] PAHO (2013), Migracion calificada en salud, Impacto financiero, arising for both lending and receiving countries following the WHO reconocimiento de titulos, Pan-American Health Organization. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 116 5. DOCTORS AND NURSES Figure 5.1. Doctors per 1 000 population, 2017 or latest year Figure 5.2. Nurses per 1 000 population, latest year available available OECD36 8.8 Cuba 7.6 Cuba 8.4 Saint Vincent and the Grenadines 7.0 Uruguay 5.1 Dominica 6.4 Trinidad and Tobago 4.2 Grenada 6.3 Argentina 4.0 Bahamas 4.6 OECD36 3.5 Antigua and Barbuda 4.5 Costa Rica 3.1 Saint Kitts and Nevis 4.2 Antigua and Barbuda 3.0 Trinidad and Tobago 4.1 Saint Kitts and Nevis 2.7 Costa Rica 3.4 Barbados 2.5 Saint Lucia 3.2 Chile ¹ 2.5 Panama 3.1 Mexico 2.4 Barbados 3.1 Colombia 2.2 Mexico 2.9 Ecuador 2.0 LAC33 2.8 LAC33 2.0 Suriname 2.8 Bahamas 2.0 Chile ¹ 2.7 Venezuela 1.9 Argentina 2.6 Brazil 1.8 Ecuador 2.5 Bolivia 1.6 Peru 2.4 Panama 1.6 Belize 2.3 El Salvador 1.6 Uruguay 1.9 Dominican Republic 1.5 El Salvador 1.8 Grenada 1.4 Paraguay 1.7 Paraguay 1.4 Bolivia 1.6 Jamaica 1.3 Nicaragua 1.5 Peru 1.3 Brazil 1.5 Suriname 1.2 Dominican Republic 1.4 Belize 1.1 Colombia 1.3 Dominica 1.1 Guyana 1.0 Nicaragua 1.0 Venezuela 0.9 Guyana 0.8 Jamaica 0.8 Saint Vincent and the Grenadines 0.7 Honduras 0.7 Saint Lucia 0.6 Haiti 0.7 Guatemala 0.4 Guatemala 0.1 Honduras 0.3 Haiti 0.2 0 5 10 Nurses per 1 000 population 0 5 10 Doctors per 1 000 population 1. Data refer to all nurses that are licensed to practice. 1. Data refer to all doctors licensed to practice. Source: OECD Health Statistics 2019; WHO Global Health Observatory Data Source: OECD Health Statistics 2019; WHO Global Health Observatory Data Repository 2019. Repository 2019. StatLink 2 https://stat.link/4oncmi StatLink 2 https://stat.link/ro1xn8 Figure 5.3. Ratio of nurses to doctors, latest year available Ratio 12 10.6 10 8 5.8 4.9 6 4.5 2.9 4 2.7 2.7 2.4 2.3 2.3 2.1 2.1 2.0 1.9 1.6 1.5 1.4 1.3 1.2 1.2 1.2 1.2 1.1 1.1 1.0 1.0 0.9 0.9 2 0.8 0.7 0.6 0.6 0.5 0.4 0.2 0 1. Data refer to all doctors and nurses licensed to practice. Source: OECD Health Statistics 2019; WHO Global Health Observatory Data Repository 2019. StatLink 2 https://stat.link/jqc0dm HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 117 5. CONSULTATIONS WITH DOCTORS Consultations with doctors are an important measure of overall average rates. In addition, higher patient co-payments can result in access to health services, since most illnesses can be managed in patients not consulting a doctor because of the cost of care (OECD, primary care without hospitalisation and a doctor consultation often 2019[7]). Moreover, inequalities may exist, as wealthier individuals precedes a hospital admission. The ability of a country to keep track are more likely to see a doctor than individuals in the lowest income and promote effective consultations as an alternative to and to quintile, for a comparable level of need. Likewise, income prevent hospitalisations is an important waste management inequalities in accessing doctors are much more marked for measure (see Chapter 2). specialists than for general practitioner consultations (OECD, Generally, the annual number of doctor consultations per person in 2019[8]). nine LAC countries is 3.5, lower than the OECD average of 6.8 (Figure 5.4). The doctor consultation rate ranges from above the OECD average in Cuba to less than one in Venezuela. In general, consultation rates tend to be higher in the high-income countries in Definition and comparability the region and significantly lower in low-income countries, Consultations with doctors are defined as contacts with suggesting that financial constrains play a role on populations’ physicians (both generalists and specialists, for more details health care-seeking behaviours, as well as the overall capacity of see indicator “Doctors and nurses” in Chapter 5). These may the system to provide access to services. It is important to point out take place in doctors’ offices or clinics, in hospital outpatient that there is limited data availability on consultations mainly due to departments and in homes. Two main data sources are used system fragmentation in many countries, which limits the analysis. to estimate consultation rates: administrative data and The number of consultations per doctor should not be taken as a household health surveys. In general, administrative data measure of productivity because consultations can vary in length sources in the non-OECD countries and economies of the and effectiveness, doctors also undertake work devoted to LAC region only cover public sector physicians or publicly inpatients, administration and, in some cases, research, and financed physicians, although physicians in the private different health system arrangements can have an impact on sector provide a large share of overall consultations in most consultations characteristics. In addition, in many lower income of these countries. Moreover, outpatient visits recorded in countries, most primary contacts are with non-doctors (i.e. medical administrative data can be also with non-physicians. The assistants, clinical officers or nurses); especially considering the alternative data source is household health surveys, but fact that most countries do not require people to register with these tend to produce lower estimates owing to incorrect specific general practitioners. Keeping these considerations in recall and non-response rates. Caution must be applied in mind, the number of consultations per doctor per year in nine LAC interpreting the data as it has been extracted from different countries with data is 1381, lower than the OECD average of 2 181 sources with varying levels of coverage and comparability. (Figure 5.5). All countries had less than 2 000 consultations a year The annual number of consultations per doctor is estimated except in Ecuador. by dividing the number of total consultations in a year by the There is a close relationship between doctor consultation rates – a number of doctors. proxy for access to services – and health care spending per capita, with consultation rates being highest in countries with highest health expenditure (Figure 5.6). This finding points to the fact that more resources available for the health system may result in higher levels of utilisation, for instance, because of a higher likelihood of References having more doctors and consultation times available. This is linked [6] Irving, G. et al. (2017), International variations in primary care to doctor consultation length that has been also found to have a physician consultation time: A systematic review of 67 countries, positive association with health care spending per capita and BMJ Publishing Group, http://dx.doi.org/10.1136/ primary care physician density (Irving et al., 2017[6]). bmjopen-2017-017902. While cultural factors play a role in explaining some of the variations [7] OECD (2019), Health at a Glance 2019: OECD Indicators, OECD across countries, policies and incentive structures also matter. For Publishing, Paris, https://dx.doi.org/10.1787/4dd50c09-en. instance, from compared analysis in OECD countries, provider [8] OECD (2019), Health for Everyone?: Social Inequalities in Health payment methods such as fee-for-service create incentives for and Health Systems, OECD Health Policy Studies, OECD overprovision of services, while salaried doctors tend to have below Publishing, Paris, https://dx.doi.org/10.1787/3c8385d0-en. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 118 5. CONSULTATIONS WITH DOCTORS Figure 5.4. Doctors consultations per capita, latest year Figure 5.5. Estimated number of consultations per physician, available latest year available Cuba (2014) 7.4 Ecuador (2011) 3 538 OECD36 6.8 OECD36 2 181 Uruguay (2013) 6.1 Uruguay (2013) 1 633 Ecuador (2011) 6.1 Chile (2017) 1 568 Chile (2017) 3.6 Brazil (2013) 1 487 LAC9 3.5 LAC9 1 381 Mexico (2017) 2.8 Paraguay (2013) 1 222 Brazil (2013) 2.8 Mexico (2017) 1 153 Costa Rica (2017) 2.1 Cuba (2014) 1 101 Colombia (2017) 1.9 Colombia (2017) 0 909 Paraguay (2013) 1.5 Costa Rica (2017) 0 711 Venezuela (2011) 0.9 Venezuela (2011) 0 489 0 2 4 6 8 0 500 1 000 1 500 2 000 2 500 3 000 3 500 4 000 Consultations per capita Consultations per doctor Source: National Sources; OECD Health Statistics 2019 for Chile, Colombia, Source: National Sources; OECD Health Statistics 2019 for Chile, Colombia, Costa Rica and Mexico. Costa Rica and Mexico. StatLink 2 https://stat.link/js4mvi StatLink 2 https://stat.link/kvwtax Figure 5.6. Doctor consultations and health expenditure per capita in USD PPP, latest year available Health expenditure per capita, USD PPP 4500 4000 OECD 3500 3000 2500 CUB CHL 2000 URY 1500 LAC9 CRI BRA R² = 0.4779 1000 MEX COL ECU PRY 500 0 0 1 2 3 4 5 6 7 8 Doctor consultations per capita Source: National Sources, Global Health Expenditure Database 2020; OECD Health Statistics 2019 for Chile, Colombia, Costa Rica and Mexico. StatLink 2 https://stat.link/cfu5b6 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 119 5. MEDICAL TECHNOLOGIES The Sustainable Development Goal 5 calls for safe, effective, and per million population. Uruguay, Suriname and Barbados are the appropriate medical technologies, which over the past century has only three countries reporting over three units per million profoundly influenced service delivery and health outcomes, and population, while seven countries report having none (Figure 5.11). have been a dominant factor in the growth of health care In general terms, LAC countries still have space to put more expenditure (Lorenzoni et al., 2019[9]). Computed tomography investment into medical technologies to improve equitable access (CT) scanners and magnetic resonance imaging (MRI) units help for the population. At the same time, such expansion in access can doctors diagnose a range of conditions by producing images of be accompanied by the development of regulatory frameworks in internal organs and structures of the body. MRI exams do not the areas of registration, assessment and purchasing rules as well expose patients to ionizing radiation, unlike conventional as in clearly orienting the clinical use of medical technologies based radiography and CT scanning. Mammography is used to diagnose on the best available scientific evidence. For instance, some OECD breast cancer, and radiation therapy units are used for cancer countries promote rational use of diagnostic technologies by treatment and palliative care. This equipment is fundamental for an implementing clinical practice guidelines to reduce the use of adequate response to diseases, but a balance must be stricken to unnecessary diagnostic tests and procedures. The guidelines ensure financial sustainability, as they are expensive technologies. include, for example, avoiding imaging studies such as MRI, CT or There are substantial differences in availability of technologies X-rays for acute low back pain without specific indications (OECD, across LAC countries. Usually, the higher the country income level 2017[10]). the higher the availability of medical equipment, but this does not seems to be the general pattern in the region. Other factors such as health spending and health care planning influence investment and availability. Definition and comparability Chile has the highest number of CT scanners with 24 per million population followed by Antigua and Barbuda with 22 (the latter is The data cover equipment installed both in hospitals and explained partially by the country’s small population). However, the ambulatory sector and public and private sectors in most they remain below the OECD average of 27. On the other hand, countries. However, there is only partial coverage for some Saint Vincent and the Grenadines has less than one CT scanner countries. Data for Antigua and Barbuda refers only to per million people, the same as Haiti and Nicaragua (Figure 5.7). equipment in the private sector. Data for Paraguay, Ecuador and Trinidad and Tobago refers to equipment in the public For MRI units, Chile has the largest number with 12 units per million sector. population, followed Antigua and Barbuda and Saint Lucia reporting 10 or more units per million population. Several countries such as Barbados, Dominica, Saint Kitts and Nevis, Saint Vincent and the Grenadines, Ecuador, Nicaragua, Colombia, Paraguay and Cuba report less than one unit per million population (Figure 5.8). References Panama reports the highest number of mammographs with more [9] Lorenzoni, L. et al. (2019), “Health Spending Projections to than 278 units per million females aged 50‑69, as opposed to 2030: New results based on a revised OECD methodology”, OECD Paraguay, Colombia, Cuba and Haiti with less than 20 Health Working Papers, No. 110, OECD Publishing, Paris, https:// mammographs available per million females aged 50‑69 dx.doi.org/10.1787/5667f23d-en. (Figure 5.9). [10] OECD (2017), New Health Technologies: Managing Access, Value In the LAC region, no countries get close to the density of and Sustainability, OECD Publishing, Paris, https://dx.doi.org/ radiotherapy units reported in OECD countries of seven units 10.1787/9789264266438-en. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 120 5. MEDICAL TECHNOLOGIES Figure 5.7. Computed tomography scanners per million Figure 5.8. MRI units per million inhabitants, latest year inhabitants, latest year available available OECD36 27.0 OECD36 Chile 24.3 Chile 12.3 16.7 Antigua and Barbuda 22.2 Antigua and Barbuda 11.1 Grenada 18.9 Saint Lucia 11.0 Saint Kitts and Nevis 18.5 Grenada 9.4 Brazil 15.4 Brazil 6.8 Dominica 13.9 Suriname 3.7 Bahamas 13.3 LAC25 3.1 Uruguay 12.9 Belize 3.0 Belize 12.1 Trinidad and Tobago 3.0 Saint Lucia 11.0 Uruguay 2.9 Panama 9.6 Panama 2.9 LAC26 8.3 Bahamas 2.7 Costa Rica 8.0 Mexico 2.6 Suriname 7.4 Costa Rica 1.6 Barbados 7.0 Jamaica 1.4 Mexico 5.8 Guyana Cuba 4.8 1.3 El Salvador 4.7 Honduras 1.1 Guyana 3.8 El Salvador 1.1 Trinidad and Tobago 3.0 Cuba 0.8 Honduras 2.1 Paraguay 0.3 Ecuador 1.6 Colombia 0.2 Jamaica 1.4 Nicaragua 0.2 Colombia 1.2 Ecuador 0.1 Paraguay 1.0 Saint Vincent and the Grenadines 0.0 Nicaragua 0.5 Saint Kitts and Nevis 0.0 Haiti 0.3 Dominica 0.0 Saint Vincent and the Grenadines 0.0 Barbados 0.0 0 5 10 15 20 25 30 0 6 12 18 Per million population Per million population Source: WHO GHO 2016; OECD Health Statistics 2019 for Chile, Colombia, Source: WHO GHO 2016; OECD Health Statistics 2019 for Chile, Colombia, Costa Rica and Mexico. Costa Rica and Mexico. StatLink 2 https://stat.link/z5bx2q StatLink 2 https://stat.link/ny7gsp Figure 5.9. Mammography units per million females Figure 5.10. Radiotherapy units, latest year available aged 50‑69, latest year available OECD32 7.2 Uruguay 3.8 Panama 278.5 Suriname 3.7 Antigua and Barbuda 272.2 Barbados 3.5 Trinidad and Tobago 3.0 Belize 258.0 Argentina 2.8 Saint Vincent and the Grenadines 229.9 Bahamas 2.7 Dominica 206.7 Venezuela 2.5 OECD28 Costa Rica 2.3 176.7 Brazil 1.7 Uruguay 172.4 Panama 1.6 Costa Rica 150.3 Colombia 1.5 Saint Kitts and Nevis 149.4 LAC32 1.4 Guyana 1.3 Grenada 134.6 Dominican Republic 1.3 Saint Lucia 131.1 Cuba 1.2 LAC24 110.4 Peru 1.1 El Salvador 1.1 Bahamas 106.6 Jamaica 1.1 Suriname 93.6 Chile 0.9 Mexico 74.5 Honduras 0.7 Guatemala 0.7 El Salvador 70.0 Paraguay 0.6 Guyana 70.0 Bolivia 0.6 Jamaica 51.3 Mexico 0.5 Nicaragua 0.3 Honduras 50.9 Ecuador 0.1 Trinidad and Tobago 35.2 Saint Vincent and the Grenadines 0.0 Chile 32.2 Saint Lucia 0.0 Saint Kitts and Nevis 0.0 Barbados 29.0 Haiti 0.0 Haiti 19.5 Grenada 0.0 Cuba 15.6 Dominica 0.0 Colombia 11.5 Belize 0.0 Paraguay 7.3 0 2 4 6 8 0 50 100 150 200 250 300 350 Per million population Per million females aged 50-69 Source: WHO GHO 2016; OECD Health Statistics 2019 for Chile, Colombia, Source: WHO GHO 2016; OECD Health Statistics 2019 for Chile, Colombia, Costa Rica and Mexico. Costa Rica and Mexico. StatLink 2 https://stat.link/eoubr7 StatLink 2 https://stat.link/kcxtf8 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 121 5. HOSPITAL CARE In most countries, hospitals account for the largest part of overall In the light of OECD countries analysis, apart from disparities in the fixed investment and hospital beds provides an indication of the average length of stay due to case mix, other factors including resources available for delivering services to inpatients. However, payment structures can explain cross-country variations. In the influence of the supply of hospital beds on admission rates has particular, the introduction of prospective payment systems that been widely documented, confirming that a greater supply encourage providers to reduce the cost of episodes in care, such as generally leads to higher admission numbers (Roemer’s Law that a diagnosis-related groups (DRG), has been credited for the “built bed is a filled bed”). Therefore, beside quality of hospital care reduction in the ALOS in hospitals. A recent OECD study analysed (see Chapter 7), it is important to use resources efficiently and the significance of a number of hospital characteristics finding that assure a coordinated access to hospital care. Increasing the hospitals with many beds (higher than 200) are associated with a numbers of beds and overnight stays in hospitals does not always longer length of stay, while a bed occupancy rate of 70% or more is bring positive outcomes in population health nor reduce waste (see associated with a shorter length of stay (Lorenzoni and Marino, Chapter 2). 2017[12]). The number of hospital beds per capita in LAC is 2.1, lower than the OECD average of 4.7, but it varies considerably (Figure 5.11). More than five beds per 1 000 population are available in Barbados, Definition and comparability Argentina and Cuba, whereas the stock is less than one per 1 000 All hospital beds include those for acute care and chronic/ population in Guatemala, Haiti, Honduras, Venezuela and long-term care, in both the public and private sectors. A Nicaragua. These large disparities reflect substantial differences in discharge is defined as the release of a patient who has the resources invested in hospital infrastructure across countries. stayed at least one night in hospital. It includes deaths in Hospital discharge is at an average of 54.4 per 1 000 population in hospital following inpatient care but usually excludes same- 11 LAC countries with data, compared with the OECD average of day separations. The discharge rates presented are not age- 154 (Figure 5.12). The highest rates are in Chile and Costa Rica, standardised, not considering differences in the age with over 89 and 73 discharges per 1 000 population in a year, structure of the population across countries. The figures respectively, while in Colombia, Panama and Peru there are less reported for ALOS refer to the number of days that patients than 40 discharges per 1 000 population, suggesting delays in spend overnight in an acute-care inpatient institution. ALOS accessing services. In general, countries with more hospital beds is generally measured by dividing the total number of days tend to have higher discharge rates, and vice versa (Figure 5.13). stayed by all patients in acute-care inpatient institutions However, there are some notable exceptions. El Salvador, Bolivia during a year by the number of admissions or discharges. and Costa Rica have low number of beds but a relatively high There are considerable variations in how countries define discharge rate, while Argentina has as many beds as the OECD acute care, and what they include or exclude in reported average but a relatively low discharge rate. statistics. For the most part, discharges and ALOS data in the In nine LAC countries with data, the average length of stay (ALOS) LAC region cover only public sector institutions. is 5.36 days, lower than the OECD average of 7.70 (Figure 5.14). The longest ALOS is 6 days or more in Jamaica, Colombia and Chile, while the shortest length of stay is under 4 days in Mexico. The ALOS is used to assess appropriate access and use, but caution is needed in its interpretation (see Chapter 2 as well). References Although all other things being equal, a shorter stay will reduce the [12] Lorenzoni, L. and A. Marino (2017), “Understanding variations in cost per discharge and provide care more efficiently by shifting care hospital length of stay and cost: Results of a pilot project”, OECD from inpatient to less expensive post-acute settings. Longer stays Health Working Papers, No. 94, OECD Publishing, Paris, https:// dx.doi.org/10.1787/ae3a5ce9-en. can be a sign of poor care coordination, resulting in some patients waiting unnecessarily in hospital until rehabilitation or long-term [11] Rojas-Garcia, A. et al. (2018), “Impact and experiences of delayed care can be arranged. At the same time, some patients may be discharge: A mixed-studies systematic review”, Health discharged too early, when staying in hospital longer could have Expectactions. improved their health outcomes or reduced chances of re- admission (Rojas-Garcia et al., 2018[11]). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 122 5. HOSPITAL CARE Figure 5.11. Hospital beds per 1 000 population, latest year Figure 5.12. Hospital discharges per 1 000 population, latest available year available Barbados (2014) 5.8 OECD36 154 Cuba (2014) 5.2 Argentina (2014) 5.0 OECD36 4.7 Chile (2017) 89 Antigua and Barbuda (2014) 3.8 Grenada (2014) 3.7 Costa Rica (2017) 73 Suriname (2010) 3.1 Trinidad and Tobago (2014) 3.0 Bolivia (2018) Bahamas (2013) 2.9 66 Uruguay (2014) 2.8 Panama (2013) 2.3 Jamaica (2017) 65 Brazil (2012) 2.3 LAC30 2.1 El Salvador (2018) 57 Chile (2017) 2.1 Jamaica (2013) 1.7 Colombia (2017) 1.7 Brazil (2012) 55 Peru (2014) 1.6 Guyana (2014) 1.6 LAC11 54 Dominican Republic (2014) 1.6 Ecuador (2013) 1.5 Mexico (2017) 1.4 Argentina (2015) 51 Saint Lucia (2013) 1.3 Paraguay (2011) 1.3 Mexico (2017) 47 El Salvador (2014) 1.3 Belize (2014) 1.3 Costa Rica (2017) 1.1 Panama (2018) 35 Bolivia (2014) 1.1 Nicaragua (2014) 0.9 Colombia (2017) 33 Venezuela (2014) 0.8 Honduras (2014) 0.7 Peru (2018) 27 Haiti (2013) 0.7 Guatemala (2014) 0.6 0 2 4 6 8 0 50 100 150 200 Per 1 000 population Per 1 000 population Source: OECD Health Statistics 2019; World Bank World Development Indicators Source: OECD Health Statistics 2019; National sources. 2019. StatLink 2 https://stat.link/d1qjlf StatLink 2 https://stat.link/5lcxwi Figure 5.13. Hospital beds per 1 000 population and hospital Figure 5.14. Average length of stays for acute care in hospitals, discharges per 1 000 population, latest year latest year available Hospital discharges, per 1 000 population 180 OECD36 7.70 OECD Jamaica (2017) 6.10 160 Chile (2017) 6.00 140 Colombia (2017) 6.00 120 R² = 0.2209 Panama (2018) 5.70 100 CHL Uruguay (2018) 5.40 80 LAC9 5.36 CRI JAM BOL ARG Costa Rica (2017) 5.30 60 BRA SLV LAC11 Peru (2018) 5.27 40 MEX PAN PER COL El Salvador (2018) 4.77 20 Mexico (2017) 3.70 0 0 2 4 6 8 10 0 1 2 3 4 5 6 Hospital beds, per 1 000 population Days Source: OECD Health Statistics 2019; World Bank World Development Indicators Source: OECD Health Statistics 2019, National Sources. 2019, National Sources. StatLink 2 https://stat.link/ha3yqw StatLink 2 https://stat.link/wn2oh3 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 123 5. PREGNANCY AND BIRTH The health of both mothers and their babies benefit from antenatal responds to key areas of maternal and perinatal health care, delivery attended by skilled health professionals and access programmes, advocating for universal coverage and ensuring to health facilities for delivery as they reduce the risk of birth skilled care at every birth within the context of a continuum of care complications and infections (see indicators “Reproductive health”, (WHO, 2019[14]). Countries can follow this guide to effectively “Preterm births and low birthweight” and “Infant and young child address issues such as pre-eclampsia and eclampsia; postpartum feeding” in Chapter 4) (Measure Evaluation, 2019[13]). The haemorrhage; postnatal care for the mother and baby; newborn Sustainable Development Goal 3.7 aims to ensure universal resuscitation; prevention of mother-to-child transmission of HIV; access to sexual and reproductive health care services, including HIV and infant feeding; malaria in pregnancy, tobacco use and for family planning, information and education, and the integration second-hand exposure in pregnancy, post-partum depression, of reproductive health into national strategies and programs by post-partum family planning and post abortion care (WHO, UNFPA, 2030. UNICEF, World Bank, 2015[15]). In 29 LAC countries, most pregnant women – on average, 87% – received the recommended four visits, but access to antenatal care varies across countries and across socio-economic groups Definition and comparability (Figure 5.15). Countries such as Uruguay and Peru have nearly complete coverage in average for the population (over 95% of four The major source of information on care during pregnancy antenatal visits), but inequalities exist: mothers in the lowest and birth are health interview surveys. Demographic and income quintile had around 4 and 8 percentage points of less Health Surveys (DHS), for example, are nationally coverage, respectively, compared to mothers in the highest income representative household surveys that provide data for a quintile. At the other end, in Haiti and Suriname, the average wide range of indicators in the areas of population, health, coverage of four antenatal care visits is less than 70%. and nutrition. Standard DHS Surveys have large sample Furthermore, Haiti has the largest inequality among countries with sizes (usually between 5 000 and 30 000 households) and data with almost 36 percentage points of difference between the typically are conducted every five years, to allow lowest and the highest income quintile mothers. Trinidad and comparisons over time. Women who had a live birth in the Tobago shows a high coverage and the lowest income inequality. five years preceding the survey are asked questions about the birth, including how many antenatal care visits they had, Most women (93% in average) had births attended by a skilled who provided assistance during delivery, and where the health professional such as a doctor, nurse or midwife in 29 LAC delivery took place. countries (Figure 5.16). However, less than one birth in two in Haiti and one in four in Guatemala are attended by a skilled health The income inequality data on antenatal care and skilled professional, with most deliveries assisted by untrained birth birth attendance was obtained from the Health Equity and attendants. Traditional birth attendants are important in several Financial Protection Indicators (HEFPI) dataset compiled other countries especially in rural settings. Inequalities between and maintained by the World Bank. mothers in the lowest and the highest income quintile are the largest in Haiti and Guatemala, showing a difference of 69 and 57 percentage points of higher coverage, respectively, in favor of the richest group. The lowest inequality is found in Barbados and References Uruguay, both having a similar high coverage across all socio- economic groups. [13] Measure Evaluation (2019), Indicator Compedium – Antenatal Care Coverage, https://www.measureevaluation.org/rbf/indicator- Delivery in health facilities varies across countries (Figure 5.17). In collections/service-use-and-coverage-indicators/antenatal-care- 11 LAC countries with data, 86% of deliveries occurred in coverage. established health care facilities. In Cuba, Dominican Republic, El [14] WHO (2019), Integrated Management of Pregnancy and Childbirth Salvador, Colombia, Belize and Mexico over 96% of deliveries take (IMPAC), https://www.who.int/maternal_child_adolescent/topics/ place at a health facility. In Haiti, most deliveries take place at home maternal/impac/en/. (60%) and the rate is also high in Guatemala (34%) and slightly less [15] WHO, UNFPA, UNICEF, World Bank (2015), Pregnancy, so in Honduras (17%) and Peru (15%). Childbirth, Postpartum and Newborn Care: A guide for essential The Integrated Management of Pregnancy and Childbirth (IMPAC) practice, https://www.who.int/maternal_child_adolescent/ is a package of guidelines and tools designed by WHO, which documents/imca-essential-practice-guide/en/. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 124 5. PREGNANCY AND BIRTH Figure 5.15. Provision of care during pregnancy and birth, first Figure 5.16. Births attended by skilled health professionals, and fifth income quintile, 2016 or latest year available first and fifth income quintile, latest year available Low income High income Low income High income Belize LAC29, 87% Barbados LAC29, 93% Colombia Belize Dominican Republic Colombia El Salvador Dominican Republic Guatemala El Salvador Guyana Guatemala Haiti Guyana Honduras Haiti Jamaica Honduras Mexico Jamaica Panama Mexico Paraguay Panama Peru Paraguay Suriname Peru Trinidad and Tobago Suriname Uruguay Trinidad and Tobago Uruguay 40 60 80 100 % of pregnant women receiving prenatal care of at 0 20 40 60 80 100 least four visits % of skilled birth attendance Note: The LAC29 average includes more countries than those represented in the Note: The LAC29 average includes more countries than those represented in the figure due to data availability. figure due to data availability. Source: DHS and MICS 2019 for income inequalities on the 16 LAC countries Source: DHS and MICS 2019 for income inequalities on the 16 LAC countries available; WHO GHO 2019 for the LAC29 average. available. WHO GHO 2019 for the LAC29 average. StatLink 2 https://stat.link/8gkzj0 StatLink 2 https://stat.link/0h9gmv Figure 5.17. Place of delivery, latest year available Other/Missing Home Healthcare facility % 100 80 60 40 20 0 Source: DHS and MICS 2019. StatLink 2 https://stat.link/9lbjme HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 125 5. INFANT AND CHILD HEALTH CARE In the LAC region, around one third of the deaths in the first year of health system can target the most vulnerable population and life occur during the neonatal period (i.e. during the first four weeks provide the most needed services. of life or days 0‑27) and childhood diarrhoea and pneumonia are Access to appropriate medical care for children with ARI can also the leading infectious causes of childhood morbidity and mortality be improved in many countries in the region. Although in average (PAHO, 2017[16]). Effective health systems can greatly limit the more than three quarters of children with symptoms are taken to a number of infant deaths, particularly by addressing life-threatening health facility, around half of them receive antibiotic treatment issues during the neonatal and childhood period. Basic care for (Figure 5.20). It is important to stress the relevance of rational infants and children includes promoting and supporting early and antibiotic use, both due to the health implications of antimicrobial exclusive breastfeeding (see indicator “Infant and young child resistance development and also as a source of waste in health feeding” in Chapter 4), identifying conditions requiring additional systems (see Chapter 2). care and counselling on when to take an infant and young child to a There is a correlation between treatment coverage for diarrhea and health facility (Tomczyk, McCracken and Contreras, 2019[17]). ARI. Antibiotic treatment for ARI is particularly low in Guyana, Haiti Several cost-effective preventive and curative exist, including and Dominican Republic, where the treatment for diarrhea is also vitamin A supplementation, vaccination, oral rehydration therapy low. This suggests an urgent need to further expand access to care (ORT) for diarrhea, and appropriate antibiotic treatment for acute to treat leading causes of child mortality in these countries. respiratory infection (ARI). Access to these services leads to better infant and child health. As part of prevention, supplementation with vitamin A is considered Definition and comparability important for children because it reduces the risk of disease and death from severe infections. Access to preventive care varies Prevention and treatment coverage data are usually across LAC as shown by the intake of vitamin A supplements collected through household surveys. Accuracy of survey (Figure 5.18) and vaccination coverage (see indicator “Childhood reporting varies and is likely to be subject to recall bias. vaccination” in Chapter 7). According to data from eight LAC Seasonal influences related to the prevalence of diarrheal countries, access to vitamin A supplementation for children disease and ARI may also affect cross-national data aged 6‑59 months is markedly low in the El Salvador and Haiti (20% comparisons. The prevalence of ARI is estimated by asking and 19%) and, especially in Peru with 4.5%, whereas Nicaragua mothers whether their children under five had been ill with a has a coverage rate of near 90%. The LAC8 average stands in cough accompanied by short, rapid breathing in the 42%. two weeks preceding a survey, as these symptoms are compatible with ARI. Appropriate treatment could also prevent deaths from diarrhea and pneumonia. Dehydration caused by severe diarrhea can be easily treated with ORT. In average, less than 47% of children under 5 years with diarrhea receive ORT in 19 LAC countries with data, with Guatemala, Dominican Republic, Ecuador, Guyana, References Suriname, Costa Rica, Peru, Paraguay, Bolivia and Argentina [16] PAHO (2017), Health in the Americas+, 2017 Edition. Summary: having less than 50%. The coverage is highest in El Salvador and Regional Outlook and Country Profiles, Pan American Health Nicaragua over 65%. Income inequalities are high in Peru where Organisation, Washington, D.C., https://www.paho.org/salud-en- 42% of children in the highest income quintile receive ORT when las-americas-2017/wp-content/uploads/2017/09/Print-Version- they need it, while only 22% of children in the lowest income quintile English.pdf. does (Figure 5.19). Notably, children in the lowest income group [17] Tomczyk, S., J. McCracken and C. Contreras (2019), “Factors receive a higher coverage than in the highest income group in associated with fatal cases of acute respiratory infection (ARI) Paraguay, Honduras and El Salvador, which suggests that the among hospitalized patients in Guatemala”, BMC Public Health. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 126 5. INFANT AND CHILD HEALTH CARE Figure 5.18. Children aged 6‑59 months who received vitamin A Figure 5.19. Children aged under 5 years with diarrhoea supplementation, latest year available receiving ORT (%), latest year available Nicaragua (2015) 89 Low income High income Honduras (2012) 73 LAC19, 46.47% Guatemala (2017) Dominican Republic 53 El Salvador LAC8 42 Guatemala Bolivia (2017) 40 Haiti Dominican Republic (2013) 34 Honduras El Salvador (2014) 20 Mexico Haiti (2017) 19 Panama Peru (2012) 5 Paraguay 0 20 40 60 80 100 % Peru Source: DHS/MICS 2019. 0 20 40 60 80 100 StatLink 2 https://stat.link/aiv4mr % of children aged under 5 years with diarrhoea receiving ORT Note: The LAC19 average includes more countries than those represented in the figure due to data availability. Source: DHS and MICS 2019 for income inequalities on the 9 LAC countries available. UNICEF 2019 for the LAC19 average. StatLink 2 https://stat.link/g5kv6b Figure 5.20. Children aged under 5 years with ARI symptoms who took antibiotic treatment (%), latest year available With antibiotics Taken to a health facility % 100 94 91 93 89 90 84 82 82 78 80 80 77 77 73 73 70 64 64 62 62 60 52 50 40 30 20 10 0 Source: DHS/MICS 2019. StatLink 2 https://stat.link/zmjq9o HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 127 5. MENTAL HEALTH CARE Mental disorders such as depression and anxiety are highly more than 50. But there are around 12 mental health nurses per prevalent – 15% of the working-age population is affected at any 100 000 population in 18 LAC countries on average, and less than given time. They are also extensively undertreated; globally around one mental health nurse in Ecuador, Grenada and Haiti, suggesting 56% of people with depression do not receive appropriate again the need for an appropriate supply of professionals in mental treatment. These disorders contribute significantly to reduced health care to assure access. productivity, sickness absences, disability and unemployment, and Some countries, such as Jamaica, have introduced innovative the total costs of mental ill-health are estimated at 3.5 – 4% of GDP schemes designed to provide additional training to mental health in OECD countries. A particular prevention priority in the area of nurses. In the Jamaica programme, nurses can become “Mental mental health concerns suicide, which accounted for an estimated health officers” after receiving training on both clinical and 800 000 deaths in 2018 (WHO, 2019[18]). Despite the enormous administrative skills. This scheme has been successful in reducing burden that mental ill-health imposes on individuals, their families, stay lengths, reducing the stigma linked to mental health and society, health systems and the economy, mental health care cutting hospitalisation costs by treating the patient primarily at the remains a neglected area of health policy in too many countries community level (McKenzie, 2008[21]). (Hewlett and Moran, 2014[19]). The inclusion of mental health and On average, there are nearly five mental health beds in general substance abuse in the Sustainable Development Agenda is likely hospitals per 100 000 population in LAC countries. Cuba is the only to have a positive impact on communities and countries, stressing country with more mental health beds than the OECD average of the importance of the promotion of mental health and well-being, almost 35, while 11 of the 25 countries with data have less than 1 and the prevention and treatment of substance abuse. mental health bed per 100 000 population (Figure 5.23). In many parts of the LAC region, appropriate care may not be available and access to mental health care may not be assured for people with mental ill health. Access to mental health care can be assessed by the supply of professionals and the availability of Definition and comparability psychiatric beds in different settings such as general hospitals, Psychiatrists have post-graduate training in psychiatry and mental health hospitals and community facilities. Psychiatrists are may also have additional training in a psychiatric specialty, generally responsible for the prevention, diagnosis and treatment of such as neuropsychiatry or child psychiatry. Psychiatrists a variety of mental health problems, including schizophrenia, can prescribe medication, which psychologists cannot do in depression, learning disabilities, alcoholism and drug use most countries. Data include psychiatrists, disorders, eating disorders and personality disorders. The number neuropsychiatrists and child psychiatrists, but psychologists of psychiatrists is lower in all countries in LAC (except in Argentina) are excluded. Mental health nurses usually have formal than the OECD average of almost 17 per 100 000 population training in nursing at a university level. Data are based on (Figure 5.21). Only Argentina and Uruguay have more than ten head counts. psychiatrists per 100 000 population, and nine out of 26 LAC countries with data have less than one per 100 000 population. This suggests that many countries in the region currently underinvest in mental health care. As it is the case for many other medical References specialties (see indicator “Doctors and nurses” in Chapter 5), psychiatrists are not distributed evenly across regions within each [20] Heinze, G., G. del Carmen Chapa and J. Carmona-Huerta (2016), country. For example, in Mexico, 60% of all psychiatrists are based “Los especialistas en psiquiatría en México”, Salud Mental 39. in the three larger cities, leaving the rest of the country severely [19] Hewlett, E. and V. Moran (2014), Making Mental Health Count: The underserved (Heinze, del Carmen Chapa and Carmona-Huerta, Social and Economic Costs of Neglecting Mental Health Care, 2016[20]). OECD Health Policy Studies, OECD Publishing, Paris, https:// dx.doi.org/10.1787/9789264208445-en. Mental health nurses play an important and increasing role in the delivery of mental health services in hospital, primary care or other [21] McKenzie, K. (2008), Jamaica: Community Mental Health Services, settings, but in many LAC countries, the number is still very low Pan-American Health Organization. (Figure 5.22). Barbados has the highest rate with over 60 mental [18] WHO (2019), Suicide, World Health Organization, https:// health nurses per 100 000 population, followed by Saint Lucia with www.who.int/news-room/fact-sheets/detail/suicide. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 128 5. MENTAL HEALTH CARE Figure 5.21. Psychiatrists, per 100 000 population, 2016 or Figure 5.22. Nurses working in mental health sector, per latest available year 100 000 population, 2016 or latest available year Argentina 21.7 Barbados 63.3 OECD36 16.8 Uruguay 14.1 Saint Lucia 50.8 Cuba 9.1 OECD36 41.8 Chile 7.0 Saint Kitts and Nevis 5.5 Brazil 34.9 Panama 4.0 Suriname 16.6 Costa Rica 3.9 LAC18 12.3 LAC26 3.4 Brazil 3.2 Jamaica 10.3 Peru 2.9 Cuba 8.9 Dominican Republic 2.3 Grenada 1.9 Antigua and Barbuda 7.0 Colombia 1.8 Peru 6.0 Belize 1.4 Costa Rica 5.7 Suriname 1.3 Jamaica 1.1 Saint Vincent and the Grenadines 4.6 Bolivia 1.1 Panama 3.5 Antigua and Barbuda 1.0 Guyana 0.9 Belize 3.3 El Salvador 0.9 Mexico 2.2 Nicaragua 0.7 Chile 1.9 Honduras 0.7 Saint Lucia 0.6 Guatemala 1.1 Guatemala 0.5 Grenada 0.9 Ecuador 0.5 Mexico 0.2 Haiti 0.2 Haiti 0.1 Ecuador 0.1 0 5 10 15 20 25 0 20 40 60 80 Per 100 000 population Per 100 000 population Source: WHO GHO 2019. Source: WHO GHO 2019. StatLink 2 https://stat.link/8td9av StatLink 2 https://stat.link/j9idnl Figure 5.23. Mental health beds, per 100 000 population, 2016 or latest available year Beds for mental health in general hospitals Beds in mental hospitals Beds in community residential facilities Per 100 000 population 250 200 150 100 50 0 Source: WHO GHO 2019. StatLink 2 https://stat.link/nhkl29 HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 129 5. BLOOD GLUCOSE AND BLOOD PRESSURE Raised levels of blood sugar can lead to the development of In ten LAC countries with data, we can observe a general positive diabetes, which is a chronic condition that can have very seriously association between people being diagnosed with hypertension damaging effects. In 2014, an estimated 422 million people had and receiving either medical advice or anti-hypertensive medication diabetes worldwide, and in 2016, 1.6 million deaths were directly (Figure 5.26). Costa Rica shows the highest levels of both caused by the disease (WHO, 2018[22]). Maintaining an population diagnosed and having access to treatment, while Belize individual’s blood glucose controlled is very important, particularly and Mexico show the lowest levels. Chile presents a relatively high for people who has been diagnosed with diabetes. Fasting blood rate of hypertension diagnosis, but low levels of treatment. To glucose (FBG) contributes to diagnose and monitor diabetes, and achieve the goal of effective treatment coverage, the main can be under control because of effective treatment with glucose- challenge for countries’ health systems is to increase detection and lowering medication and as a result of health promotion activities. provide population-wide health promotion activities and medical Therefore, controlled fasting blood glucose is thus a proxy for both treatment to the population in need (WHO, 2019[23]). promotion of healthy diets and behaviours and medical treatment of diabetes, all of which is normally provided in primary care settings (WHO, 2019[23]). Definition and comparability High blood pressure or hypertension manifests by causing The prevalence of raised blood pressure is defined as the headaches, difficulty breathing or nosebleeds, and, if left untreated percentage of the population with systolic blood pressure can lead to more serious cardiovascular problems such as stroke, equal or over 140, or diastolic blood pressure equal or myocardial infarction and kidney disease. Worldwide, 1.13 billion over 90. It is based on measured blood pressure. If multiple people have hypertension and fewer than 1 in 5 people with blood pressure readings were taken, first reading per hypertension have the problem under control (WHO, 2019[24]). participant was dropped and average of remaining readings The absence of hypertension is a result of prevention efforts such was used. The prevalence of raised FBG is defined as the as the promotion of physical activity and healthy diets. When percentage of the population with fasting glucose equal or hypertension develops, it can be controlled with medication as well over 126 mg/dl (7.0 mmol/l) or history of diagnosis with as with life style adjustments. This indicator is thus a proxy for both diabetes or use of insulin or oral hypoglycaemic drugs. It is health promotion and medical services, usually primary care based on measured blood glucose. The percentage of the (WHO, 2019[23]). population receiving advice or treatment (Figure 5.26, The prevalence of raised FBG is higher than the OECD average in (Geldsetzer et al., 2019[26])) was defined as people who all LAC countries (Figure 5.24). In 2014, Saint Lucia and Saint Kitts were diagnosed with hypertension and had received relevant and Nevis had the highest prevalence with over 14% of the lifestyle advice (i.e. losing weight, exercising, reducing salt population having raised FBG, while Peru, Bolivia and Ecuador had intake, or quitting tobacco use) or anti-hypertensive the lowest with 8% or less. Moreover, between 2004 and 2014, all medication. LAC countries increased the prevalence of raised FBG, with a regional average growth of 22%. Only Venezuela grew in a smaller rate than in OECD countries, and Saint Lucia was the only country with an increase of over 50%. The increases in FBG can be linked to the growing overweight epidemic in LAC countries (see section References on Overweight and Obesity in Chapter 4). [26] Geldsetzer, P. et al. (2019), “The state of hypertension care in 44 In 2015, the average prevalence of raised blood pressure in LAC low-income and middle-income countries: a cross-sectional study was 22%, close to the OECD average of 21% (Figure 5.25). Saint of nationally representative individual-level data from 1·1 million adults”, The Lancet, Vol. 394/10199, pp. 652‑662, http://dx.doi.org/ Kitts and Nevis, Suriname and Peru had the highest prevalence of 10.1016/S0140-6736(19)30955-9. over 25%, while the lowest prevalence was observed in Paraguay, the only country below 15%. Between 2005 and 2015, most of LAC [23] WHO (2019), Primary health care on the road to universal health countries reduced the prevalence of raised blood pressure with an coverage: 2019 monitoring report. average of ‑8%, lower than the OECD reduction of ‑16%. Four [24] WHO (2019), Hypertension, World Health Organization, https:// countries experienced an increase in the period: Suriname (8%), www.who.int/news-room/fact-sheets/detail/hypertension. Saint Kitts and Nevis (4%), Antigua and Barbuda (3%) and [22] WHO (2018), Global Health Estimates 2016: Disease burden by Guatemala (2%). Changes in risk factors and improvements in Cause, Age, Sex, by Country and by Region, 2000‑2016. detection and treatment of raised blood pressure have, at least [25] Zhou, B. et al. (2017), “Worldwide trends in blood pressure from partly, contributed to these general reductions, but other factors 1975 to 2015: a pooled analysis of 1479 population-based such as improvements in early childhood nutrition and year-round measurement studies with 19·1 million participants”, The Lancet, availability of fruits and vegetables, might explain it as well (Zhou Vol. 389/10064, pp. 37‑55, http://dx.doi.org/10.1016/ et al., 2017[25]). S0140-6736(16)31919-5. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 130 5. BLOOD GLUCOSE AND BLOOD PRESSURE Figure 5.24. Raised fasting blood glucose among adults, 2004 and 2014 2004 2014 % of population with raised fasting blood glucose 20 14.5 14.5 12.7 16 12.5 12.3 12.2 11.9 11.7 11.5 11.2 11.1 11.1 10.9 10.6 10.5 10.3 10.1 10.1 10.1 9.7 9.7 9.5 9.5 9.3 9.3 12 8.9 8.7 8.5 8.4 8.3 8.1 8.0 8.0 7.7 6.6 8 4 0 Source: WHO GHO 2017. StatLink 2 https://stat.link/nby6au Figure 5.25. Raised blood pressure among adults, 2005 and 2015 2005 2015 % of population with raised blood pressure 35 27.1 25.8 30 23.4 23.1 25 25.3 20 24.6 24.6 24.5 24.4 23.3 23.3 22.7 22.6 22.5 22.4 21.8 21.6 21.5 21.4 21.2 20.9 20.9 20.9 20.8 20.7 15 19.9 19.7 19.2 19.0 18.7 18.7 18.6 17.9 17.9 10 13.7 5 0 Source: WHO GHO 2017. StatLink 2 https://stat.link/c0xval Figure 5.26. Percentage of the population with hypertension aware of their diagnosis vs population that have received advice or medication % advice or medication 80 CRI (2010) 70 BRA (2013) 60 ECU (2012) GRD (2011) R² = 0.6787 50 VCT (2013) LAC10 GUY (2016) MEX (2012) CHL (2010) 40 PER (2012) 30 BLZ (2010) 20 40 45 50 55 60 65 70 75 80 % diagnosed Source: Data from Geldsetzer et al (2019[26]), “The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults”, http://dx.doi.org/10.1016/S0140-6736(19)30955-9. StatLink 2 https://stat.link/rvnyef HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 131 Health at a Glance: Latin America and the Caribbean 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 Chapter 6 Health expenditure and financing 133 6. HEALTH EXPENDITURE PER CAPITA AND IN RELATION TO GDP A wide range of demographic, social and economic factors, as well as the financing and organisational arrangements of the health Definition and comparability system can explain the level and changes over time of health spending in a country, covering both individual needs and Health expenditure is given by the sum of expenditure on population health as a whole. all the core health care functions – that is total health care services, medical goods dispensed to outpatient, prevention The average OECD current health spending per capita in 2017 was and public health services, and health administration and around four times that of the countries in LAC (USD PPP 3 994 health insurance. Expenditure on these functions is included versus 1 025). Much variation in per capita health care spending as long as it is borne by final use of resident units i.e. as long levels can be observed in LAC countries (Figure 6.1), ranging from as it is final consumption by nationals in the country or Haiti health spending per capita of only 83 international dollars abroad. For this reason, imports for final use are included and (current USD PPP) to Cuba’s 2 484 international dollars (current exports for final use are excluded. USD PPP). In average, LAC countries devote 59% to government and compulsory insurance schemes, and the remaining 41% goes Health care financing can be analysed from the point of to out-of-pocket payments, voluntary payment schemes and view of financing schemes (financing arrangements through external resources. which health services are paid for and obtained by people, e.g. social health insurance), financing agents (organisations On average, between 2010 and 2017, the growth rate in per capita managing the financing schemes, e.g. social insurance health spending was 3.6% per year in LAC, higher than the 3% agency), and types of revenues (e.g. social insurance observed for gross domestic product (GDP) (Figure 6.2). The contributions). Here “financing” is used in the sense of growth in health spending was more rapid in Nicaragua, Bolivia and financing schemes as defined in the System of Health Paraguay – more than twice the average rate for the region. Accounts (OECD, Eurostat and WHO, 2011) and includes Venezuela reported decreasing rates in current health spending government schemes, compulsory health insurance as well between 2010‑17. as voluntary health insurance and private funds such as Health spending growth and GDP growth are positively associated, households’ out-of-pocket payments, NGOs and private meaning that in general terms an increase or decrease in one of corporations. Out-of-pocket payments are expenditures them follows the other. In many LAC countries, health spending has borne directly by patients and include cost-sharing exceeded economic growth over the past five years, resulting in an arrangements and any informal payments to health care increasing share of the economy devoted to health. All countries providers. above the diagonal line in Figure 6.2 report that health expenditure The economy-wide (GDP) PPPs are used as the most has grown faster than income. This means that the share of health available conversion rates. These are based on a broad care expenditure in total expenditure has continued to increase. In basket of goods and services, chosen to be representative of all countries below the line, the increase in health spending – on all economic activity. The use of economy-wide PPPs means average – was lower than the increase in GDP. Hence, the share of that the resulting variations in health expenditure across health spending in total spending declined in those countries. countries might reflect not only variations in the volume of Overall health spending growth and economic performance can health services, but also any variations in the prices of health explain how much countries spend on health care over time. services relative to prices in the rest of the economy. Current health expenditure accounted for 6.6% of GDP in the LAC To make useful comparisons of real growth rates over region in 2017, an increase of around 0.09 percentage points from time, it is necessary to deflate (i.e. remove inflation from) 2010. The OECD countries averaged a current health expenditure nominal health expenditure through the use of a suitable of 8.8% of the GDP in 2018. This indicator varied from 1.1% in price index, and also to divide by the population, to derive Venezuela to up to 11.7% in Cuba and 9.2% in Uruguay real spending per capita. Due to the limited availability of (Figure 6.3). Generally, the richer a country is, the more it spends reliable health price indices, an economy-wide (GDP) price on health. Between 2010 and 2017, the share of health in relation to index is used in this publication. GDP declined almost 6 percentage points in Venezuela, whereas it To take into account the timing of the government budget increased more than 2 percentage points in Paraguay and Chile. allocation process, comparison over time look at the latest Capital has been an increasingly important factor of production of five years for which expenditure data are available. health services over recent decades, as reflected for example by Gross fixed capital formation in the health sector is the growing importance of diagnostic and therapeutic equipment or measured by the total value of the fixed assets that health the expansion of information and communications technology (ICT) providers have acquired during the accounting period (less in health care. Capital investments in health tends to fluctuate more the value of the disposals of assets) and that are used with economic cycles than current spending on health care. repeatedly or continuously for more than one year in the However, slowing down investments in health infrastructure and production of health services. The breakdown by assets equipment will affect service delivery. As a proportion of GDP, includes infrastructure (e.g. hospitals, clinics, etc.), Panama and Saint Vincent and the Grenadines were the highest machinery and equipment (including diagnostic and surgical spenders on capital investment in 2017 with more than 0.7% of their machinery, ambulances, and ICT equipment), as well as GDP going on construction, equipment and technology in the software and databases. Gross fixed capital formation is health and social sector (Figure 6.4). However, capital spending reported by many countries under the System of Health can be significantly lower: in Venezuela, Argentina and Antigua and Accounts. Barbuda accounted for less than 0.002% in 2017. On average, it represents 0.2% of GDP across LAC compared to 0.5% in OECD countries in 2015. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 134 6. HEALTH EXPENDITURE PER CAPITA AND IN RELATION TO GDP Figure 6.1. Total health expenditure per capita (USD PPP), 2017 Figure 6.2. Average annual growth rate in current health spending and GDP per capita, 2010‑17 Government/Compulsory Voluntary/Out-of-pocket Health expenditure (%) Cuba 2484 12 Trinidad and Tobago 2206 Chile 2182 Uruguay 2102 Argentina 1907 PRY Panama 1786 10 Bahamas 1746 NIC Saint Kitts and Nevis 1442 BOL Barbados 1317 Costa Rica 1285 COL Brazil 1280 8 DOM PAN Mexico 1138 Antigua and Barbuda 1071 CHL LAC33 1026 Dominican Republic 978 6 ECU PER Colombia 960 TTO Ecuador 954 SUR URY Suriname 944 JAM Paraguay 864 BRA Grenada 714 4 CUB HTI GUY Peru 680 ARG CRI LAC Saint Lucia 661 BRB Dominica 636 VCT GTM R² = 0.2725 El Salvador 582 Jamaica 532 2 MEX DMAKNA HND Saint Vincent and the Grenadines 522 OECD, 3994 USD PPP BLZ SLV Bolivia 480 ATG Belize 473 BHS LCA GRD Guatemala 470 Nicaragua 468 0 Guyana 385 Honduras 373 VEN Venezuela 141 (-4 ; -19.9) Haiti 83 -2 0 1000 2000 3000 -2 0 2 4 6 8 USD PPP GDP (%) Note: 2018 data for Brazil, Chile, Colombia, Costa Rica and Mexico. Source: WHO GHED 2020; OECD Health Statistics 2019 for Brazil, Chile, Source: WHO Global Health Expenditure Database 2020; OECD Health Statistics Colombia, Costa Rica and Mexico. 2019 for Brazil, Chile, Colombia, Costa Rica and Mexico. StatLink 2 https://stat.link/jkzdts StatLink 2 https://stat.link/tpq71j Figure 6.3. Change in total expenditure on health as a share of Figure 6.4. Grossed fixed capital formation in the health care GDP, 2010‑17 sector as a share of GDP, 2017 CHE diff 2010-17, pp Saint Vincent and the Grenadines CHE as share of GDP, 2017 Panama Cuba Bolivia Uruguay Nicaragua Brazil OECD Argentina Haiti Chile Brazil OECD36 Dominican Republic Nicaragua Peru Ecuador Cuba Haiti Ecuador Honduras Costa Rica Costa Rica Saint Lucia Panama Saint Kitts and Nevis El Salvador Honduras Colombia Paraguay Trinidad and Tobago Chile Barbados LAC33 Paraguay Uruguay LAC33 Bolivia Trinidad and Tobago Suriname Mexico Dominican Republic Barbados Jamaica Guatemala Dominica Argentina Guatemala Antigua and Barbuda Bahamas Venezuela Belize Suriname Mexico Jamaica Saint Kitts and Nevis Guyana Peru Grenada Guyana El Salvador Grenada Dominica Saint Lucia Colombia Antigua and Barbuda Belize Saint Vincent and the Grenadines Bahamas Venezuela -10 -5 0 5 10 15 0 0.2 0.4 0.6 0.8 % % Note: 2018 data for Brazil, Chile, Colombia, Costa Rica and Mexico. Note: OECD average corresponds to 2015. Source: WHO GHED 2020; OECD Health Statistics 2019 for Brazil, Chile, Source: WHO GHED 2020, OECD Health Statistics 2019 for Chile and Mexico. Colombia, Costa Rica and Mexico. StatLink 2 https://stat.link/qmlewp StatLink 2 https://stat.link/iv5g6u HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 135 6. FINANCING OF HEALTH CARE FROM GOVERNMENT AND COMPULSORY HEALTH INSURANCE SCHEMES Health system financing arrangements can be broadly classified in the LAC region between 2010 and 2017. The largest increase according to their compulsory or voluntary nature, providing occurred in Venezuela (40.2 percentage points) and Suriname coverage against the cost of health care by purchasing health care (25.9), while reductions happened in 13 countries, led by Antigua services. In some countries, health care might be predominantly and Barbuda (‑23) and Saint Vincent and the Grenadines (‑23.1). financed through government schemes by which individuals are Healthcare is one of multiple governmental public services for automatically entitled to care based on their residency. In other which they devote their overall budgets. A number of factors cases, compulsory health insurance schemes (either through including, among others, the type of system in place, the fiscal public or private entities) linked to the payment of social space and the policy and political priority of the health sector contributions or health insurance premiums finance the bulk of determines the size of public funds allocated to health. Relative health spending. In addition to these, a varying proportion of health budget priorities may also shift from year to year as a result of care spending consists households’ out-of-pocket payments – political decision-making and economic effects. In 2017, general either as standalone payments or as part of co-payment government health expenditure as a share of total government arrangements – as well as various forms of voluntary payment expenditure stood at 12.75% in LAC, well below the 24.5% in schemes such as voluntary health insurance. In the LAC region, OECD countries (Figure 6.7). In Costa Rica and Panama more than substantial fragmentation in health systems often leads to 20% of public spending was dedicated to health care. On the other coexisting financing schemes and in some cases, overlap (see hand, less than 6% of government expenditure was allocated to Chapter 2). Most standard models of public financing exist in the health care in Haiti and Venezuela. In the 2010‑17 period, public region (Lorenzoni et al., 2019[1]). health expenditure as a share of government expenditure Figure 6.5 reports the expenditure financed by general government increased the most in Panama, similar to the 8 percentage points health expenditure (which includes government expenditure and increase in OECD countries, while it decreased the most in Antigua funds linked to compulsory health insurance) as a share of GDP in and Barbuda (‑6 percentage points) and Venezuela (‑4.8). 2017 and its trend in the 2010‑17 period. The countries with the highest share are Cuba (10.5%), Argentina (6.6%), Uruguay (6.6%) and Costa Rica (5.7%). The countries with the lowest share are Definition and comparability Venezuela and Haiti, with 0.2 and 1% the only two below a share of 2% in the region and well below the LAC average of 3.7%. On The financing classification used in the System of Health average, the LAC region increased its share of public expenditure Accounts provides a complete breakdown of health as percentage of GDP by around 0.38 percentage points. expenditure into public and private units incurring Nicaragua was the only country reporting an increase of more than expenditure on health. General government health 2 percentage points in the period, whereas ten countries saw a expenditure includes government expenditure and social decrease: Mexico (‑0.1), Costa Rica (‑0.2), Bahamas (‑0.3), security funds. Relating spending from government and Panama (‑0.39), Haiti (‑0.50), Grenada (‑0.51), Honduras (‑0.55), compulsory insurance schemes to total government Barbados (‑0.62), Antigua and Barbuda (‑0.82) and Venezuela expenditure can lead to an overestimation in countries where (‑2.40). private insurers provide compulsory insurance. In the majority of LAC countries, general government health expenditure constituted the main source of funding in 2017 (regional average of 54.3%) (Figure 6.6). Cuba has the largest share with 89.4%, followed by Costa Rica with 75.1%, the only two References countries over 75%. On the other side, the lowest share were [1] Lorenzoni, L. et al. (2019), “Health systems characteristics: A survey observed in Honduras (11.9%), Haiti (15.9%) and Guatemala of 21 Latin American and Caribbean countries”, OECD Health (35.8%). In average, general government health expenditure as Working Papers, No. 111, OECD Publishing, Paris, https:// share of current health expenditure grew by 2.1 percentage points dx.doi.org/10.1787/0e8da4bd-en. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 136 6. FINANCING OF HEALTH CARE FROM GOVERNMENT AND COMPULSORY HEALTH INSURANCE SCHEMES Figure 6.5. Change in health expenditure by government scheme and compulsory insurance scheme as a share of GDP, 2010‑17 2010 2017 % of GDP 12 10.5 10 8 6.6 6.6 6.6 5.4 5.3 5.0 6 4.6 4.4 4.4 4.4 4.0 3.9 3.8 3.76 3.7 3.6 5.7 3.2 3.0 3.0 2.9 4 2.8 2.3 2.2 3.8 2.1 2 3.2 3.0 2.8 2.5 2.1 2.0 0.2 0 1.0 Source: WHO Global Health Expenditure Database (2020), OECD Health Statistics (2019). StatLink 2 https://stat.link/s49tcm Figure 6.6. Change in health expenditure by government scheme and compulsory insurance scheme share of current expenditure on health, 2010‑17 2010 2017 % of current health expenditure 100 73.6 73.5 75.1 70.8 90 72.4 68.5 68.0 64.3 63.4 80 89.4 65.0 59.9 59.9 59.9 63.7 58.6 53.2 52.8 51.6 51.5 54.3 70 46.6 46.0 60 35.8 50 58.1 40 49.0 47.0 45.5 44.2 43.9 43.0 42.7 30 40.1 20 15.9 11.9 10 0 Source: WHO Global Health Expenditure Database (2020); OECD Health Statistics (2019). StatLink 2 https://stat.link/zfcgue Figure 6.7. Change in health expenditure by government and compulsory insurance scheme as a share of total government expenditure, 2010‑17 2010 2017 % of total government expenditure 35 24.5 30 20.1 19.8 19.7 19.2 29.2 25 18.6 17.2 15.9 20 14.9 13.3 11.8 11.5 11.2 12.7 11.9 10.5 15 9.9 9.5 8.9 8.5 16.1 8.2 15.6 10 13.4 11.7 11.3 11.0 10.4 9.5 9.0 9.1 5 7.3 5.2 0 Source: WHO Global Health Expenditure Database (2020); OECD Health Statistics (2019). StatLink 2 https://stat.link/9ky3sl HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 137 6. FINANCING OF HEALTH CARE FROM HOUSEHOLDS’ OUT-OF-POCKET PAYMENTS, VOLUNTARY PAYMENT SCHEMES AND EXTERNAL RESOURCES Private health expenditure refers to the health spending from non- However, it is a very significant source of financing in Haiti public agents, and it is often divided between out-of-pocket (over 43%), illustrating the reliance on external resources from a expenditure (OOP), voluntary payment schemes and external variety of donors in this country (Figure 6.10). sources. OOP expenditure refers to payments made to pay directly for health care, while voluntary payment schemes refers to payment of private insurance premiums, which grant coverage for Definition and comparability services from private providers. External resources covers the The financing classification used in the System of Health funds for health received from different donors or similar sources. Accounts provides a complete breakdown of health On average, the share of health spending paid out of-pocket is 34% expenditure into public and private units incurring in the LAC region, well above the OECD average of almost 21% expenditure on health. Private sector comprises pre-paid and (Figure 6.8). The highest presence of OOP is observed in risk pooling plans, household out-of-pocket expenditure and Venezuela (63%) followed by Guatemala (54%) and Grenada non-profit institutions serving households and corporations. (52%), the three countries above 50% in the region. At the other Out-of-pocket payments are expenditures borne directly by end, only five countries stand below 20%: Cuba (10%), Argentina the patient. They include cost-sharing and, in certain (15%), Colombia (16%), Jamaica (17%) and Uruguay (17%). countries, estimations of informal payments to health care The OOP as a share of health expenditure has fallen by providers. 1.5 percentage points from 2010 to 2017 in LAC (Figure 6.8). The Voluntary health care payments schemes include decrease was greatest in Nicaragua (‑11.8) and St Lucia (‑12.1). voluntary health insurance, Non-profit institutions serving However, 11 countries experienced increases in OOP, being led by households (NPISH) and enterprises financing schemes. Venezuela (+20.07) and Antigua and Barbuda (+10.71). OOP Data on voluntary insurance coverage was taken from the expenditure above 20% of current health expenditure is considered responses provided by countries to the 2018 Health System problematic as it indicates high vulnerability to catastrophic health Characteristics Survey in Latin America and the Caribbean. expenditure in the event of a health emergency. The section about “Financial Protection” in the present chapter examines the extent to External funding for health is measured as Official which people in LAC is at risk of falling into poverty due to Development Assistance disbursements for health from all catastrophic health expenditures. donors. Disbursements represent the actual international transfer of financial resources. Disbursements for health are Figure 6.9 shows that health expenditure by voluntary payment identified by using the classification of sector of destination schemes represented – on average – 8% of current expenditure on codes 121 (health, general except 12181, medical education/ health in LAC, above the OECD average of 5.5%. This share training and 12182, medical research), 122 (basic health) increased in most countries from 2010‑17, particularly in Antigua and 130 (population policies/programmes and reproductive and Barbuda where it increased by 12.5 percentage points. On the health except 13010 Population policy and administrative other hand, in Uruguay and Jamaica it decreased by more than management), and 510 (general budget support) 7 percentage points. Less than 1% of current health expenditure (www.oecd.org/dac/stats/ aidtohealth.htm). General budget was from voluntary payment schemes in Dominica, while it was the support to health is estimated by applying the share of highest in Brazil (30%), Bahamas (25%) and Venezuela (21%), the government expenditure on health over total general only three countries above 20%. Private health insurance is an government expenditures to the value reported in ODA. important source of secondary coverage in most countries, either Given that disbursement money is spent over several years supplementing coverage of goods and services not included in the by countries, funds disbursed at year t are compared to total basic benefit package, complementing coverage by covering costs health expenditure in year t+1. or duplicating coverage for those patients looking for private care. The share of health expenditure coming from external sources is low across the region (under 1% in 19 out of 30 countries with data). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 138 6. FINANCING OF HEALTH CARE FROM HOUSEHOLDS’ OUT-OF-POCKET PAYMENTS, VOLUNTARY PAYMENT SCHEMES AND EXTERNAL RESOURCES Figure 6.8. Change in out-of-pocket spending as a share of current expenditure on health, 2010‑17 2010 2017 % 70 63.0 60 48.7 46.3 44.7 50 40.2 35.0 54.1 33.3 52.4 31.2 31.0 40 47.8 26.4 44.8 44.2 24.2 20.6 41.3 30 39.8 39.4 32.6 34.1 33.5 32.5 20 31.0 10.5 29.2 28.2 27.4 25.1 22.0 10 17.5 17.2 16.3 15.0 0 Source: WHO Global Health Expenditure Database (2020); OECD Health Statistics (2019). StatLink 2 https://stat.link/3s8p12 Figure 6.9. Change in health expenditure by voluntary health care payment schemes as a share of health expenditure, 2010 to 2017 2010 2017 % 35 29.5 30 24.6 18.0 25 20 10.1 20.9 10.2 15 8.0 7.2 7.2 7.0 7.0 6.6 6.3 6.3 6.3 10 3.9 3.8 4.9 3.2 2.9 2.9 11.2 1.6 5 1.4 9.2 0.8 4.6 7.5 5.6 6.1 6.4 5.5 5.6 0 Source: WHO Global Health Expenditure Database (2020); OECD Health Statistics (2019). StatLink 2 https://stat.link/6y81f3 Figure 6.10. Change in external resources as a share of current health expenditure, 2010‑17 2010 2017 % 50 45 40 43.06 35 30 25 20 15 7.49 5.40 0.14 2.64 2.30 1.08 0.25 3.20 0.47 2.06 1.97 1.58 1.23 1.96 10 0.94 0.74 0.59 0.54 0.50 0.33 0.28 0.24 0.23 0.09 0.08 0.08 0.02 0.02 0.01 0.00 4.90 5 0 Source: WHO Global Health Expenditure Database (2020). StatLink 2 https://stat.link/mes6pz HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 139 6. FINANCIAL PROTECTION As reported in the previous section on private and external As discussed in Chapter 2, wasteful spending in LAC health expenditure, high levels of out-of-pocket (OOP) spending in the systems is taking resources that could be spent in more and better region present a challenge not only for governments looking to health care. For instance, fragmentation of LAC health systems is improve access but also to individuals, household and not only a relevant source of waste but also contributes to create communities. High OOP means that the population is directly barriers for expanding access and financial protection, and financing a substantial part of care when they need it, which in turn therefore improving health outcomes. Fragmentation limits the can push them into poverty or financial hardship. The global pooling of funds and the existence of more effective insurance incidence of catastrophic spending at 10% or more of OOP relative mechanisms, components that lead to better access to necessary to household income or consumption has been estimated at 9.7% care and improved population health, with the largest gains in 2000, 11.4% in 2005, and 11.7% in 2010. This means that accruing to poorer people (Moreno-Serra and Smith, 2012[5]). globally 808 million people in 2010 incurred catastrophic health spending (Flores et al., 2018[2]). In addition, high OOP can have very negative consequences for the financial and social wellbeing Definition and comparability of households, in some cases leading them into poverty. It has Data on financial protection indicators was taken from the been estimated that at the USD 1.90 per day poverty line, the World Bank Health Equity and Financial Protection dataset. worldwide incidence of impoverishment decreased between 2000 The dataset has grown over time from the first dataset and 2010, from 131 million people (2.1% of the world’s population) published in 2000 which pulled data from 42 surveys and one to 97 million people (1.4%) (Wagstaff et al., 2018[3]). type of survey, covered just 42 countries, and included just Figure 6.11 shows the proportion of households spending 34 indicators, which all concerned maternal and child health. over 10% of income or consumption (depending on the proxy In 2013, for the first time, the database included household chosen to estimate wealth) on OOP health care expenditures in 16 out-of-pocket health expenditures, noncommunicable LAC countries. This excludes private pre-paid payments. On disease indicators (NCD), and data from high-income average, almost 8% of the population spends more than 10% of countries. The 2018 database follows this trend by employing their household consumption or income. The proportion is low in a over 1 600 surveys, covering 183 countries, and number of countries such as El Salvador, Mexico and Guatemala encompassing multiple years of data, richer NCD data, and (under 2%), but it is almost 17% in Barbados followed by Nicaragua more extensive data on household out-of-pocket and Chile around 15%. In addition, most countries have a low expenditures. proportion of households spending over 25% of their income or consumption on OOP, but Haiti is much higher than the rest with 4% The poverty line is defined here as the higher of the of the population spending a quarter of their household income in USD 1.90 (USD 2011 PPP) poverty line and a 50% of median OOP for health care. consumption poverty line (%). As high OOP expenditure on health can take people into financial ruin, Figure 6.12 shows the proportion of households that have been pushed below the poverty line. In 15 LAC countries, 1.7% of the population was pushed by OOP health care expenditure below References the societal poverty line compared with the 1.2% in OECD [2] Flores, G. et al. (2018), “Progress on catastrophic health spending in countries. Consistent with the high proportion of households 133 countries: a retrospective observational study”, Articles Lancet making OOP payments over 10% and 25% of the income or Glob Health, Vol. 6, pp. 169‑79, http://dx.doi.org/10.1016/ consumption, over 5% of Nicaraguan households have been driven S2214-109X(17)30429-1. below the poverty line, followed by Haiti (3.3%), Chile (2.6%) and [5] Moreno-Serra, R. and P. Smith (2012), Does progress towards Ecuador (2.4%). On the other hand, the proportion is lower in universal health coverage improve population health?, Lancet several countries such as Bahamas, Honduras or El Salvador Publishing Group, http://dx.doi.org/10.1016/ where less than 0.5% of the population falls into poverty because of S0140-6736(12)61039-3. OOP health care expenditures. [3] Wagstaff, A. et al. (2018), “Progress on impoverishing health To ensure adequate access and coverage for all groups, spending in 122 countries: a retrospective observational study”, governments must implement efforts to protect households against The Lancet Global Health, Vol. 6, pp. e180‑e192, http://dx.doi.org/ excessive OOP expenditures that can drive people into poverty. 10.1016/S2214-109X(17)30486-2. Some common aspects of successful reforms include pooled or [4] WHO (2018), Health financing, World Health Organization, https:// coordinated use of different revenue sources; progressively www.who.int/health-topics/health-financing. increasing the size of compulsory prepaid funds; redistribution of money form prepaid funds; and new organisations and institutional arrangements to support and enable change (WHO, 2018[4]). HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 140 6. FINANCIAL PROTECTION Figure 6.11. Proportion of population spending more than 25% and 10% of household consumption or income through out-of- pocket health care expenditure Above 10% Above 25% % 18 16.4 16 14.8 14.6 14 12 11.5 10.3 9.8 10 9.2 8.2 7.8 8 7.1 6.0 6 4.9 3.9 4 2.7 1.7 1.6 1.4 2 0 Note: Countries with data older than 2010 were excluded. Source: World Bank Health Equity and Financial Protection 2020. StatLink 2 https://stat.link/48ae7c Figure 6.12. Proportion of population pushed by out-of-pocket health care expenditure below the societal poverty line % 6 5.2 5 4 3.3 3 2.6 2.4 2 1.8 1.7 1.7 1.4 1.4 1.4 1.2 1.2 0.9 1 0.8 0.4 0.3 0.1 0 Note: Countries with data older than 2010 were excluded. Source: World Bank Health Equity and Financial Protection 2019. StatLink 2 https://stat.link/e9y2ix HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 141 Health at a Glance: Latin America and the Caribbean 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 Chapter 7 Quality of care 143 7. CHILDHOOD VACCINATION PROGRAMMES Childhood vaccination programmes often take up a large share of a Figure 7.3 shows that the average percentage of children aged one country’s prevention strategy as they are one of the most effective who are vaccinated for hepatitis B is 89%, similar to the average and cost-effective health policy interventions (Chan et al., 2017[1]). coverage rate than for measles and DTP and just below the 90% The WHO estimates that vaccines prevent between 2 million and target. Rates for most countries are above 80%, with significantly 3 million deaths each year worldwide, and that an additional lower rates than average in Mexico, Haiti and Venezuela. 1.5 million deaths could be avoided with global vaccination, through In LAC countries, several barriers to vaccination still exist. direct protection of those vaccinated and prevention of the spread ‘Individual/group influences’ (e.g. beliefs and attitudes, mistrust in of disease to those unvaccinated. Therefore, vaccination the health system, lack of physician recommendation, dearth of programmes exist in all LAC countries, which include several official information against misconceptions) were the most routine vaccines (i.e. against diseases such polio, diphtheria, frequently reported barrier category. Then, ‘contextual influences’ tetanus, pertussis, measles) and additional vaccines (i.e. against (e.g. lower socio-economic and educational status, advanced age, pneumococcus, rotavirus and human papilloma virus) are included religious and cultural beliefs, fear of adverse events and vaccine at national or subnational level based on local morbidity, mortality misinformation) was the second most relevant group (Guzman- and cost-effectiveness analysis. Coverage of these programmes Holst et al., 2019[3]). Eroding public confidence in the safety and can be considered as a quality of health care indicators as they efficacy of vaccination, despite the lack of scientific evidence to effectively reduce burden of vaccine preventable diseases support this, seems to be an area that LAC countries could address subsequently. As examples, diphtheria, tetanus toxoid and to strengthen vaccination strategies. pertussis (DTP), measles and hepatitis B are presented in this section as they represent, in timing and frequency of vaccination, the full spectrum of organisational challenges related to routine vaccination for children. Definition and comparability Despite generally high overall rates, 12 out of the 33 LAC countries fall short of attaining the minimum immunisation levels Vaccination rates reflect the percentage of children at recommended by the WHO to prevent the spread of DTP (90%) either age one or two that receives the last dose of primary (Figure 7.1) and 21 out of 33 fail to meet this target for measles immunisation series by the respective vaccination (95%) in 2018 (Figure 7.2). Furthermore, high national coverage programme in the recommended timeframe. Childhood rates may not be sufficient to stop disease spread, as low coverage vaccination policies differ slightly across countries. Thus, in local populations or certain geographical areas can lead to these indicators are based on the actual policy in a given outbreaks. On average, only one out of every ten children in the country. Some countries administer combination vaccines region does not receive one of the two vaccines (90% coverage (e.g. MR for measles and rubella) while others administer the rate for both vaccines). The majority of countries have rates vaccinations separately. Some countries ascertain over 80%, which, although high, is insufficient to ensure interruption vaccinations based on surveys and others based on of disease transmission and protection of the whole population, as administrative data, which may influence the results. local outbreaks can occur. Two countries in particular had exceptionally low rates of around 60‑65%, Haiti and Venezuela. In 2007, more than 170 countries had adopted the WHO recommendation to incorporate hepatitis B vaccine including birth References dose as an integral part of their national infant immunisation [1] Chan, M. et al. (2017), Reaching everyone, everywhere with life- programme. Hepatitis B vaccination is recommended for all saving vaccines, Lancet Publishing Group, http://dx.doi.org/ children worldwide and reaching all children with at least three 10.1016/S0140-6736(17)30554-8. doses of hepatitis B vaccine should be the standard for all national [3] Guzman-Holst, A. et al. (2019), Barriers to vaccination in Latin immunisation programmes (WHO, 2014[2]). Most countries in the America: A systematic literature review, Elsevier Ltd, http:// LAC region started their hepatitis B vaccination programmes at the dx.doi.org/10.1016/j.vaccine.2019.10.088. end of the 1990s. Data reveals that hepatitis B vaccination across the LAC region has greatly reduced the incidence of hepatitis B, [2] WHO (2014), Resolution WHA67.6. Hepatitis. In: Sixty-seventh World Health Assembly, Geneva, 19‑24 May 2014, World Health even already having achieved the 2020 WHO goal for the region. Organization, Geneva, http://apps.who.int/gb/ebwha/pdf_files/ The elimination of hepatitis B transmission among children and wha67/a67_r6-en.pdf?ua=1. infants is within reach. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 144 7. CHILDHOOD VACCINATION PROGRAMMES Figure 7.1. Vaccination rates for diphtheria, tetanus toxoid and pertussis (DTP3), children aged around 1, 2018 % vaccinated 100 90 80 70 60 50 99 99 98 97 97 97 96 96 95 95 95 95 95 95 95 94 94 94 92 91 90 90 90 88 88 88 86 86 85 84 83 83 40 81 64 30 60 20 10 0 Source: WHO, Global Health Observatory 2019. StatLink 2 https://stat.link/dkv6ih Figure 7.2. Measles-containing-vaccine first-dose (MCV1) immunisation coverage among 1‑year‑olds (%), 2018 % vaccinated 100 90 80 70 60 50 99 99 99 98 98 98 97 97 97 96 96 95 95 94 94 93 93 93 90 90 89 89 89 89 87 86 85 85 84 84 84 83 40 81 74 69 30 20 10 0 Source: WHO, Global Health Observatory 2019. StatLink 2 https://stat.link/iha798 Figure 7.3. Hepatitis B (HepB3) immunisation coverage among 1‑year‑olds (%), 2018 % vaccinated 100 90 80 70 60 50 99 99 98 98 98 97 97 96 96 95 95 95 95 95 95 94 92 92 91 91 90 90 89 88 88 86 86 85 84 83 83 40 81 64 30 60 55 20 10 0 Source: WHO, Global Health Observatory 2019. StatLink 2 https://stat.link/zew7jb HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 145 7. IN-HOSPITAL MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION AND STROKE Ischaemic heart diseases and stroke were two major causes of efforts can be also done to improve care for patients with CVD. For death in Latin America in 2017, accounting for 78% of all instance, ensuring primary care is financially accessible to cardiovascular diseases (CVD) deaths in LAC countries combined, everyone and the gap between recommended care and care very similar to the 77% in OECD countries (see Chapter 3, ‘Mortality provided in practice is closed, while improving accountability and from cardiovascular diseases’). Additionally, both are associated transparency of primary care performance is key. In addition, with significant health, economic, social and non-financial costs, establishing a national framework to improve quality of acute care because of the persistent disabilities suffered by many survivors. of CVD and set national standards for the measurement and Treatment following acute myocardial infarction (AMI) and stroke continuous quality improvement of emergency services and care has advanced greatly over the past decade. The introduction and provided in hospitals can help to address the complexity of treating diffusion of new technologies such as cholesterol and blood CVD (OECD, 2015[4]). pressure lowering medications, thrombolysis and angioplasty over recent decades have had a marked effect on the quality of cardiovascular care (OECD, 2015[4]). Definition and comparability Case-fatality rate is a useful measure of acute care quality for both AMI and stroke. It reflects the processes of care, such as effective The in-hospital case-fatality rate following AMI, ischemic medical interventions, including early thrombolysis, angioplasty or and haemorrhagic stroke is defined as the number of people treatment with aspirin when appropriate and co-ordinated and who die within 30 days of being admitted to hospital. This timely transport of patients, but may be also influenced by individual indicator is based on unique hospital admissions and characteristics such as the severity of AMI and stroke. For AMI, restricted to mortality within the same hospital, differences in age-sex standardised in-hospital case fatality rates within 30 days practices in discharging and transferring patients may of admission was reported as very low in Costa Rica (0.3%), while influence the findings. Standardised rates adjust for the highest rates are in Mexico (28.1%) (Figure 7.4), much higher differences in age (45+ years) and sex and facilitate more than the OECD average (6.9%). meaningful international comparisons. For ischaemic stroke, the lowest case-fatality rates was reported in Data presented here do not take account of patients that Costa Rica (2.7%), the only country below the OECD average of are transferred to other hospitals during their care or reflect 7.7%. Mexico reported the highest rate of 19.2%, while Uruguay patients who died out of hospitals within 30 days. Using a and Chile were also over the OECD average (Figure 7.5). unique patient identifier patient data can be linked across Fatality rates for haemorrhagic stroke are significantly higher than hospitals and with death registers to generate more robust for ischaemic stroke, and countries that achieve better survival for indicators for national monitoring and international one type of stroke also tend to do well for the other. Again, the comparison. Currently, very few countries in Latin America lowest case-fatality rates for haemorrhagic stroke were reported in and the Caribbean can track patients in this way and hence Costa Rica (1.6%) with Mexico and Uruguay reporting the highest this form of indicator is not shown here. rate: 29.9% and 30.5%, respectively (Figure 7.6). Chile, with a fatality-rate of 21.3%, was below the average of 24% in OECD countries. Since very few countries in the region can report this type of quality References of care data, efforts can be put in place to develop their health [4] OECD (2015), Cardiovascular Disease and Diabetes: Policies for system information infrastructure, along with capacity building to Better Health and Quality of Care, OECD Health Policy Studies, produce and use the information. In terms of policies, while the OECD Publishing, Paris, https://dx.doi.org/ promotion of healthier lifestyles to reduce CVD burden is a priority, 10.1787/9789264233010-en. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 146 7. IN-HOSPITAL MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION AND STROKE Figure 7.4. In-hospital case-fatality rates within 30 days after admission for AMI, patients 45 years old and over, 2017 Age-sex standardised rate per 100 patients 30 27 24 21 18 15 12 9 6 3 0 Costa Rica (2015) Colombia OECD32 Chile Uruguay LAC6 Brazil Mexico Source: OECD Health Statistics 2019 and Ministries of Health of Brazil and Uruguay. StatLink 2 https://stat.link/myp8f4 Figure 7.5. In-hospital case-fatality rates within 30 days after admission for ischemic stroke, patients 45 years old and over, 2017 (or nearest year) Age-sex standardised rate per 100 patients 25 20 15 10 5 0 Costa Rica (2015) OECD33 Chile Uruguay LAC5 Brazil Mexico (2015) Source: OECD Health Statistics 2019 and Ministries of Health of Brazil and Uruguay. StatLink 2 https://stat.link/y9m6zs Figure 7.6. In-hospital case-fatality rates within 30 days after admission for haemorrhagic stroke, patients 45 years old and over, 2017 (or nearest year) Age-sex standardised rate per 100 patients 35 30 25 20 15 10 5 0 Costa Rica (2015) Chile LAC5 OECD21 Brazil Mexico Uruguay Source: Health Statistics 2019 and Ministries of Health of Brazil and Uruguay. StatLink 2 https://stat.link/mv91rj HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 147 7. CANCER SURVIVAL The overall effectiveness of a country’s health service in delivering net survival is below the OECD average of 60.6% in all eight LAC cancer care can be assessed by international comparison of countries for which data are available (Figure 7.10). The highest current levels and recent trends in population-based estimates of five‑year net survival was in Peru (54.8%), with the lowest in Chile net survival for all patients diagnosed with each type of cancer. (32.7%). Global surveillance of cancer survival helps to identify and report avoidable inequalities, which can encourage policies and actions to reduce them (Coleman, 2014[5]). Cancer is estimated to have been the cause of over 670 000 deaths Definition and comparability in 2018 in the LAC region (Bray et al., 2018[6]), the second cause of Five-year net survival refers to the cumulative probability of death after cardiovascular diseases (see Chapter 3). Breast cancer cancer patients surviving five years after diagnosis, after in women accounts for over 50 000 deaths a year in LAC. Several correction for the risk of death from other causes, which factors increase the risk, such as age, the woman’s reproductive varies widely between countries, over time, by age and sex. history, post-menopausal oestrogen replacement therapy and Net survival is expressed as a percentage in the range alcohol use, while breastfeeding and physical activity have a 0‑100%. The period approach is used to allow estimation of protective effect. five‑year survival where five years of follow-up are not Close to 30 000 deaths per year in LAC are caused by cervical available for all patients. Cancer survival estimates for all cancer (Bray et al., 2018[6]). Approximately 95% of all cases are ages combined are age-standardised with the International caused by sexual exposure to the human papilloma virus, HPV. Cancer Survival Standard weights. Data collection, quality Pap-smear and HPV DNA testing increases the probability of control and analysis were performed centrally as part of the detecting premalignant lesions. Primary prevention through HPV CONCORD programme for the global surveillance of cancer vaccination programmes has been shown to reduce HPV infections survival, led by the London School of Hygiene and Tropical and cervical intraepithelial neoplasia among girls and women, and Medicine (Allemani et al., 2018[9]). Where national data were ano-genital warts among girls, women, boys and men (Drolet et al., not available, the CONCORD programme analysed the 2019[7]). available data from regional registries, but in most countries Colorectal cancer causes almost 65 000 deaths per year in LAC the analyses were based on national coverage, facilitating (Bray et al., 2018[6]). Risk factors include a diet high in fat, a international comparison. sedentary lifestyle and family history. Colorectal cancer incidence and mortality rates vary with the national level of human development, and rapid increases have occurred in countries undergoing socio-economic transition, such as Brazil and References Costa Rica. Secondary prevention of colorectal cancer by faecal occult blood test (e.g. guaiac test, faecal immunochemical test), [9] Allemani, C. et al. (2018), “Global surveillance of trends in cancer sigmoidoscopy or colonoscopy is increasingly being recommended survival 2000‑14 (CONCORD‑3): analysis of individual records for for adults in the age range 50‑74 years, while new blood tests are 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries”, The Lancet, still under research (Dekker et al., 2019[8]). Vol. 391/10125, pp. 1023‑1075, http://dx.doi.org/10.1016/ Among eight LAC countries with available data for breast cancer, S0140-6736(17)33326-3. age-standardised five‑year net survival among women diagnosed [6] Bray, F. et al. (2018), “Global cancer statistics 2018: GLOBOCAN during 2010‑14 was the highest in Costa Rica (86.7%), the only estimates of incidence and mortality worldwide for 36 cancers in LAC country over the OECD average of 84.8%. In Cuba, the 185 countries”, CA: A Cancer Journal for Clinicians, Vol. 68/6, corresponding probability that women with breast cancer survive pp. 394‑424, http://dx.doi.org/10.3322/caac.21492. for at least five years is 75.1% (Figure 7.7). [5] Coleman, M. (2014), “Cancer survival: Global surveillance will For cervical cancer, age-standardised five‑year net survival in stimulate health policy and improve equity”, Vol. 383, pp. 564‑573, Cuba was among the highest in LAC (72.9%) and the lowest in http://dx.doi.org/10.1016/S0140-6736(13)62225-4. Ecuador (52.0%) (Figure 7.8). The difference in survival is partially [8] Dekker, E. et al. (2019), Colorectal cancer, Lancet Publishing Group, explained by differences in the effectiveness of population http://dx.doi.org/10.1016/S0140-6736(19)32319-0. screening programmes and access to high-quality treatment. [7] Drolet, M. et al. (2019), “Population-level impact and herd effects For colon cancer, five‑year net survival in Costa Rica was among following the introduction of human papillomavirus vaccination the highest in LAC (60.1%), slightly below the OECD average of programmes: updated systematic review and meta-analysis”, The 62.1%. In Ecuador, five‑year survival was among the lowest Lancet, Vol. 394/10197, pp. 497‑509, http://dx.doi.org/10.1016/ (47.8%) (Figure 7.9). For rectal cancer, age-standardised five‑year S0140-6736(19)30298-3. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 148 7. CANCER SURVIVAL Figure 7.7. Breast cancer 5‑year net survival (%), adults Figure 7.8. Cervical cancer 5‑year net survival (%), adults (15‑99 years), 2010‑14 (15‑99 years), 2010‑14 Costa Rica 86.7 Costa Rica¹ 78.0 OECD26 84.8 Cuba 72.9 Argentina 84.4 Brazil 59.9 Peru 82.3 LAC9 59.5 LAC8 78.4 Peru 57.4 Ecuador 75.5 Chile¹ 56.7 Chile¹ 75.5 Uruguay 56.5 Brazil¹ 75.2 Argentina 52.7 Cuba 75.1 Ecuador 52.0 Colombia¹ 72.1 Colombia¹ 49.4 0 20 40 60 80 100 0 20 40 60 80 100 Age-standardised 5-year net srurvival (%) Age-standardised 5-year net survival (%) Note: National coverage in Costa Rica and Cuba. 1. Survival estimates are Note: National coverage in Costa Rica, Cuba and Uruguay. 1. Survival estimates considered less reliable: see Allemani et al. (2018[9]) for more information. are considered less reliable: see Allemani et al. (2018[9]) for more information. Source: CONCORD programme, London School of Hygiene and Tropical Source: CONCORD programme, London School of Hygiene and Tropical Medicine. Medicine. StatLink 2 https://stat.link/u6wm4c StatLink 2 https://stat.link/kwuxav Figure 7.9. Colon cancer 5‑year net survival (%), adults Figure 7.10. Rectum cancer 5‑year net survival (%), adults (15‑99 years), 2010‑14 (15‑99 years), 2010‑14 Cuba¹ 63.9 OECD32 60.6 OECD32 62.1 Peru 54.8 Costa Rica 60.1 Costa Rica 53.9 Peru 59.0 Uruguay 50.1 Argentina¹ 54.4 Argentina 49.9 Uruguay 53.5 LAC8 45.8 LAC9 51.7 Ecuador 44.5 Brazil¹ 48.3 Brazil¹ 42.6 Ecuador 47.8 Colombia¹ 38.0 Chile¹ 43.9 Chile¹ 32.7 Colombia¹ 34.5 0 20 40 60 80 0 20 40 60 80 Age-standardised 5-year net survival (%) Age-standardised 5-year net survival (%) Note: National coverage in Costa Rica, Cuba and Uruguay. 1. Survival estimates Note: National coverage in Costa Rica, Cuba and Uruguay. 1. Survival estimates are considered less reliable: see Allemani et al. (2018[9]) for more information. are considered less reliable: see Allemani et al. (2018[9]) for more information. Source: CONCORD programme, London School of Hygiene and Tropical Source: CONCORD programme, London School of Hygiene and Tropical Medicine. Medicine. StatLink 2 https://stat.link/jtekcf StatLink 2 https://stat.link/hqx46t HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 149 7. AVOIDABLE HOSPITAL ADMISSIONS Most health systems have developed a ‘primary level’ of care As discussed in Chapter 2, while these figures suggest that these whose functions include health promotion and disease prevention, five LAC countries in general have been successful at minimising serve as the first point of contact for managing new health avoidable admissions, it is important to mention that access complaints and chronic conditions, and referring patients to remains relatively unequal, and that a certain degree of secondary level and hospital-based services when appropriate. A underutilisation of hospital resources might be taking place. Finding key aim is to keep people well, by providing a consistent point of an adequate balance to ensure the least wasteful level of hospital care over the longer-term, tailoring and coordinating care for those utilisation, while ensuring adequate access across the entire with multiple health care needs and supporting the patient in self- population should be the ultimate goal. Another factor to consider is education and self-management. In this context, a high-performing that the non-communicable diseases burden is relatively lower in primary care system, where accessible and high quality services the LAC region than in the OECD due to its demographic and are provided, can reduce acute deterioration in people living with epidemiological profile. LAC countries must continue to invest in asthma, chronic obstructive pulmonary disease (COPD), building primary care capacity in order to minimise waste and congestive heart failure (CHF), high blood pressure and diabetes, prepare for a heavier burden caused by these diseases as and reduce unnecessary admissions to hospital. populations will likely continue ageing and growing in health-related Asthma, COPD, (CHF), hypertension and diabetes are five widely complexity. prevalent long-term conditions in LAC. Both asthma and COPD limit the ability to breathe: asthma symptoms are usually intermittent and reversible with treatment, whilst COPD is a Definition and comparability progressive disease that almost exclusively affects current or prior smokers. In 2016, asthma affected more than 339 million people The indicators are defined as the number of hospital worldwide and 420 000 people died from it (Global Asthma admissions with a primary diagnosis of asthma, COPD, CHF, Network, 2018[10]). In 2015, around 174.5 million people had hypertension and diabetes among people aged 15 years and COPD and about 3.2 million people died of the disease (Soriano over per 100 000 population. Rates are age-sex et al., 2017[11]). CHF is a serious medical condition in which the standardised to the 2010 OECD population aged 15 and heart is unable to pump enough blood to meet the body’s needs. over. Admissions resulting from a transfer from another CHF is often caused by other conditions, including hypertension hospital and where the patient dies during the admission are and diabetes. Heart failure is estimated to affect over 26 million excluded from the calculation as these admissions are people worldwide resulting in more than 1 million hospitalisations considered unlikely to be avoidable. Disease prevalence and annually in both the United States and Europe (Ponikowski et al., availability of hospital care may explain some, not all, 2014[12]). High blood pressure or hypertension manifests by variations in cross-country rates. Differences in coding causing headaches, difficulty breathing or nosebleeds, and, if left practices among countries may also affect the comparability untreated can lead to more serious cardiovascular problems. of data. For example, the exclusion of “transfers” cannot be Worldwide, 1.13 billion people have hypertension and fewer than 1 fully complied with by some countries. Differences in data in 5 people with hypertension have the problem under control coverage of the national hospital sector across countries may (WHO, 2019[13]). Diabetes is another chronic condition that leads also influence indicator rates. Differences in coding practices to raised levels of blood sugar that can have very seriously across countries must be considered as a possible sources damaging effects. In 2014, an estimated 422 million people had of bias, for instance, in the case of hypertension. diabetes, and in 2016, 1.6 million deaths were directly caused by the disease (WHO, 2018[14]). The hospital admission rates for asthma and COPD are shown in Figure 7.11. Admission rates for asthma vary widely but all five LAC References countries currently reporting this indicator are well below the OECD [10] Global Asthma Network (2018), The Global Asthma Report 2018, average. Mexico’s rate is particularly low, at 8 admissions per http://www.globalasthmanetwork.org. 100 000 population. Hospital admission rates for COPD are also [12] Ponikowski, P. et al. (2014), “Heart failure: preventing disease and lower in LAC6 than the OECD average. Mexico again reports the death worldwide”, ESC Heart Failure, Vol. 1/1, pp. 4‑25, http:// lowest rate, with 77 admissions per 100 000 population. dx.doi.org/10.1002/ehf2.12005. Figure 7.12 shows admission rates for CHF and hypertension. It [11] Soriano, J. et al. (2017), “Global, regional, and national deaths, reveals that the reporting LAC countries have lower rates than prevalence, disability-adjusted life years, and years lived with OECD countries. Costa Rica reports the lowest rate of CHF related disability for chronic obstructive pulmonary disease and asthma, admissions (39) while Chile accounts for the lowest rate of 1990‑2015: a systematic analysis for the Global Burden of Disease hypertension admissions (18). Study 2015”, The Lancet Respiratory Medicine, Vol. 5/9, pp. 691‑706, http://dx.doi.org/10.1016/s2213-2600(17)30293-x. Figure 7.13 displays admission rates for diabetes. Contrary to the trend observed in the previous figures, Chile and Costa Rica both [13] WHO (2019), Hypertension, World Health Organization, http:// report admission rates closer to the OECD average, while Mexico’s ttps://www.who.int/news-room/fact-sheets/detail/hypertension. is significantly higher. Colombia stands well below the average of [14] WHO (2018), Global Health Estimates 2016: Disease burden by the six LAC countries. Cause, Age, Sex, by Country and by Region, 2000‑2016. HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 150 7. AVOIDABLE HOSPITAL ADMISSIONS Figure 7.11. Asthma and COPD hospital admissions in adults, 2017 (or nearest year) Asthma COPD Age-standardised rates per 100 000 population 200 183.3 180 160 135.9 140 119.6 120 98.8 99.3 100 85.2 76.9 79.6 80 60 41.9 40 22.8 26.7 22.9 18.5 18.4 20 7.6 12.1 0 Mexico Chile Brazil Costa Rica LAC6 Colombia Uruguay OECD35 Source: OECD Health Statistics 2019 and Ministries of Health of Brazil and Uruguay. StatLink 2 https://stat.link/97cpqd Figure 7.12. Congestive heart failure (CHF) and hypertension hospital admissions in adults, 2017 (or nearest year) CHF Hypertension Age-standardised rates per 100 000 population 250 233.0 200 182.3 166.7 150 96.4 100.3 100 84.3 75.3 57.0 60.5 48.1 50 38.8 38.8 26.0 27.0 17.5 0 Costa Rica Mexico Colombia Chile LAC6/5 Brazil Uruguay OECD34/21 Source: OECD Health Statistics 2019 and Ministries of Health of Brazil and Uruguay. StatLink 2 https://stat.link/gy34ji Figure 7.13. Diabetes hospital admissions in adults, 2017 (or nearest year) Age-sex standardised rates per 100 000 population 300 248.5 250 200 150 128.9 131.9 118.7 122.5 91.8 100 82.18 62.1 50 0 Colombia Uruguay Brazil Chile LAC6 OECD33 Costa Rica Mexico Source: OECD Health Statistics 2019 and Ministries of Health of Brazil and Uruguay. StatLink 2 https://stat.link/ivjwhe HEALTH AT A GLANCE: LATIN AMERICA AND THE CARIBBEAN 2020 © OECD/The International Bank for Reconstruction and Development/The World Bank 2020 151 Health at a Glance: Latin America and the Caribbean 2020 Health at a Glance: Latin America and the Caribbean 2020 presents key indicators on health and health systems in 33 Latin America and the Caribbean countries. This first Health at a Glance publication to cover the Latin America and the Caribbean region was prepared jointly by OECD and the World Bank. Analysis is based on the latest comparable data across almost 100 indicators including equity, health status, determinants of health, health care resources and utilisation, health expenditure and financing, and quality of care. The editorial discusses the main challenges for the region brought by the COVID‑19 pandemic, such as managing the outbreak as well as mobilising adequate resources and using them efficiently to ensure an effective response to the epidemic. An initial chapter summarises the comparative performance of countries before the crisis, followed by a special chapter about addressing wasteful health spending that is either ineffective or does not lead to improvement in health outcomes so that to direct saved resources where they are urgently needed. Consult this publication on line at https://doi.org/10.1787/6089164f-en. This work is published on the OECD iLibrary, which gathers all OECD books, periodicals and statistical databases. Visit www.oecd-ilibrary.org for more information. PRINT ISBN 978-92-64-69289-3 9HSTCQE*gjcijd+