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HEALTH IN LATIN AMERICA

Dr. Jaime Llambías-Wolff,

York University Canada

450 Million people 33 COUNTRIES

Regions: • South America (12 Countries) • Central America & Mexico ( 8 Countries)

• Caribbean (13 Countries)

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CONTRADICTIONS OF POST-WAR ECONOMIC GROWTH

•  From 1940’s onwards, Latin America has gone through an important socio-economic transformation.

•  Industrialization and growth in population brought in high demands of food production that could not be met by the agricultural sector.

• Modernization generated unexpected waves of unemployment leading 70% of the population into poverty by the 1980’s .

• Modernization has produced an acceleration of the growth in the largest cities creating urbanization.

Health care and social security = determined by changing economic, political and social conditions and changes Post – war economic growth (in terms of GNP) : § 5% in 1950s § 5.5% in 1960s § 6.3% IN 1970s § 2.6% in 1980s § 10% in 1990s § 7% in 2000s

Still great disparities between the population : poor, middle sectors and upper class

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CONTRADICTIONS OF POST-WAR ECONOMIC GROWTH

² Urban growth rates were caused by the increase in rural-urban migration.

Rural-rural migration movements brought on two main sets of health care problem: 1.  The need to give health care to illegal

workers; improve the hazardous social conditions of workers

2.  The need to solve the difficulties of sanitary control in border areas

Mostly an URBAN region, since 1960s and in the Caribbean, since the 1970s

We will concentrate on The Latin American Region

•  Latin America population is predominantly urban since the 1960’s, only 28% of L.A. live in rural areas.

•  In the cities, 20-30% live in marginal areas, 21% don’t have drinkable water, 52% not connected to sewage system so waste percolates into water and air causing major health threats and have poor health care services.

•  Along with urbanization is increasing violence, drug

abuse, accidents, homicide, and suicides.

Urban Latin America

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• 20% to 30% of population in large cities live in marginal areas, with poor sanitation conditions.

• Rural migration increases expecting better life: more violence, overcrowded villages, sanitation problems, drugs, criminality, lack of work, etc. Triple burden of diseases : • Diseases of poverty • Chronic diseases • Inequity and poor public health care services in most countries

MODERNIZATION, SOCIAL CHANGES AND HEALTH CARE

² Health care systems in Latin America were formed through social struggle

² When the national health departments were created, access to health was limited to upper elite groups

² As modernization and industrialization began to take over the region, founding a new educated middle class, trade unions etc, access to health care began to expand

² Populism, a powerful political movement in Latin America which thrived in the 1940s, also contributed to the expansion of health care access

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1: Private health care systems with profit-making characteristics for high socio-economic status groups, financed by direct payment in advance and private insurance.

2: Health care systems provided by health department of

ministries, financed by the state through taxes. 3: Social security health care designed for workers and

their families, financed through the state, workers and their employers. Contribution is based on salary level.

Health Care Systems in Latin America

MODERNIZATION AND SOCIAL IMPROVEMENTS ALWAYS A STUGGLE BEWEEN SOCIAL CLASSES AND INTERESTS GROUPS

(Political parties, unions, business, etc.) LOCAL NATIVE POPULATION Mostly traditional medicine, public services, herbal methods, healers PESEANTS AND URBAN POORS Charitable services, extended poorly public sector. Minimal coverage, public clinics and urban public hospitals INDUSTRIAL WORKERS Have social security for medical care. Public hospitals (salaries and employers premiums)

INDUSTRIAL WORKERS FROM BIG COMPANIES Unions. Special health care programs WHITE COLLAR AND SMALL ENTREPRENEURS Insurance programs (salary deductions) Better quality and access to more services MILITARY AND POLICE Special hospitals. Special insurance plans Better coverage UPPER CLASS Private health care services. Private Health Insurance Plans or direct payments

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Countries in which the responsibility for health care is preserve of health ministries

Social Security System

Ministry of Health & Social Security

Cuba, Nicaragua, Haiti, English speaking Caribbean

Argentina, Brazil, Costa Rica, Mexico, Panama, Uruguay, Venezuela

Bolivia, Colombia, Ecuador, El Salvador, Guatemala, Honduras, Paraguay, Peru, Dominican Republic

75-100% Coverage Under 20% coverage Under 10% coverage

Cuba, Argentina, Costa Rica, Uruguay, Chile

Paraguay, Guatemala, Colombia, Peru

Nicaragua, Ecuador, Dominican Republic, Honduras, El Salvador, Haiti

Combinations of these health care systems

•  Increased unemployment rates+ lowered income due to inflation= less contribution + tax collection for health care= poorer health care.

•  The unemployed don’t contribute but still receive care. •  Third World predominance for expensive curative medical care

instead of cheaper and more preventative care.

•  Also there is a preference for high technology and excessive use of medicines.

Crisis for some countries health services?

Less Income Fewer Imports

Public Income Lower tax revenue

Private Income Lower real salaries More unemployment

High morbidity; malnutrition; accidents; mental ill-health

Lower payments to private health care

Lower coverage of social services

Lower payments to social services

Lower public expenditure on health

Changes in the composition of health expenditure

More demand for public health care

Lower quantity/quality of public health care

Poorer health in the

population

The relationship between income reductions, expenditure on health and public health levels

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Time Line 1880 2000 1940 1960 1980 1920 1900

National Health departments created in Argentina, Uruguay, Brazil, Paraguay Pan American Sanitary

Bureau created (1902)

National health department of Cuba created

National health department if Haiti, El Salvador, Costa Rica

Social health care services in Argentina, Chile, Uruguay, Brazil, Cuba

National health department of Panama, Guatemala, Nicaragua

Latin America undergoes socioeconomic transformation

Populist political movements flourished

Mexico, Colombia, Venezuela, Peru establish social security systems influenced by International Labour Organizations

Introduction of DDT

GNP grows by 5%

Pressure from wage workers ensures growth of health coverage and social services

1950-1980 share of GNP grew 17-25% (modernization period)

Unicef, USAID, IADB support extensive immunization against 6 diseases

GNP grows by 6.3%

40% of Latin America’s population live in poverty

Caribbean population predominantly urban

GNP grows by 5.5 %

Food production per capita less than in prewar years

Latin America’s population becomes predominantly urban

Growth of private hospitals & hospital beds

Latin America has easy access to International credit

Latin American societies universally experience a new process of change influences by world tendencies of democracy and decentralization

Oral rehydration therapy support increase

70% poverty, 40% indigence

SILOS established

1985 poverty level at 30-50% of Latin American families

1984 Sao Paula measles epidemic

1994 life expectancy over 70 in half of Latin America

60’s and 70’s political changes reduced the power of the pressure groups

Under and Unemployment

1950- 17% 1980 – 19% 1970 – 17%

FOLK MEDICINE •  In Latin America, folk or traditional medical systems coexist

with modern systems.

•  Folk medicine involves a magico-religious concept in which diseases are viewed as supernatural phenomena produced by spiritual forces.

•  The folk therapy can be herbal, mineral, animal, magical, empirical and intuitive.

•  Folk medicine has a strong bond with culture and tradition. This puts pressure on physicians to appreciate the existence of folk thought, because health actions can generate a high resistance among people. The objective of improved sanitation and environmental health cannot be obtained without popular co-operation.

Conclusion

•  Latin America’s health issues and health care systems differ greatly from the rest of the world due to its particular history and the impact of world economic and political transformations to the region, as well as cultural and regional factors specific to each country.

•  There is need for a health care model independent from infectious disease to better respond to the issues and causes of chronic diseases. The infectious disease model needs more community participation and better sanitation and intervention methods. The chronic disease model, on the other hand, need medical technology to help diagnosis and treat patients and needs to have a integrative community and individual approach.

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Conclusion

• The stress of the public and private sector of Latin America. The public sector suffer from lack of resources and the private sector has decreased in funds due to lack of clients as most of the population cannot afford the rates. As a consequence, the majority of Latin Americans live with inadequate health protection.

SOME COUNTRIES BETTER THAN OTHERS They developed very strong public systems Argentina, Chile, Brazil, Cuba, Uruguay, Mexico, Costa Rica In general coverage for Latin America protects about 61% of the Population. § In some countries Argentina, Chile, Cuba, Uruguay, and Costa Rica coverage is between 75% and 100%. § In other countries the coverage is very low (10% to 20%) = Paraguay, Peru, Guatemala, Colombia, Nicaragua, Ecuador, Honduras, Haiti, etc.

THE CASE STUDIES OF CUBA AND CHILE

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•  Cuba  challenges  the  assump0on  that  genera0ng  wealth  is  a  fundamental  condi0on  for  improving  health  

•  Cuba  is  able  to  sustain  itself  from  the  margins  of  globaliza0on  

•  Cuba,  like  most  of  La0n  America,  has  pronounced  income  inequality  

•  “Cubans  live  like  the  poor  &  die  like  the  rich“  

•  Cuba  able  to  sustain  itself    o For  ex.  Cuba  developed  the  human  resources  to  meet  its  health  needs  &  developed  a  self-­‐reliance  approach  

•  Cuba  uses  alterna0ve  public  policy  approaches    o Educa0on,  housing,  employment,  nutri0on,  sports  &  culture  

•  New  policies  reorganized  the  healthcare  system  +  social,  poli0cal,  &  educa0on  systems  

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•  Low under-5 mortality rate •  High life expectancy •  Use of traditional & alternate

treatments used •  Good human resources to meet

health needs •  Health system financed by state

o  For ex. preventive medical care free, low prices & subsidized by state

•  Primary care & vertical integration

QUESTIONS

Social capital is seen as representing trust and

connectedness within a society.

Why is it important to health?

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Are good health outcomes more strongly associated with policies supportive of neo-

liberalism (stimulating economic growth) or those stressing equity & distribution of wealth?

•  Why do you think biomedical doctors do not recognise the Andean system when dealing with certain sicknesses while LN recognise both?

Los Naturistas – Healers

Acknowledgments: I wish to recognize and thank the many students that, during several years, have kindly facilitated various slides, which are incorporated in this presentation.

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THE END