Editorial | Health at a Glance: Latin America and the Caribbean 2020

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.

Figure 1. Out-of-pocket spending as a share of current expenditure on health in 33 LAC countries, 2017

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

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

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.

Figure 4. Capacity of intensive care beds in selected LAC countries and OECD average, 2020 (or nearest year)

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 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 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

Directorate for Employment, Labour and Social Affairs

OECD

Muhammad Pate

Global Director, Health, Nutrition and Population

Director, Global Financing Facility for Women, Children and Adolescents (GFF)

World Bank