The Epidemiological Transition Policy and Planning Implications for Developing Countries (1993) / Chapter Skim
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HEALTH POLICY ISSUES IN THREE LATIN AMERICAN COUNTRIES: IMPLICATIONS OF THE EPIDEMIOLOGICAL TRANSITION
HEALTH POLICY ISSUES IN THREE LATIN AMERICAN COUNTRIES: IMPLICATIONS OF THE EPIDEMIOLOGICAL TRANSITION
Pages 145-169
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(1981) INTRODUCTION This paper is concerned with health policy issues in Latin American countries, with emphasis on the changes that health systems need to introduce to meet the health needs resulting from the demographic and epidemiological transitions.
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Two other factors differ between developing and industrialized countries: first, most developing countries still lack the required health infrastructure to deal with the most pressing health needs of their populations, and to judge from their gross national products and the proportions spent on health, this situation is not likely to improve in the near future; second, most governments of developing countries are being pressed to adopt the therapeutic medical model to deal with the burden of noncommunicable diseases. The current health care paradigms for developing countries, characterized by the primary health care model, have been effective in dealing with epidemiological scenarios in which infection and reproductive health problems dominate.
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are able to reduce substantially the burden of infectious and parasitic diseases. Thus, health policies in developing countries are addressing an increasingly broader set of issues related to the health status of populations.
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The contribution of fertility decline to the aging of populations and changing mortality levels and profiles have been described elsewhere (Bobadilla et al., 1993; Jamison and Mosley, 19911. It is worth mentioning that these demographic factors may play a far more relevant role in the epidemiologi Current Health .
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Others, such as case management of noncommunicable diseases, are identified through demands from the population. Needs and demands are clearly not synonymous, because demand depends on the health status and the perception of illness by individuals and families.
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per capita, which ranges from U.S.$1,200 in Colombia to U.S.$2,540 in Brazil, and average annual inflation, which ranges from less than 24 percent in Colombia to more than 200 percent in Brazil, as shown in the appendix. Nevertheless, all three countries share similar patterns of income concentration, with about 40 percent of income in the highest 10 percent income group and from 1 to 4 percent of income in the lowest 20 percent income group.
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Although these indicators show a considerably better health status than many developing countries, they are quite unsatisfactory when compared with countries that have similar or lower annual income per capita such as Costa Rica and Chile. The epidemiological profile of the three countries shows that according to mortality statistics, infectious and parasitic diseases are no longer responsible for the majority of deaths.
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The coverage of mortality statistics in Brazil is less than in the other two countries; thus the information in Table 2 probably underestimates the number of deaths due to infectious and parasitic diseases in Brazil. To understand better the heterogeneity in epidemiological profiles, health status indicators at the national level need to be stratified by socioeconomic variables.
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. the population and the Social Security Institute covers only a small proportion of the population active in the labor force.
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The reforms, still in process in the three countries, are all oriented in the same general directions: greater unification of health institutions, more decentralization of operations, greater responsibility of the government to finance health care, and sustained commitment to expand the coverage of services and strengthen the primary level of care. It is also difficult to assess the effectiveness of health policies that are implemented by other This process was a
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HEALTH POLICY ISSUES AND OPTIONS Analysis of the complex epidemiological transition process in these three Latin American countries suggests that it is not possible to formulate a homogeneous health policy agenda for developing countries. The health problems faced by the middle-income countries need to be addressed differently from those of low-income countries where infectious diseases and undernutrition still clearly predominate.
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Its importance should be stressed now because the current trend in Brazil, Colombia, and Mexico is to reproduce the therapeutic component of the health care model for noncommunicable diseases, as is done in industrialized countries. Most of the technologies and interventions available to treat the most common chronic and degenerative diseases are extremely expensive and relatively ineffective (Jamison and Mosley, 1991~.
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On the other hand, in communities where transportation is readily available, potential still exists for increasing coverage. Successful models that use community health workers to reach the rural communities in the three countries should be replicated and the scope of their activities reviewed to assess their abilities to prevent noncommunicable diseases.
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Perhaps the most successful experience that has applied these reforms to the health care model comes from Call, Colombia. Several reports have shown that with limited investment, these policies led to improved efficiency and effectiveness at the hospital level, greater coverage of delivery care and
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Improved Efficiency and Quality of Care The evidence for inefficiency in the use of resources abounds in the health sectors of developing countries (Akin et al., 19871. The most common example is given by the low output of facilities and health personnel at the primary and secondary levels of care.
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The problems of the quality of hospital-based services are more difficult to solve and have more severe consequences than those of the health centers or doctors' offices. It has been documented that cuts in the health budgets of many Latin American countries affected the purchase of drugs and supplies, as well as salary levels, but left the scope, number, and content of existing health programs largely untouched (Cruz et al., 1991~.
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. The relative rise in noncommunicable diseases will pose additional problems to health institutions that are currently not orenared to deal adequately with complex services.
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Development and Strengthening of Essential National Health Research Essential National Health Research has been proposed (Commission on Health Research for Development, 1990) as one of the most effective means to overcome the heavy burden of disease in developing countries and to reduce the health status inequalities within and among them.
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health policies deal more with increasing overall health status of populations, and evaluations of the health system are more often linking resources with health improvements; (3) inclusion of health problems of all age groups and not only children in the analysis of the burden of disease, and inclusion of noncommunicable diseases and injury in the spectrum of preventable causes of ill-health; and (4)
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Finally, it is worth remembering that immediate political interests have not been considered because they are beyond the scope of this analysis. The challenge facing all developing countries in the next century will be to define realistic and feasible strategies able to avoid the increasing burden of noncommunicable diseases and injuries before they reach the levels observed in developed countries and, at the same time, to maintain the efforts to reduce the "unfinished agenda." More than a decade ago, John Evans and colleagues (1981:1126)
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Paper prepared for the workshop held in the Oswaldo Cruz Foundation with the Commision on Health Research for Development, Rio de Janeiro, October.
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Background paper to the discussion of the Takemi Research Proposal, Takemi Program in International Health, Harvard School of Public Health, Boston, October. Rondinelli, D.A., and G
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Guerra, and S.F. Camargo 1990 O Financiamento da Descentralizacoo dos Servicos de Saude: Criterios para transfe'encias de Recursos Federals para Estados e Municipios.
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: 12%.a Health Status Life expectancy at birth (1989) : 69 years.a Mortality under 5 (1989)
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: 5.1%.d Percentage of deaths due to infectious diseases (1986) : 20%.e Malnutrition in rural areas is still a high public health priority; inequalities of health status between population groups are very wide.
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