NOTAS E INFORMAÇÕES NOTES AND INFORMATION
Notes on health care planning in Latin America and the Caribbean
Notas sobre planejamento de assistência médica na América Latina e no Caribe
José Maria Pacheco de SouzaI; Dagmar RaczynskiII; George B. PatinoIII; Anthony T. RibeiroIV; Emilio FeliuV
IDo Departamento de Epidemiologia da Faculdade de Saúde Pública da USP Av. Dr. Arnaldo, 715 São Paulo, SP Brasil
IIDo Instituto de Sociologia da Universidade Católica de Chile, Santiago, Chile
IIIDo Instituto Presidente Castelo Branco do Ministério da Saúde, Rio de Janeiro, RJ - Brasil
IVDo Ministry of Education, Health and Social Affairs, St. Kitts
VDo Hospital Bariloche, Bariloche, Argentina
Attention is called to the fact that the efforts to improve health of populations in Latin America have generally failed. The inequality in the distribution of ill-health is great. The authors accept the fact that the lack of resources available to the health sector may be a restriction towards the improvement of the situation, but they argue that a much more important issue is the misuse of such resources and their maldistribution within the health sector. The lack of integration and coordination between the health services, the conflict of public and private health systems, the under-utilization of existing services and the gap between planning and real implementation are discussed.
Uniterms: Medical assistance. Health and welfare planning for developing countries. Health services.
Chama-se a atenção para o fato de que os esforços para a melhoria da saúde das populações da América Latina, geralmente têm falhado. A desigualdade na distribuição de saúde é grande. Aceita-se o fato de que a falta de recursos disponíveis para o setor saúde pode ser empecilho para a melhoria da situação, mas argumenta-se que um fator muito mais importante é o uso indevido de tais recursos e sua má distribuição dentro do setor saúde. São discutidas as faltas de integração e coordenação dos serviços de saúde, o conflito entre sistemas público e privado de saúde, a sub-utilização dos serviços existentes, o distanciamento entre o planejamento e a sua real implementação.
Unitermos: Planejamento de Saúde em países em desenvolvimento. Serviços de Saúde. Assistência médico-sanitária.
1. Research, practical experience and field work in the health sectors of many Latin American countries show that:
a) efforts to improve health status have resulted in a relatively small betterment of the situation of those most in need. In spite of reduction of the average infant mortality rate for many countries, the rates of improvement within sub-groups of the population tend to show an inverse correlation with the magnitude of the infant mortality rate in those subgroups. This points out a situation of increased inequality in the distribution of ill-health;
b) the observable improvements in health are far more attributed to factors related to economic growth and development and improvement in living standards and environmental conditions than to interventions in the health field as well as more to social factors than to medical technology;
c) there are important gaps between the intentions expressed in health plans and policies and the actual implementation and achievements at the national, regional and local levels (3, 4). The only exception to these general patterns and to some of the other conclusions we will mention further ahead, seems to be Cuba (5, 7).
2. The Latin American countries differ greatly in area, population size, natural resources, ecological characteristics, pace and level of economic development, composition, structure and setlement of population, and other variable. Even so, there are similarities in the factors and processes underlying their problems.
3. It has often been said that the main problem is the lack of available resources for the health sector. Although the availability of resources is a restriction, we maintain that the use of such resources and their distribution within the sector is far more important. For an effective use of health resources and, as a result, a more equal distribution of health, pne has to look into the specific situation of each country in search of factors that might have been responsible for failures in many health policies. There seems to be a lack of awareneness of the inter-relationships between the problem of health and other economic, social, cultural and political issues during the elaboration and implementation of plans in the sector.
4. These inter-relationships should be analysed from two different angles, the distributional and the relational ones. The distributional aspects suggest that health needs are strongly correlated to the distribution of other factors related to the level of living and quality of life of the population. Some of the most important among these are employment and level of income, education and access to information, housing and access to adequate sanitary and environmental conditions.
Knowledge of the inter-relationships between these aspects and health suggests that in many situations medical technology cannot solve health problems and that populations most at risk are in this condition because of their social environment. Without improvement of this environment, little can be done towards the health situation, and medical intervention is hardly more than a palliative. Improvement of environment requires an integrated approach that takes into account the different dimensions of poverty and deprivation. It is not enough to increase the income but also to improve its use (e.g. food for children vs. alcohol). It is here that education becames most crucial. We must be aware that different life chances are not only correlated at a given time but are transmited from one generation to the next, resulting in inherent attitudes and patterns of behaviour that reinforce each other and may create distinct subcultures. It is fundamental for communication with and a breakthrough in the health situation of these groups that there be involvement and participation of the community in health matters.
5. The relational aspects of health suggest that health issues often are political ones and as such have roots in the centres of influence of the decision-making process. Physicians have a very high influence on the health system in Latin America. This reinforces and is reinforced by the type of health care system they, consciously or uncounsciously, implement: hospital centred, curatively oriented and, excellence for a very few. At the same time, the population groups most in need have little means of expressing their needs and scarce access to what is being provided. Again, we come to the conclusion that community involvement and participation is fundamental as regards a real solution.
6. Awareness of the importance of social, economic and political issues to health imposes certain requirements and raises problems that have to be tackled in the health planning process. There is need for an overall development objective and for health policies integrated with this objective. Unfortunately, the Latin American experience is otherwise. It is well sumarised by R. T. Batten when he discusses community development:
". . . each social and economic development agency, and there are many, pursues its own objectives with its own selected clientele and too readily assumes that by achieving such objectives it contributes its share to betterment. What is much needed, but in practice is lacking, is any common agreed and overal purpose of development to which every agency aims to contribute and by which it continually assesses the results of its work." (1)
The overall development objective should be economic growth geared towards a less unequal society, that is, growth with redistribution (2). This requires specific measures for defined population groups in keeping up with reality. There is need to know exactly who the "poor" are, where they live, what characteristics they have. Within the health field it is required to know which are the population groups with the largest health need, where they are located, what their social, economic and cultural characteristics are, social factors that are related to their disease paterns. Given the reality of these groups, what kind of measures should have priority? What may be the most efficient methods available to attain goals? Obviously, there is need for improved and more relevant information systems if these questions are to be answered. Health planning in Latin-American countries has to be centralized, integrated and coordinated at the national level, but at the same time it should be flexible, meaning that the implementation has to be decentralized and adapted to the regional and local areas (a mixture of macro and micro planning).
7. Running the risk of giving a very stereotyped view of the health problems and health sector in Latin America we may say that they are characterized by the following:
a) high rates of mortality, specially infant and child mortality, prevalence of infectious and respiratory diseases, mixed with nutritional problems;
b) unequal distribution of ill-health among geographical regions, between urban and rural areas and within urban areas;
c) remoteness of the physician from the real problems, the super-specialisation of the profession, duplication of facilities and maldistribution of resources;
d) dominance of the physician in the delivery of health care, shortage of well trained auxiliaries and a general lack of intermediate medical personnel. The appalling lack of trained intermediate manpower is directly related to the educational system where only the elite goes up into the university and no intermediate educational (vocational) institutions exist. Until shortcomings in the educational system are remediated the value of health and the dignity of the health worker at all levels will be unrealised by the society on the whole;
e) urban and hospital based health delivery system centred around curative activities;
f) a heavy and strongly influential private sector coexisting with an often uncoordinated public health sector and a health insurance scheme of variable size and complexity, each with its own clientele which correlates highly with the stratification system of each country;
g) highly developed multinational drug industries which coexist in some countries with smaller state owned drug industries;
h) national health plans have been formulated in some of the Latin American countries. They have proclaimed among their aims the urgency in giving priority to preventive measures and to the health problems of the poorest group both in rural and in urban areas. A comparison between these aims and the actual achievements show little consistency.
8. The III Special Meeting of Ministers of Health of the Americas held in Santiago, Chile, in October 1972, recommended a comprehensive list of goals for the decade.
It is important to stress that the targets incorporated into this plan are far too general. For effective planning what is needed is a more specific definition of priorities and of strategies of implementation, keeping up with the reality of each country and its often very heterogeneous population groups.
9. Planning for manpower needs should entail definition of:
a) The level of care to be given;
b) the category of staff providing the care;
c) the functions of various categories of staff;
d) the utilisation of staff;
e) the management function.
It should be realised that there is no "correct" mixture of optimum ratio for staffing but the maximising of available resources should be of the greatest importance as generally personnel accounts for the largest part of the budget.
10. There is a lack of integration and coordination of health services, particularly in relation to central hospitals, district child-health-clinics and private doctors. The development of the team approach to programme management should be encouraged as well as active solicitation of community participation in the definition of health needs to ensure better utilization of resources. Better quality of services can encourage a higher level of client participation. A system for monitoring and supervision should be estabilished to ensure that care is being provided in accordance to agreed standards and procedures. Community education and motivation programmes should aim at stimulating use of health facilities.
11. Unfortunately, in Latin America the various attempts at improving health care have largely resulted in variations on the same theme without any fundamental change. Much is taught and written about planning based on demand, yet obvious needs go unmet because of intrenched schemes. Shocking under-utilization exists in the face of need. Much is said about rationalising the pharmaceutical supply but unless governments take drastic action much wastage of resources will continue.
12. The mixture of a mixed public sector, private sector and various forms of health insurance makes planning difficult. The tackling of the relationship between the private and the public sector is most important in Latin America. Much has to be studied and learned about the proper mixture between the two sectors and the characteristics each one of them has to assume in order to avoid conflict and get the better of both. Means should be devised in order to solve the problem of incompatibility of serving simultaneously the two systems.
13. As a final remark, it should be remembered that several developing countries have been trying different types of solution for the problems of the health sector, outside the socio-economic and political complex. The book "Health by the people" of the World Health Organization (6) shows the experiences of Venezuela, Iran, Guatemala, Indonesia and other nations, serving as a guide for new roads in the search of better and more well distributed health in the countries of Latin America and the Caribbean.
1. BATTEN, T. R. The major issues and future directions of community development. Community Develop. J., 9: 2, April 1974.
2. CHENERY, H. et al. Redistribution with growth. New York, Oxford University Press, 1974.
3. De KADT, E. Aspectos distributivos de la salud en Chile. In: CEPLAN Bienestar y pobreza. Santiago, Chile. Ed. Nueva Universidad, 1974. p. 2.
4. LIVINGSTONE, M. & RACZYNSKI, D. (ed.) Salud publica y bienestar social, Santiago de Chile, CEPLAN, Universidad Católica de Chile, 1976.
5. NAVARRO, V. Health, health services and health planning in Cuba. Int. J. Hlth Serv., 2:397-431, 1972.
6. NEWELL, K. W. ed. Health by the people. Geneva, World Health Organization, 1975.
7. STEIN, Z. & SUSSER, M. The Cuban health system: a trial of a comprehensive service in a poor country. Int. J. Hlth Serv., 2:551-66, 1972.
Recebido para publicação em 22/03/1976
Aprovado para publicação em 14/06/1976
This paper presents the conclusion to which the authors came while attending the very interesting seminar on "Health, health care planning and development", held at the Institute of Development Studies (I.D.S. ), University of Sussex, England, in May-June 1975. The authors wish to thank the organizers of the seminar, Profs. Emanuel de Kadt, Oscar Gish and Malcolm Segall, as well as its participants, and express their gratitude towards the British Council for the fellowships it provided.