Healthcare infrastructure in Latin American is burdened by complex causes of sickness and death, compound with the multiple challenges brought by the COVID-19 pandemic. Ways forward demand more active States and larger investments.
The World Health Organization (WHO) declared the SARS-CoV2 pandemic on March 11, 2020. Within a relatively short span of time, the outbreak first developed on western Europe, but by late May, the epicenter of contagion had shifted to Latin America. The region encompasses countries with varying income levels, including low-income and middle-income countries (LMICs); but is also characterized by fragile welfare systems and substantial socioeconomic disparities regarding healthcare resources, access to medical services, and health outcomes. Despite accounting for merely 8% of the global population, Latin America bore responsibility for almost 30% of the total deaths attributed to the virus in 2020.
Now that the world has moved back to epidemic control of COVID-19, it becomes crucial to assess the state of health systems in Latin America and to identify the underlying structural factors that rendered this region more vulnerable to the pandemic than its European counterparts. Such insights into the current condition of health systems are needed to illuminate potential avenues for their reconstruction.
Assessing the Disproportionate Effects of COVID-19 on Latin America compared to Europe
In western Europe, the response to the COVID-19 pandemic has shown significant variation, particularly when compared to Latin America. Western European countries, with generally older populations, experienced major spikes in COVID-19 cases and deaths. Still, their healthcare systems were better equipped to handle the crisis, thanks to the ability to expand hospital capacity, including intensive care units (ICUs), and the rapid upscaling of SARS-CoV-2 testing. Preexisting, institutionalized social welfare systems allowed for economic interventions to support businesses and unemployed citizens, mitigating the adverse health, economic, and social impact of the pandemic.
Latin America, in turn, faced greater challenges in responding to the pandemic. Insufficiently allocated resources to health systems, prevalent health and socioeconomic disparities, and limited state capacity have impeded comprehensive health, social, and economic responses to the crisis. These factors, coupled with the cha;;enges faced by low-income and middle-income countries (LMICs) in the region, have resulted in varying levels of preparedness, disparities in population behavior, and a multitude of localized responses to the COVID-19 pandemic.
The socio-economic circumstances prevailing in Latin America exerted a substantial influence on the swift dissemination and consequential impact of the Covid-19 pandemic. The region's pronounced levels of poverty, prevalent informal labor markets, and densely populated living arrangements collectively engendered an environment conducive to the efficient transmission of the virus. The implementation of social distancing measures within countries characterized where informal labor sectors can account for up to 70% of the overall workforce thus demanded the expeditious formulation of cash transfer policies.
Regrettably, most Latin American countries lack systematic and comprehensive registries of informal workers and exhibit limited institutional capacity for the effective execution of such policies. In consequence, and despite the apparent commitment of political elites in most of the region to adopt science-driven and empirically supported approaches, enforcing these technically informed decisions proved unfeasible. Regrettably, exceptions to the commitment to science-based pandemic policies were observed in Brazil, Mexico, and Nicaragua.
The performance of Health Systems in Latin-America
The fragility of the region's health systems evidences another dimension of the limited state capacity. Unlike the United States, most Latin American countries acknowledge health as a fundamental right, shaped by social and political movements’ demands. Since the 1930s, the right to health has been regarded as vital for economic and social development. While most countries in the region have included the right to health in their constitutions, there are differences in the extent of that recognition. Some countries state the right without committing specific measures, while others ensure universal access to quality healthcare, including financing guidelines. Colombia, Cuba, Chile, Mexico, Nicaragua, Panama, Paraguay, Peru, Brazil, Ecuador, and Venezuela recognize the universality of the right to health, ensuring access to the healthcare system for all; the latter three also add an explicit responsibility of the state to grant the fulfillment of this right.
However, Implementation varies based on the country's political, economic, and social context, as health systems are not always accorded priority in national budgetary decisions. When considering health expenditures as a percentage of GDP, the total expenditure on health (both public and private) in Latin America averages 6.4%, which is lower than the OECD average of 9%. This observation gains further support from a cursory examination of public health expenditures. For instance, Mexico allocates only 3% of its GDP to public health, while the same figure stands at 6.7% for Italy. The OECD average stands at 6.6%; the regional average for Latin America is nearly half of that figure, at a mere 3.7%.
Notably, when examining countries where governments bear a constitutional obligation to ensure health provision for the entire population, the disparities become more evident. Take Ecuador (4.3% of GDP) and Venezuela (1.7% of GDP), or even Brazil (3.8%), where private expenditures outweigh public expenditures despite the existence of a free and universal public system for 210 million inhabitants.
Wide deficits also persist in terms of healthcare workforce and infrastructure. Across Latin American and Caribbean countries, the average physician-to-population ratio is 2 physicians per 1,000 inhabitants, with the majority falling below the OECD average of 3.5/1,000. However, there is more regional variation in this area. Cuba has the highest density of physicians per capita at 8 physicians per 1,000 inhabitants, more than double the OECD average. Argentina, Trinidad and Tobago, and Uruguay surpass the OECD average, with physician densities exceeding 4 per 1,000 inhabitants. Conversely, Haiti, Honduras, and Guatemala exhibit the lowest physician-to-population ratios, with densities below or equal to 0.5 per 1,000 inhabitants.
Rebuilding Health Systems
A comprehensive understanding of healthcare systems requires prioritizing an analysis of the population's health needs before addressing infrastructure and healthcare actions. In Latin America, the epidemiological landscape is complex, with varying disease profiles. The region faces a triple burden of disease, encompassing infectious diseases, non-communicable diseases, and injuries, which pose significant challenges for public health.
Infectious diseases remain a major health concern in the region. Progress has been made in reducing tuberculosis, malaria, and HIV/AIDS, but challenges persist with neglected tropical and emerging diseases. Recent outbreaks of Zika, Chikungunya, and Dengue highlight the ongoing threat of vector-borne diseases. In 2020, there were over two million Dengue cases and over 1,300 deaths in the region. Neglected tropical diseases affect marginalized populations, with around 25 million people infected with Chagas disease, which can pose severe health risks if untreated.
Non-communicable diseases (NCDs) pose an additional growing concern in Latin America, with cardiovascular diseases, cancer, and diabetes as the leading causes of death. NCDs accounted for 81% of deaths in the region as of 2019, impacting both individuals' quality of life and the healthcare systems and economies of the countries. High prevalence of risk factors like tobacco use, unhealthy diets, and physical inactivity contribute to the disease burden. Limited access to NCD care, especially in rural and marginalized areas, further exacerbates the issue.
Finally, trauma, including road accidents, violence, and self-harm, contributes significantly to morbidity and mortality in the region. In 2017, trauma accounted for 10% of deaths in Brazil. Latin America has one of the highest road accident mortality rates globally, with vulnerable road users being particularly affected. The region also experiences high rates of violence. Trauma and violence result in disabilities, impacting individuals' quality of life and leading to frequent hospitalizations in the region.
The complex burden of disease associated with inequalities faces Latin American countries with the much-needed implementation of universal health systems with effectively universal coverage. The solution is easy to state but complex to implement: public healthcare needs strengthening.
In the past few decades, these countries have made efforts to address social disparities and improve healthcare access through social policy and health-system reforms. These initiatives have played a crucial role in reducing poverty and expanding the reach of healthcare services. However, despite these advancements, the region continues to face profound inequalities. It remains the most unequal region in the world, characterized by significant income gaps between the affluent and the underprivileged. Moreover, disparities in social determinants of health persist, contributing to variations in access to and quality of public and private healthcare services.
To achieve universality, states must substantially increase their involvement in healthcare. Currently, only 52% of healthcare spending in Latin America is public, similar to the United States, but significantly lower than the 70-80% of OECD countries. Such increase in public spending would be offset by a decrease in total healthcare expenditure, since more fragmented systems spend more on administrative costs. The call for increased involvement by Latin American states does not imply the elimination of the private sector. Service provision could still remain (partially) private, even with public financing, as is the case in Canada.