Congestion in public hospitals is frequent in Latin America even without epidemics. Long waits and the need to resort to out-of-pocket spending to obtain medical assistance are common in the region. CREDIT: Courtesy of Integralatampost

By Humberto Márquez
CARACAS, Apr 4 2020 (IPS)

Health systems in Latin America, already falling short in their capacity to serve the population, especially the poor, are in a weak position and face serious risks when it comes to addressing the COVID-19 pandemic.

Low levels of health spending and a relative scarcity of hospital beds are indicators that most countries in the region do not guarantee universal access to healthcare and risk being overwhelmed by the wave of the new coronavirus.

“Even in well-organised and robust health systems the challenges posed by a pandemic are felt swiftly, and this is even more true in weak ones like those in much of Latin America. In epidemiology, if you trail behind an epidemic, you are going to suffer havoc,” former Venezuelan health minister José Félix Oletta (1997-1999) told IPS.

Of the 630 million people in Latin America and the Caribbean, 30 percent do not have regular access to health services, mainly due to geographic or income issues, according to the Pan American Health Organisation (PAHO), an affiliate of the World Health Organisation (WHO).

That figure is in line with the proportion of people living in poverty, according to the Economic Commission for Latin America and the Caribbean (ECLAC), which counts 185 million poor people in the region, and reports that over 10 percent of the total regional population – 68 million people – live in extreme poverty.

The regional average for health spending is under four percent of gross domestic product (GDP) and only 2.2 percent is central government expenditure, according to ECLAC and PAHO figures.

In 2014, the region’s governments committed to raising health spending to at least six percent of GDP, but only Cuba (10.6 percent), Costa Rica (6.8 percent) and Uruguay (6.1 percent) have met that goal.

The most industrialised countries spend eight percent of GDP on health, between 3,000 and 4,000 dollars per inhabitant per year, compared to about 1,000 dollars per person in Latin America. Argentina, Chile, Cuba and Uruguay spend around 2,000 dollars per person, but Haiti, Honduras and Venezuela spend less than 400.

Out-of-pocket spending (the amount people spend directly on a service) is low in Cuba, Costa Rica or Uruguay (10 to 20 percent) and very high in others such as Venezuela (63 percent), Guatemala (54 percent) or the Dominican Republic (45 percent).

These out-of-pocket payments by individuals illustrate the inadequacy of public health provision, as well as of social security or private insurance, and the fact that the poor are the most vulnerable because they sometimes refrain from seeking care that they cannot afford.

Another indicator is the number of beds available in hospitals, which does not measure the quality of infrastructure, staffing or efficiency in these facilities: the regional average is 27 per 10,000 inhabitants. A portion, sometimes very small, are intensive care beds.

But “it is not enough to have hospitals and health centres. They must properly combine human resources, infrastructure and equipment, medicines and other health technologies, to provide quality care,” said PAHO Director Carissa Etienne.

If the COVID-19 pandemic continues to spread in the region, Bolivia, Guatemala, Haiti, Honduras, Nicaragua, Paraguay and Venezuela are “the Latin American countries most at risk,” according to PAHO.

A view of the University Hospital of Maracaibo, the “oil capital” of Venezuela, in the west of the country. Large hospitals do not guarantee good-quality service in and of themselves, because skilled staff and adequate equipment and technology are also needed, says PAHO. CREDIT: SAHUM

IPS took a closer look at the situation in four countries to show the different weaknesses and strengths of health systems in the region.

Brazil, persistent inequality

Over the last three decades, the largest country in the region, with a population of 211 million, has developed a unique public health system, with programmes such as Mais Médicos, Farmácia Brasil Poupa Lar and Estratégia Saúde da Família. The latter is a strategy enabling a team of doctors, nurses and assistants to care for up to 3,000 people at a local level.

Mais Médicos deployed up to 18,000 doctors, more than half of them Cuban, in remote villages and isolated rural communities in Brazil. But since December 2018 the programme shrank after Brasilia severed relations with Havana and thousands of Cuban doctors were forced to return home.

The social gap is widening, since public health, with 44 percent of the hospital beds, must serve 75 percent of the population, while private clinics have more than half of the beds for 25 percent of the inhabitants.

In 2009, Brazil had 18.7 beds per 10,000 inhabitants, which dropped to 17.2 in 2017, half of them in four of its 27 states, in the wealthier southeast. It has 47,000 intensive care beds, but for every one in the public health system – 90 percent of which are occupied – there are 4.6 in the private health sector.

Brazil “is not prepared to face the coronavirus epidemic, not so much because of a lack of resources, but due to their poor distribution, the high level of inequality in terms of access to services, poor management and lack of equity,” epidemiologist Eduardo Costa, an international cooperation advisor at the National School of Public Health, told IPS.

Cuba, medicine for export

The Cuban health system, touted by the socialist government as one of the achievements of the revolution, is public and free of charge for the country’s population of 11.2 million, with 90 doctors for every 10,000 inhabitants, according to official figures.

Although there are no precise figures on how many of its 47,000 beds are for intensive care – and there are complaints from the public about delays for non-urgent surgical procedures – Health Minister José Ángel Portal said the island nation has 274 beds to treat seriously ill coronavirus patients and plans to add another 200.

One of Cuba’s flagship programmes is the international medical cooperation missions, which began in 1963 and have sent 407,000 doctors, technicians and assistants to 164 countries, providing free medical assistance to poor countries, under the format of cost-sharing to other nations, or as a source of income in some cases.

The annual income from this programme – 29,000 doctors worked in 65 countries in 2019 – exceeds six billion dollars. For the COVID-19 pandemic, Cuba is setting up 14 medical brigades with 600 members, more than half of whom are women.

Chile is prepared, although it’s never enough

In Chile, a country of 18.7 million people, health coverage is public for 14 million and private for three million, and there is a separate system for the 400,000 members of the armed forces, put in place by the dictatorship of General Augusto Pinochet (1973-1990), which has not been modified.

All workers are required to contribute seven percent of their wages to the health institution of their choice. Those who are covered by the public health system complain about long waits of weeks or months to see a doctor and of up to a year or even more for surgery.

These were some of the shortcomings that fueled the mass protests that broke out in Chile in October 2019 and raged for months until a referendum was agreed to allow voters to choose whether to replace the constitution inherited from the dictatorship.

Chile has 22 hospital beds for every 10,000 inhabitants. That is a total of about 32,000, with 3,300 for emergencies, which the government aims to increase to 5,200 in the face of the pandemic.

Nelly Alvarado, a professor at the Diego Portales University and a public health specialist, told IPS that “the health system’s capacity is never going to be enough in the face of an unexpected situation coming from the rest of the world.”

She pointed out that critical care beds “have never been abundant either in Chile or the rest of the world. They are expensive and highly complex, because sophisticated equipment and specialised staff are required.”

Venezuela, on the verge of collapse

Official health statistics became unavailable in Venezuela over the past decade. But studies by non-governmental organisations warn that the health care system is on the verge of collapse and that the country is experiencing a “complex humanitarian emergency.”

Venezuela, a country of 30 million people, is at the bottom of the regional charts in terms of health spending and the provision of hospital beds. The NGO Doctors for Health reported that during 2019 there were power failures in 63 percent of 40 large hospitals it monitors, and water supply failures in 78 percent.

Barrio Adentro, a programme launched in 2003 that brought thousands of Cuban doctors to low-income areas, has almost disappeared and most of its premises have closed.

“We are at the bottom of a PAHO list of 33 countries in the hemisphere in terms of preparing for COVID-19,” Oletta said. “And the pandemic follows setbacks in vaccination campaigns and containment of preventable diseases that have re-emerged, such as malaria, measles and tuberculosis.”

The health crisis is part of the general collapse of basic services that has accompanied the economic recession over the past five years and hyperinflation over the past three years, driving the exodus of almost five million of Venezuela’s 32 million inhabitants. Among those who have emigrated were more than 22,000 doctors, according to the medical association.

Latin America, lagging behind in health care and spending, should heed the call of Maria Neira, WHO Director for the Department of Public Health, Environmental and Social Determinants of Health: “Something we have all forgotten is that investment in public health and health systems should not be regretted…it is always going to be a profitable investment.”

This article includes reporting by Ivet González in Havana, Mario Osava in Rio de Janeiro, and Orlando Milesi in Santiago.

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