Equity in health systems



Carissa F. Etienne

Director, Pan American Sanitary Bureau, -Washington, D.C., United States of America



The Latin America and Caribbean (LAC) region has experienced remarkable progress in terms of economic development and health outcomes, enjoying a relatively good position in the developing world context. Unfortunately, this apparent privileged position in terms of accomplishments is based on regional averages that hide troubling and persistent inequalities among and within the countries. These inequalities are closely associated with political marginalization, inequitable and poor access to public health care services, which threaten the health gains of the last few decades and jeopardize growth and development.

Levels of mortality and morbidity differ greatly by economic and social factors and geographic boundaries both within and between countries of the Region and are concentrated among disadvantaged populations, who also experience earlier onset of chronic diseases and higher levels of disability. Inequalities in life expectancy are observed when people in Haiti are expected to live 62.2 years on average, as compared to 79.4 years for people in Costa Rica. Infant mortality in Guyana has a rate of 22 per 1 000 live births, while in Cuba, only 5 out of every 1 000 live births result in infant death (1). Within countries, similar differences exist. In Bolivia, maternal mortality rates in rural areas that are predominantly indigenous are twice that of the valley areas (2). Infant mortality rate in the Brazilian state of Amapa is 25.4 per 1 000 live births, more than twice the rate of Rio Grande do Sul of 11.3 per 1 000 live births (3).

Several countries in LAC have implemented policies and programs geared toward universal health coverage and equitable access to health services, opting to provide their citizens with needed health services without fear of impoverishment. This level of commitment emphasizes the need for evidence and understanding as to which policies have been successful in reducing or eliminating inequities in their health systems and how the different approaches to the organization and financing of health systems affect their performance.

The studies comprising this special section include a methodological article for measuring income-related inequalities in health outcomes and health care utilization and assessing possible determinants over time in six countries: Brazil, Chile, Colombia, Jamaica, Mexico, and Peru. These studies provide important evidence to inform policies on the evolution of income-related inequality in health outcomes and health services utilization/access in these countries' health systems.

Without exception, each of the six countries that have completed this study have implemented policies, developed targeted programs, and even amended constitutions to expand coverage and/or increase access to health care, which is free at the point of the service, to their most vulnerable citizens. This level of commitment has taken them closer to universal coverage. Five of the six countries have reached levels of health care coverage above 90%. The approaches used to improve coverage and increase access are diverse. Some have used decentralization (Brazil, Peru), coupled with public health insurance financed with public funds to provide coverage for low-income persons (Peru) or constitutional rights to health care for all and expansion of the existing Family Health Program (Brazil). Expansions such as that of the private sector (Colombia), a guaranteed package of services (Chile), and Mexico's Seguro Popular de Salud (People's Health Insurance) have also contributed to higher levels of coverage and better access to needed health services (4).

The added value of the studies that follow is the availability of evidence to shed light onto which processes and policies toward universal health coverage have led to improved equity in health outcomes and health care utilization.



1. Pan American Health Organization. Health Information and Analysis Project. Regional Core Health Data Initiative. Washington DC, 2010.         

2. Pan American Health Organization. PAHO Today. Mothers and Children: Make Them Count. Available from: http://www.paho.org/english/dd/pin/ptoday01_apr05.htm Accessed on 12 February 2013.         

3. Indicadores e Dados Básicos Brasil 2011. Ministerio da Saude. Available from: http://tabnet.datasus.gov.br/cgi/idb2011/c01b.htm Accessed on 25 January 2013.         

4. Pan American Health Organization. Health in the Americas, 2012 Edition. Washington, DC: PAHO 2012. Pp 209-11.         


Note of thanks

The Pan American Journal of Public Health recognizes with appreciation the contribution of Tania Dmytraczenko and André Medici, Senior Economists (Health), World Bank, as well as other anonymous peer reviewers, in the revision of the manuscripts included in the special section on equity in health systems. Special thanks to Guillermo Padrón and Heitor Werneck for their contributions during the editorial process.

Organización Panamericana de la Salud Washington - Washington - United States
E-mail: contacto_rpsp@paho.org