Preface to the 2019 Special Issue on Public Healthcare in the Developing World

Health and Healthcare Systems in Latin America and the Developing World

Complaining about health and healthcare is part of the human condition. People always find fault with their system of medical care, no matter how well or poorly it is provided because the reality is that pain, suffering, and death come to all of us. We reach out to healers to help us and our loved ones, but too often, they can do little or nothing to ease our miseries. Sometimes physicians make errors and cause harm, but often doctors cannot help because medicine cannot solve the problems that we all inevitably must face. Many people want someone or something to blame, and the doctors or the healthcare system provide convenient targets. Money is the core issue. As health researchers Jeanette Vega and Patricia Frenz, writing in The Lancet, correctly note, “in view of the gap between what is medically possible and what is financially feasible, some type of rationing is inevitable in all societies” (Vega & Frenz, 2015, p. e31).

This volume focuses on the health and healthcare issues in selected case studies from across the developing world. Provisioning for healthcare in developing societies is an especially acute problem, particularly since tax revenue as a proportion of GDP in the developing world is low as compared to other regions. In Europe, for example, 41 percent of GDP flows to government in the form of taxation, but in developed nations as a whole, tax revenue equals 36 percent of GDP. In Latin America alone, 17 percent of GDP goes to taxes. Worse, in Latin America, as is commonly the case in much of the developing world, most of the tax burden falls on those who are least able to pay, with the Latin American region worst off of all, suffering under the most regressive taxation systems in the world. As a result, developing world governments have far less to spend on everything, including public healthcare (Giovanella et al., 2012, pp. 51–52).

Uneven Progress: Comparison of Healthcare Systems in Latin America and Developing Societies

From the post-World War II period to the present, the world as a whole has seen great improvements in health conditions, with a rise in life expectancy, a significant fall in infant and childhood mortality rates, and a sharp reduction in most deadly infectious illnesses. The world has seen even more gains in recent years. Worldwide, life expectancy increased nearly by 16 years from 1965 to 2010 (Hambleton et al., 2015, p. 4). However, as healthcare researcher Randall Kuhn has noted, there are three global exceptions to the most recent positive trends: in areas impacted by war, especially in sub-Saharan Africa, where combat and its collateral damage on civilians have now become the leading causes of death; in regions where HIV/AIDs is prevalent, especially in the southern African region, where the virus remains a leading killer; and in the nations of the former Soviet Union, where long-term degenerative and noncommunicable diseases, especially those caused by poor diets and smoking, as well as injuries, are the leading causes of death (Kuhn, 2010, pp. 655, 667).

Intriguingly, as international health expert Ilona Kickbusch has observed, “the most influential actions to create health are found in sectors other than health” (Kickbusch, 2007, p. v). This means, as researcher Geoffrey Rose has noted that “the primary determinants of disease are mainly economic and social, [and that] therefore its remedies must also be economic and social” (Kickbusch, 2007, p. vi). The World Health Organization has for some time accepted these basic precepts, linking poor health to poverty and social inequality (García-Ramírez & Vélez-Álvarez, 2013, pp. 731–742). Economic growth alone cannot correct this situation. Even as the world GDP grew at 2.5 percent per year for the decade from the late 1990s to the early 2000s, by the end of this period, nearly 85 million people globally had joined with those trying to live on US$2 a day or less (Kawachi & Wamala, 2007b, p. 4).

In recent years, the greatest progress in healthcare coverage in the developing world has come for salaried formal sector workers, if not for the majority, or near-majority, of workers in the informal or black market sector. In Latin America alone, the formal sector workers covered by health plans increased from around half of the population in 2002 to about two-thirds of population in 2011. Yet for this progress, there remain serious gaps in the region; in six Latin American nations—Bolivia, El Salvador, Guatemala, Honduras, Nicaragua, and Paraguay—still fewer than half of salaried workers are not signed up to health plans. In the region as a whole, today still approximately 4 of 10 people do not have any health coverage, a pension or health insurance (Belén Herrero & Tussie, 2015, pp. 261–277; Scotti, 2013, pp. 873–895). This situation is far too prevalent in developing societies.

Most healthcare systems around the world are historical relics of political struggles from bygone eras, the remnants of tests of strength by unionized workers who collectively pushed for social security plans that included medical care components. As a result, most developing nations have today fragmented healthcare systems, with one plan for unionized works in the formal sector who utilize their own hospitals and clinics; top-notch private facilities for the élite; and then a public system for the vast majority, too often providing sub-par care. To this confusing array of systems are added hundreds of non-governmental organizations (NGOs) that come in to try to fill the healthcare gaps, each NGO with its own well-intentioned agenda, zones of regional coverage, or specific disease they had decided to focus upon. This NGO fragmentation of missions and coverage generates considerable confusion for nations trying to manage policy and can often serve to baffle those individuals desperately seeking care (Bárcena, 2015, pp. e29–e30; McMurray, 2004, p. 97; Monteiro de Andrade et al., 2015, p. 1345).

In light of this situation, in 2012, the United Nations made explicit its adoption of the goal of universal healthcare for all (Clark, 2015, p. 221). The goal, however, has actually been a longstanding objective for many nations, developing from the late nineteenth century progress in Western Europe where social security systems which included healthcare coverage for unionized workers gradually expanded alongside wider voting rights. Government, as it was understood from the beginning, would assure healthcare universality. Others joined in this view of state responsibility.

In 1924, in Latin America, the Pan-American Sanitary Bureau, the forerunner of today’s Pan American Health Organization, explicitly defined health as “a responsibility of the state” (Cotlear et al., 2015, p. 1249). In Latin America and other developing regions, the hope was that eventually more and more of the workforce would move into the formal sector, carrying their health benefits with them. At first, this approach seemed to work. In the post-World War II period, as more people gained the right to vote, an increase in social security coverage followed. In Latin America, in the 1930s and in the 1940s, about a quarter of families came to be covered under social security systems that offered healthcare for unionized, formal sector workers (Giovanella et al., 2012, p. 36).

The trouble was, however, that this approach to provisioning healthcare left many people behind. In Latin America today, nearly half of workers are employed in the informal sector, an all too common situation in developing societies. These people have no employer health plan and hence they are not covered under the social security system. Health coverage in cases like this, in Latin America and around the developing world, usually falls to the Ministry of Public Health. These government agencies usually operate their own hospitals and clinics, but such facilities, dependent on government outlays, are routinely starved for adequate funding.

As a result, most developing nations have disintegrated healthcare systems, with good facilities for those in formal sector with social security (often augmented with private health plans purchased individually and paid for out-of-pocket); good facilities built specially for those in the military services and sometimes those in the police services; high-quality private facilities for those with the income to pay the costs, either directly out-of-pocket or with the assistance of a private health insurance plans they buy on the open market; then the underfunded public facilities (usually located only in the leading cities) for everyone else, that is, for most people, those who work in the urban informal sector and rural people.

The public hospitals and clinics suffer from long waiting periods, the lack of modern diagnostic and treatment equipment, and are usually critically understaffed. Doctors who work in the underfunded public sector too often seem to focus their best efforts on recruiting patients for their much more lucrative private practices where they spend their afternoons. At public facilities, patients routinely have to rely on family or friends to bring them food, bedding, and to purchase of any drugs that might be needed for operations or other care. Out-of-pocket spending on healthcare is highest in Latin America as compared to all other regions in the world, with nearly half of all healthcare outlays in Latin America paid privately. Latin Americans spend more on out-of-pocket expenses as a portion of GDP than even do people in most developed nations (Atun et al., 2015, p. 1236; Clark, 2015, p. 222; Titelaman, Cetrángolo, & Lucía Acosta, 2015, p. 1359; Vargas Bustamante & Méndez, 2014, pp. 842, 850–851).

In the 1980s, privatization schemes for healthcare were launched, for Latin America beginning with the dictatorship of Augusto Pinochet (1973–1990) in Chile, followed soon by Colombia and Mexico. The great free market experiment of the 1980s into the early 2000s in Latin America and around the developing world (see Nhapi in this issue) led many nations to toss aside their longstanding public health systems in favor of the adoption of private insurance schemes, seeking to provide health insurance for all, mainly by contracting the services of multinational health insurance companies. Some of the MNCs that rushed in had little or no experience in the sale of health insurance, even if they spotted a good money-making opportunity in trying their hand at this enterprise. By the late 1980s, the movement toward free market solutions in healthcare was being actively promoted by the World Bank and the International Monetary Fund (IMF). Responding to pressure from the IMF and the World Bank, Chile, Colombia, and Mexico adopted free market programs beginning in the 1980s, bringing considerable changes in the ways healthcare could be accessed in their nations.

In its 1993 report, Investing in Health, the World Bank called for deeper privatization of healthcare, carving out a larger role for international health insurance companies, globalized private managed care services, accompanied by slashing government spending on healthcare needs. These measures sought to bring the logic of market capitalism to this sector of the economy, treating healthcare like any other purchasable commodity. Once established, the MNCs soon began to charge steep co-pays and other user fees to their customers. As a result of this policy push, most Latin American and developing nation healthcare systems had been privatized by the 1990s, with a new domain created for profit-taking for international health insurance and health provider companies. Under neoliberalism, the list of available healthcare services, when and where, were all fully determined by one’s ability to pay (Badawi, 2004, pp. 77–78; Belén Herrero & Tussie, 2015, p. 266; De Vos & Van der Stuyft, 2015, pp. 367–368; Giovanella et al., 2012, p. 63; Harris & Seid, 2004, p. 32; Hartmann, 2016, p. 2148).

In time, as the failures and cruelty of the radical free market experiment became undeniably manifest, a political “pink tide,” the rise of left-oriented governments in the late 1990s and in the 2000s, brought more elected leaders who placed healthcare for all as a top priority. Healthcare was included as a basic human right in the new constitution of left-oriented Venezuela (1999), Ecuador (2008), and Bolivia (2009) (Hartmann, 2016, p. 2147; Salama, 2015, pp. 86–88; Vargas Bustamante & Méndez, 2014, p. 843).

Today, several Latin American nations have government-run unitary healthcare systems. Such systems can be found in Cuba, Costa Rica, and Brazil, although with the latter two the private sector continues to play a role. In Brazil, when the nation returned to democracy in 1988, healthcare reform was included in the new constitution. Still, in Brazil today, a quarter of the population continues to receive their medical attention outside of the public system, with roughly half of all healthcare expenditures coming from out-of-pocket outlays. Colombia, Chile, and Mexico have universal health insurance schemes in place that cover nearly all people. Still, there are important differences in unitary healthcare and unitary insurance schemes. With unitary systems run by the government, as in Cuba and Brazil, costs are lower. With mandatory universal insurance systems, as in Chile and Colombia, or in Mexico’s mixed system, healthcare costs for the nation are higher (Atun et al., 2015, pp. 1234, 1237, 1240; Cotlear et al., 2015, pp. 1248–1259; De Vos & Van der Stuyft, 2015, p. 370; García-Ramírez & Vélez-Álvarez, 2013, p. 736; Hartmann, 2016, p. 2147; Heredia et al., 2015, p. e36).

Universality of access is certainly becoming the explicit goal for most developing nations, but there is wide variance in achievement and different pathways to realize this end. Costa Rica, for example, reached universality by extending the social security system health benefits to those in the informal sector, including even immigrants. Costa Rica formed its social security system beginning in 1941 and substantially broadened the program in 1973. With steady progress, in Costa Rica, healthcare is largely determined by need, not by ability to pay (Clark, 2015, p. 222; De Vos & Van der Stuyft, 2015, p. 369). But there remain vast differences in how Latin American and other developing nations understand the meaning of universalism. Chile’s Plan Acceso Universal con Garantías Explicítas en Salud (or Universal Plan of Explicit Guarantees in Health, or AUGE), added to its privatized healthcare system in 2004, offered a form of basic universalism, selecting certain key health conditions and then mandating health insurance coverage for all people suffering from these afflictions, but only for these specific diseases. In Chile, under the AUGE plan, co-pays are low and capped for each user. By 2015, some 80 diseases or health conditions had come under AUGE coverage in Chile. As a result, this means that most Chilean people have at least some health protection, aided by government subsidies. Still, about half of healthcare expenditures are out-of-pocket for all Chileans (Atun et al., 2015, p. 1237; Clark, 2015, p. 223; Vargas Bustamante & Méndez, 2014, pp. 842, 877).

Colombia followed Chile’s neoliberal example, privatizing healthcare in 1993, but soon encountered the same trouble that other developing nations found when experimenting in this way. In 2008 and 2013, therefore, Colombia revised its approach with its new Plan Obligatorio de Salud Subsidiano (Obligatory Health Subsidy Plan, or POSS), seeking not so much to assure universal healthcare for all so much as access to universal health insurance for all, following some of the central precepts of the free market model still favored by the World Bank and the IMF. Under the POSS program, Colombia welcomed multinational healthcare companies to sell health insurance. Low-income families were offered subsidies to help defray some of the costs of stripped-down health service insurance plans. However, Colombian government revenues to pay these costs soon failed to keep pace with the steadily rising medical prices, even for the austere, limited-service, private insurance plans. As a result, the government of Colombian President Álvaro Uribe (2002–2010) had no choice but to enact by an executive decree a host of special taxes in 2010 to try to keep pace with increasing government healthcare outlays. Before these changes, more than half of Colombians had no health insurance. Today, nearly everyone has some sort of health coverage in Colombia, however tight-fisted their plan might actually be. However, one of the key problems with this approach to universalism, that is, universal access to health insurance, is that the focus remains on curative medicine and hospital care, not on community involvement, prevention, water and sanitation, and public health. The latter approach, as we will see in the essays that follow, is far less expensive and much more effective in increasing life expectancy, improving quality of life, and lowering childhood and infant mortality in developing societies (Giovanella et al., 2012, p. 53; Vargas Bustamante & Méndez, 2014, pp. 845–846, 855, 864).

Lamentably, a more typical example of the healthcare provisioning situation in Latin America and across the developing world would be the fragmented system found today in Perú, where poor and marginalized people routinely lack access to healthcare. A third of Peruvians get their coverage under the more expensive private, out-of-pocket, systems; a third are covered under the social security systems, with its own facilities for formal sector workers; and a third, the poor, are seen only at the underfunded public facilities or are not treated at all (Atun et al., 2015, p. 1237; Quispe Quispe, 2012, p. 1). This is the most common situation for healthcare provisioning in developing societies.

Each nation must address its situation on its own, although there are signs that regional organizations can help in pushing progress forward. In Latin America, awareness of the connections between poverty, inequality, and poor health has led to a series of significant policy recommendation and nascent initiatives by the Unión de Naciones Suramericanas (Union of South American Nations, or Unasur, founded in 2008) and its Instituto Suramerican de Gobierno en Salud (South American Institute for Government in Health, or ISAGS, founded in 2011). Unasur, through its ISAGS program, has effectively pushed for information-sharing and a concerted response to cross-border health concerns. Indeed, healthcare has been one of the signature goals of Unasur in Latin America, working, for example, to organize a united front in negotiating with the large multinational drugs companies (MNCs) to buy medicines in bulk and negotiate lower prices for the drugs for which MNCs enjoy patient rights. Unasur’s initiatives provide an example of what regional organizations can do to provide collective developing world action on vital healthcare matters.

Paying for Health

Spending on healthcare as a percentage of GDP varies widely around the world. Health spending across Latin America nations ranges from 4 percent to 9 percent of GDP. At the top are Cuba and Costa Rica, which allocate approximately 10 percent of GDP on healthcare. In Latin America as a whole, out-of-pocket expenses still total nearly half of all healthcare outlays (Giovanella et al., 2012, p. 24; Hartmann, 2016, p. 2149; Mizrahi, 2014; Vargas Bustamante & Méndez, 2014, p. 877; Whiteford & Branch, 2008, p. 3). Nketiah-Amponsah, in this special issue, extends this discussion looking at healthcare allocations in sub-Saharan African nations’ budgets.

One key determinant of the strength of a nation’s healthcare response is the extent of socioeconomic inequality. There exists a very strong relationship between marked economic inequality and poor public healthcare on the one hand, and a clear relationship between nations with more even distribution of income, better socioeconomic conditions, and stronger public healthcare systems, on the other hand. Latin America, it is worth noting in this regard, suffers from the most uneven distribution of income of any region in the world.

For Cuba, noteworthy for its much more even distribution of income, the achievement of some of the best health metrics in the world was not just due to improvement in public health services. More significant was the vast reduction in income inequality following the triumph of the Revolution in 1959. In Cuba, people were not suffering diseases of poverty; they were not getting sick in the first place (Whiteford & Branch, 2008, pp. 9, 10–11).

As a rule, in developing societies, the poorest classes suffer worse overall health conditions and typically cannot afford high-quality health insurance or first-class curative treatments. Paying for public health needs is a political question. Where income is most unevenly divided, under-privileged groups most lack in relative political power. The poor, less able to command political attention, find that the reforms that might address their health concerns are far less likely. Therefore, it is not just the wealth of a nation that matters, even if wealthier nations can and do spend more on public health, but rather a question of political pressure and political will. Even if a nation is relatively better off economically compared to other countries, those nations with a large economy or higher per capita income, if the overall national income is maldistributed, then poorer groups lack the financial resources that would allow them to exert the political pressure that might bring progressive reform. Researchers need to pay attention to both the overall wealth of each nation and distribution of income within these nations if they are to fully understand the relative strength or weakness of countries in the provisioning public healthcare. International organizations must begin by recognizing that poverty and maldistribution of wealth are the principal causes of poor health in developing societies. To address healthcare issues, the focus of energy must be placed on attacking the problems of political economy.

Essays for this Special Edition

In the first essay of this special edition of the JDS, Ronn Pineo focuses on healthcare in Cuba. Despite many challenges the nation has faced, from the attacks by the Central Intelligence Agency, the US economic blockade, to battering hurricanes, Cuba has achieved the best health metrics of any nation in the Western Hemisphere, even better than the USA or Canada. Pineo seeks to explain the many successes, focusing on Cuba’s commitment to community involvement, “social medicine,” and preventive care.

Roy Smith offers an insightful essay providing a strong survey of the health situation in the South Pacific region, focusing mainly on environmental challenges triggered by climate change, alongside the social implications of rising economic globalization. The diets and lifestyles of many South Pacific Islanders have changed profoundly in recent years, and with these changes have come many heretofore all-but-unknown health challenges, including a steep rise in cancer, heart disease, and diabetes. Smith looks at the overall context for these troubling changes, assessing the extent to which personal agency or external factors most underlie these emerging health issues.

Lorena Androutsou and Theodore Metaxas explore the refugee crisis facing European nations, assessing the often desperate healthcare needs of the migrants, clearly setting forth the serious health issues these individuals face. The concerns are many, from the trauma of flight from their homes, the dangers of the journey, to the difficult living conditions migrant families often must deal with when they arrive to their European host nation. Metaxas and Androutsou argue that provisioning proper healthcare is not only a moral necessity but also a legal obligation. Beyond this, the authors show that good health for all is beneficial for any economy, for healthy people make the most productive contributors to economic well-being. Metaxas and Androutsou argue that even if policymakers are not persuaded to provide adequate healthcare on ethical grounds, or even because it makes economic sense, they must do so because the law demands it.

J. Prachitha, Akshay Dhume, and S. Subramanian take a careful look at India’s efforts to meet the Millennium 2000 goals for reaching key healthcare benchmarks and explore the reasons why India fell short. The authors provide a strong summary of the leading health initiatives in India recent years, and then evaluate the efficacy of each of these programs. After examining the best available data, the authors analyze the regional unevenness of India’s achievements. In the end, as the authors ably demonstrate, the setting of nation-wide numerical goals is not the most effective approach for a nation as vast and varied as India. Along the way, the authors develop a compelling case for a strong role for the national government in public health if meaningful progress in improving healthcare for all is to be realized.

Edward Nketiah-Amponsah offers a detailed analysis of health expenditures as a percentage of GDP and the relationship between these outlays and the realization of positive health outcomes for the population in sub-Saharan Africa. Nketiah-Amponsah provides strong data on maternal mortality, HIV/AIDS, and infant and childhood mortality, showing that the nations that spend the most on health may not always be those with the best health measurements. Civil wars and HIV/AIDS prevalence, he shows, do much to impact the actual health situation in the sub-Saharan African nations today. Nketiah-Amponsah provides an excellent summation of the recent challenges and the current health conditions facing sub-Saharan Africa.

Tatenda Goodman Nhapi takes a thorough look at the challenging socioeconomic conditions in Zimbabwe, exploring the connections between poverty and poor health. Nhapi underscores how recent political and social upheavals in Zimbabwe served to erode the nation’s prior progress in improving socioeconomic conditions and public health. Nhapi is highly critical of current public healthcare provisioning in Zimbabwe, finding much of sharp concern. Nhapi builds a powerful case for more funding for public health and healthcare services in Zimbabwe.

We end this special edition with a report by Jashim Uddin Ahmed on the Friendship Floating Hospitals that ply the rivers of Bangladesh. The Friendship initiative is a special outreach program that brings healthcare to Bangladesh’s poorest and most remote people, the char island people. Providing full-fledged hospitals inside a ship, these hospitals sail to the thresholds of the riverine people of Bangladesh and dock nearby to allow people access to their basic right to decent health. It is a story of how a vision of compassion when joined with considerable ingenuity can provide example and inspiration as we work toward the goal of providing healthcare for all.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.