Latin America: Improving Governance to Tackle Health Inequalities

In this presentation on Latin American countries (LACs) and health policy, the author poses the question, "Twenty Years of Health Policy Studies: What difference have we made?" Through a series of graphs and charts, the presentation shows statistical changes in child mortality from 1999 -2002, accompanied by a description of efforts to reduce health inequalities among economically marginalised populations. A diagram demonstrates health priorities and conditions for policy achievement, along with a description of who sets policy priorities. Another shows a plan for more responsive health services, and a third diagram shows a model of governance and rights engagement.

The graphs show that better educated and urban-dwelling women have fewer child deaths than those who are less educated and rural-dwelling. The presentation lists the following efforts to reduce inequalities by improving health for the economically poor:

•"…Most LAC countries lack...comprehensive approaches / co-ordinations amongst public sectors…
•Health policy goals with greater attention to specific health problems of the [economically] poor, instead of national averages...
•Changes in health systems to address barriers … for accessing good quality health services: tax-based reimbursements of health service costs / aid in cash to different categories of people / decentralization & democratization of decision making…
•Most initiatives oriented to promote [World Health Organization's] WHO’s 2000 Fair Financial contribution to health systems. Few measures to improve human resources performance / quality of health care or to address physical (geographical) barriers or cultural approaches (& expectations) of those most excluded."

Elements, shown diagrammatically on priorities and conditions for policy achievement, are: policy contents, implementing processes, and context as they affect and are acted upon by individuals and members of collectives. In discussing inequalities, rights, and citizen voices, the presentation describes the right to health as involving universal quality health care, a healthy environment, and healthy living conditions, all of which are supported by progressive development and resource availability. Resource allocation is defined in public policies, particularly, as stated here, social policies, which can support health rights and reduce health inequalities. The advocacy for social policy can involve social participation as a means of influencing public policy and as citizen empowerment and citizenship building.

The next diagram is the World Bank Accountability triangle. It illustrates relationships between coalitions and citizens using: "political voice" to advocate with government; "voice" to effect change in insurance and contract agreements between government and health providers; and "empowerment" in local planning, budgets, and provider choice at the physician and hospital level of local participation.

The final diagram shows relationships on a variety of levels between "rights holders" (community members) and "duty bearers". The layers include the level of capacity building to hold dialogues, negotiate and make decisions; the interface where planning, negotiation, and service delivery occur; the broader policy environment underlying the governance efforts; and the international community and its influence on rights promotion and government accountability.