Health Systems in Latin America: Principal Components of Attention

This article discusses the evolution of healthcare systems in Latin American countries, their origins and main characteristics and sources of financing, coverage and the availability of services and human resources from the Donabedian perspective, which also considers indicators of behaviors and preferences and social values underlying healthcare in different societies. The method adopted is the estimation of correlations and principal components to explore how health expenditures, poverty and inequalities are associated with healthcare indicators such as life expectancy, immunizations, treatments offered by health systems in transmissible and chronic diseases, considering in-direct indicators of patient’s behaviors and preferences, as well as social values and cultural diversity in Latin American societies. The results show that the expansion and actual availability of immunization, treatments against transmissible diseases and hospital beds are the main criteria responsible for the results in healthcare and increase in life expectancy; the availability of health services is an important component for secondary level of care and al-lows the population to be committed to positive behaviors in a context of poverty and inequalities, with disadvantages for indigenous people.

This fragmented character of the healthcare systems remains well-established today in the majority of the countries-citizens with formal contracts have total health coverage with access to all the levels of complexity, from primary to tertiary services and treatments, while the poor receive only limited coverage in prevention, access and treatments. Fragmentation in health systems contributes to social inequalities in the region-the most unequal in the world.
In the 1940-1950s, the national states assumed responsibility for both health protection and attention, and health ministries were created in all the region's countries to provide vaccinations, preventive action and basic care, without achieving universal coverage [1] [2]. In the 1970s health systems experienced increasing costs around the world, due to the rapid development of the healthcare market, the inflationary prices of new products and technologies, and a growing and uncontrollable demand. Increases in spending on healthcare generated a reallocation of state financing for this sector, even in developed countries with universal Welfare States. Sustainability became uncertain in Europe and also in Latin America, where universal healthcare coverage had never been a reality.
Public investment in the health sector was reduced even more in the years of economic crisis.
In the 1980s, different reforms in constitutions, legislation and in health systems were carried out through changes in management decentralization, competition between providers with the participation of the private sector, regulation and monitoring by independent agencies, and restrictions in public officials' positions in planning and managing health systems.
Until the 1990s, the majority of the Latin American population was assisted by the Ministries of Health that, according to the law, were obliged to offer most preventive services, including immunization, basic healthcare and disease control, and mainly for the poor, informal workers, among other vulnerable groups.
Despite the effort to extend coverage through law reforms, at the end of the 1980s it was still estimated that there were 130 million poor Latin American citizens with access to health systems [3]. The coverage of contributory Social Security covered the majority of the population in Costa Rica (85%) and Panama (55%), countries in which the Ministry of Health only financed health care for a minority of the population. However, in Peru, Colombia, Ecuador, Dominican Republic and other countries, the contributory Social Security only covered a small percentage of the population (24%, 18%, 11% and 9%, respectively) and, as a result, the Ministry of Health had to cover almost the entire population in terms of prevention and attention to health, which implied huge investments in the public health sector.
Likewise, public expenses did not correspond to the unequal needs for coverage of high proportions of the population. For example, in Colombia, the State devoted 38% of its resources to 82% of the population (being served by the Ministry of Health), and invested 62% of the health sector resources to only 18% of C. Gomes DOI: 10.4236/health.2019.1110100 1301 Health the population, which was affiliated to the contributive social security system [3]. Therefore, in the Latin American countries with the largest proportions of poor and unskilled citizens, this largest part of the population, with higher mortality and mobility rates, received the lowest investment in health.
In Costa Rica, health insurance also covered affiliated domestic and rural workers, peasants, the self-employed, micro and macro entrepreneurs, unpaid workers and pensioners. The Uruguayan health insurance did not cover the latter groups and, in Peru, farmers, unpaid workers and employees of large companies were excluded from health insurance. In the Dominican Republic, the public sector covered micro-entrepreneurs. In Mexico there was voluntary insurance but-in practice-it wasn't used by the majority of the population [3].
Facing this persistent exclusion of the poorer groups, in the 1990s new reforms were put in place to cut spending and bureaucracy, and to promote new financing mechanisms and costs recovery, competence, private participation and the social control of public health management systems in the region. created private plans, but they covered only 18.5% of the population, and the old public system covered 67.5% [4].
Colombia reformed its health system in 1993 [5] combining public financing, managing and regulation with private participation and three affiliation arrangements; a contributory scheme that included self-employed, a subsidized scheme for the poor and a regime of affiliates in the public sector. The new system increased coverage to 57% of the population in 2002 but financial transfers generated crises in hospitals.
In Brazil the corporate institutes were unified in 1966, and in 1977 the State was converted into a buyer of services from the private sector, favoring corruption, particularly in the tertiary sector. In 1988, the constitution approved a unified system that provided universal access to the decentralized health system.
Municipalities are the main providers of services and Health Councils were created in 1990 to promote participation [6]. Reference [7] identifies as common trends in the reforms of Chile, Brazil and Colombia the decentralization of healthcare to municipalities, the evolution to a public-private plurality in which the public sector bureaucracy has power over the entire system, and fragmented complementary, private and corporative subsystems over the relationships and negotiations between lenders and service providers. Fragmentation, public-private partnership, increasing inflationary costs, and decentralization are factors of instability and crisis in financing, managing and evaluating these systems. Consequently, tensions are recurrent between the decentralization processes based on an "insurance base" and "local participation" aimed at guaranteeing access and improvements to services. Beyond these conflicts, it is expected that reforms could be an opportunity to deepen democracy in the region, including the poor as beneficiaries of these systems and increasing their capacity for empowerment through their participation in deci- Health. Brazil has a universal system that doesn't specify the diverse federal sources of resources, and attends the whole population equally, independent of their labor market insertion or level of income [8].

Inequalities in Health and Social Justice
There is a need-especially for the groups excluded from health systems (which are basically poor people, and of indigenous ethnic groups and afro-descendants) -to establish guidelines to ensure their inclusion and the service's quality, as this could quickly impact poorly sensitive indicators of access, use and quality of attention. Funding, coverage, quality and equality seem to follow the more up-to-date health systems in the region. Health systems are based on norms, services and human resources available, and management mechanisms that are used to evaluate the results and quality of their actions and results. According to References [9] [10] the quality of health-C. Gomes care depends on three components: 1) the physical environment, including infrastructure, material and human resources available (e.g. hospital beds and doctors), and also actual availability and performance (comparing the actual conditions to the ideal or the best you can expect to attain; 2) the technological and scientific bases (the coexistence of western and non-western bases of knowledge and attention (e.g. the presence of indigenous medicine in the countries); and 3) the characteristics, behaviors and preferences of the patients. Biological characteristics, for example, are the exposure to infectious pathogens (vaccines), behaviors are related to how the patients accept and follow medical recommendations and treatment regimens, and preferences means what the societies value, such as attachment to life, fear of death, willingness to take risks (accidents and violence), and what societies consider useful or dominant in their lifestyles (diet, diabetes, hypertension). All these factors are oriented by the social objectives of health systems, conceptualized as efficiency in the allocation of resources and equity by the values of social justice in each society [11] [12] (Table 1).

Context of Coverage and Inequalities in Health in Latin American Countries
The Fragmented systems reinforce inequalities in health, and all aspects of healthcare provision. That is why References [9] [10] [11] suggests analyzing the quality and performance of health systems comparing actual observation in each country to the ideal situation, e.g. the minimum standards of coverage established by the WHO in terms of hospital beds or doctors available to attend the population. Another way to establish an ideal norm is to compare national data with the average of Latin America, as a minimum to achieve in all the countries.
The availability of infrastructure and human resources includes the set of services unit facilities, materials and equipment, health service workers (doctors, nurses, and technical personnel), and medicines. This article analyzes two indicators for which there is a higher coverage of data-the number of hospital beds per 10,000 inhabitants and the number of doctors per 1000 inhabitants in each country.
Regarding material infrastructure, the number of hospital beds is one indicator of availability of tertiary attention that is registered in administrative records, at least in the public sector. In Europe there are 63 hospital beds per 10,000 inhabitants, compared to 10 in the African Region [13]. Human resources are usually expressed as the number of qualified healthcare personal per 10,000 inhabitants. The WHO considers having fewer than 23 healthcare professionals (including doctors, nurses and midwives) for every 10,000 inhabitants insufficient to provide adequate attention [14]. Considering just physicians, there are 13 doctors for every 10,000 inhabitants worldwide, with large variations between countries and regions-from 2 doctors per 10,000 inhabitants in Africa to 32 in Europe and 19 doctors in the Americas [12]. The Latin American average, at 2.07, was much lower in 2012 and most of the countries do not even produce or publish this data. The few Latin American countries with available information are mostly below the African average. In 2013-2016, the average was 0.47 physicians per 1000 inhabitants in Jamaica, 0.9 in Nicaragua, 1.2 in Costa Rica, 1.6 in Panama, 1.8 in Colombia, and 1.9 in Brazil. Only three countries recorded higher than Africa's average, but were still very distant from the European average-Mexico (2.2), Argentina (3.9) and Cuba (7.5) [15].
On the demand side, patients interact with services and healthcare personnel, and are also responsible for health achievements since their characteristics, be-

C. Gomes
haviors and preferences play an important role in adhering to and successfully following the recommendations and treatments offered by health services.

Methods
The main questions of this research are "what are the relationships between inequalities, budget and the results in health?" and "how do the huge presence of indigenous people, and poverty and inequality correlate to health conditions?".
To answer these questions, data from twenty-one Latin American countries were analyzed using component analysis methods to analyze a set of indicators, based on the Donabedian's perspective of the provision and quality of health systems, and also on poverty, inequalities and multicultural indicators.
The countries selected in the sample were all the countries from Central and South America. Only Jamaica from the Caribbean is included, due to the availability of information.

Information from each domain was taken from the 2012-2017 World Bank
Database [14] and from the 2016 WHO database and documents [12] [13]. Some indicators had to be excluded due to the data being incomplete for most of the countries, such as the proportion of indigenous population attended to by health services. Health

Correlation Matrix
The correlation matrix indicates that there are some highly correlated variables and others that are not. The highest correlations are observed in the domain of immunizations against DPT, tuberculosis, poliomyelitis and hepatitis ( Table 2).
As expected, all the variables of this domain of immunizations are highly negatively correlated to the percent of deaths by transmissible, maternal and child mortality and nutrition, and also with immunization against tuberculosis. These

Principal Components
The results of the method extract five principal components, and the first three components explain 60.7% of the total variance.  (Table 3).
The coefficients in Table 4 indicate the relative weighting of each variable in the component. The higher the absolute value of the coefficient, the more important the corresponding variable will be in the calculation of the component.
In this study, the absolute value of a coefficient to be considered relevant is the value 0.5.
The second principal component has large positive associations with the percentage of cases of pneumonia attended by a health provider, the percentage of pregnant women with at least four visits for antenatal control and the average blood pressure, which is a proxy for access to health services for blood pressure

Discussion
The The third group of principal components in health care mainly includes populations' behaviors and preferences toward risks. In Latin America, the population is more exposed to social risks such as excesses in sugar consumption and tolerance to violence (measured as the incidence of diabetes, the ratio of deaths due to injury, and the annual number of homicides), in the same group with the Gini index of inequalities. It is important to consider that Latin America has the highest Gini index among all the regions in the world, and some of their metropolitan areas are among the ones with the highest homicide rates in the world.
This component reinforces the social base of disadvantages for healthcare, related to attitudes and life-styles towards taking risks, for example, in relation to diet-e.g. sugar consumption-and to tolerance of violence.
These are additional and complex challenges for healthcare in Latin America, during a moment of demographic transition in which the population is composed of high proportions of youth and adults of productive ages, who are more exposed to violence and market pressures which encourage an increase in the consumption of high caloric and processed food, for example. These current risk behaviors and attitudes will impact their aging process, and is expected to occur within the next two decades. Risk behaviors, and preferences and life-styles in risk diet and violence, combined with structural inequalities and the historical exclusion of discriminated indigenous people would bring heavy consequences in next two decades, such as producing increasing rates of chronic diseases, aftermath and disabilities from early ages, and with high levels of dependency, high costs and demands for both families and health systems, and-quite possibly-decreases in life expectancy.
Finally, health assurance in Latin America is a result of three principal components that are associated; in the first place, with a set of immunizations and other material resources, such as the number of hospital beds. In second place, a set of primary and secondary care includes the prevention and successful treat- Moreover, achievements in extending immunizations programs, primary and secondary care, and the willingness of the population to monitor its health condition also depend on patients' financing, since out of pocket expenses are also included among the main determinants negatively affecting healthcare. In a scenario of poverty and inequality in the region with the highest multiculturalism in the world, it is relevant to consider the strong disadvantages and discrimination of indigenous people, since these out of pocket expenses means additional barriers for indigenous to continue improving their health conditions and, for the countries, to reduce gaps in healthcare performance.
Even after the recent decades of extension of health coverage and affirmative policies in most countries in Latin America, these structural disadvantages persist and need more incisive actions to promote equality and social justice. In particular it is relevant to develop and implement programs of health education, to promote changes in behaviors, attitudes and practices, and create incentives towards positive preferences and life-styles, values and attitudes against risk attitudes and behaviors.
The exclusion and discrimination of indigenous groups and of their cultures are additional obstacles to achieving the main objectives of health policies, which are the distribution and the efficient allocation of resources based on equity promotion and social justice. The technical and multicultural medicine and social base present in Latin America would receive incentives to recognize diversity, promote traditional healthy diets, and preventive behaviors and life-styles.
The inclusion of these vulnerable groups and the recognition of their culture and non-Western values would contribute to the re-education of the non-indigenous towards anti-discriminatory behavior, and to take advantage of multiculturalism. Indigenous social disadvantages and gaps in health would be analyzed, as well as the recognition of their positive contributions in healthy diet, behaviors and culture, which can be brought to improve the health of the general population, to be identified.
Occidental medicine and the extension of health systems in Latin America have extended primary and secondary care leading to increasing average life expectancies. However, recommendations would be made to continue guaranteeing the successful results of preventive and curative basic services and, at the same time, to implement measures to reduce social inequalities in health. Some suggestions include adopting education in health and the promotion of changes in life-styles and behaviors, as well as adopting a culturally sensitive approach to include indigenous people through affirmative policies to reduce their disadvantages. This would reduce social and economic inequalities that create obstacles to achieving real universalization and a better quality of health.
There are already many barriers to accessing healthcare, both from the demand side, and on the supply side. The financial barrier that forces people to use out of pocket expenses to cover health needs is a significant barrier on the demand side, but also changes in behaviors and preferences toward risks should be an important and urgent objective of policies in health.
Therefore, integral actions would combine universal coverage beyond the limited discussion of universal access to health systems, since there are incentives from the market related to risk attitudes and behaviors, with increasing demand for new occidental medicines and healthcare technologies that compete for public investment made by the State in healthcare, particularly in hospitals and for more complex exams and treatments, or increasingly expensive health commodities.
The discussion on healthcare in Latin America would be more concentrated on the discussion of health needs, considering investments in education about populations' risk preferences and life-styles and, at the same time, reducing health inequalities, not only in access to health services, but also in the real capacity of the indigenous and poorest groups to pay for services or to contribute to pre-paid funds.
In this sense, new plans oriented to poor and indigenous people can be contradictory in a context of poverty, inequalities, vulnerabilities, discrimination, and the incapacity of several groups to pay for healthcare, either from their own pockets or through pre-paid plans.
The most important challenge in continuing to improve healthcare in Latin America is the reduction of inequalities while continuing to expand access and quality in public services and creating incentives for the poorest and for indigenous groups to successfully use western healthcare under equal conditions to other groups. These mechanisms would not be successful through charging the costs to the poorest population, since poverty is the negative framework under which healthcare is operating. At the same time, it would contribute to reducing C. Gomes Health inequalities and discrimination in order to study, value and exchange the possible advantages of non-western medicine, and the positive behaviors and life-styles of indigenous cultures that characterize the region.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.