The World Bank 23314 ____ Sep~ter-nber 2001 The Health of Women in Latin America an-d the Caribbean *1~~~~~~~~~~~~~~~~~~t .,, L~~~~~~~J . wtam ~FILE COPYX Ruth Levine Amanda Glassman, and Miriam Schneidman H Health of Women in Latin America and the Caribbean Ruth Levine Amanda Glassman Miriam Schneidman 2001 Copyright © 2001 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, USA All rights reserved Manufactured in the United States of America First printing September 2001 1 2 3 4 03 02 01 00 The findings, interpretations, and conclusions expressed in this book are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Direc- tors or the countries they represent. 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All other queries on rights and licenses should be addressed to the Office of the Publisher, World Bank, at the address above or faxed to 202-522-2422. Library of Congress Cataloging-in-Publication data Levine, Ruth, 1959- The health of women in Latin America and the Caribbean / Ruth Levine, Miriam Schneidman, Amanda Glassman. p. cm. Includes bibliographical references. ISBN 0-8213-4930-9 1. Women-Health and hygiene-Latin America. 2. Women-Health and hygiene-Caribbean Area. l. Schneidman, Miriam, 1954- II. Glassman, Amanda, 1970- I I. Title. RA564.85 .48 2001 613' .04244'098-dc21 2001045340 ABLE OF CONTENTS Table of Figures, Tables, and Boxes ________________________________ iv Acknowledgments__________________________________________ v Abbreviations and Acronyms ___________________________________ vi Executive Summary - - - - - - - - - - - - - - - - - - - - - - - - - __ _ 1 overview 7 Objectives and Organization -------------------________________ 7 What Is Women's Health? 8 Why Do We Need to Pay Attention to Women's Health? ----------------- -____ 9 A Framework to Understand Women's Health and Health Policies ____ 11 1. Women's Health Conditions 15 The Typology ______________________________________________ 16 Poor, Rural, and Uneducated Women Face Extreme Reproductive Health Risks ________ 16 Women Face a Large Burden from Chronic Disease, and the Poor, Rural, and Uneducated Individuals Are Most Affected ____ 26 What Does This Information Tell Policymakers and Program Managers? ____________ 30 2. Delivery and Financing of Women's Health Services ___________________ 33 Characteristics of Women's Health Services 34 Financing of Women's Health Services _______________________________ 37 Unmet Needs and the Spending Gap p……38 What Does This Information Tell Policymakers and Program Managers?_____________ 41 3. Women's Health and Health Sector Reform: Synergies and Risks _____ _____ 43 Women's Health and Health Sector Reform Are Two Sides of the Same Coin ____ 44 The Links Between Four Elements of Health Sector Reform and Women's Health in Latin America and the Caribbean 45 4. Conclusion 55 Expansion of Reproductive Health Services ____________________________ 55 Addressing Noncommunicable Diseases - 56 Tweaking Health Reform __________________________________ _____ 56 Notes 59 References Cited 63 le of Figures, Tables, and Boxes Figures Figure 1 Total Fertility Rate by Wealth Quintile 19 Figure 2 At Least Two Prenatal Visits, by Wealth Quintile 23 Figure 3 Delivery at Home, by Wealth Quintile 23 Figure 4 Differences in Women's Use-for-Need, Brazil 37 Tables Table 1 Average Values for Indicators by Country Grouping 17 Table 2 Maternal Mortality by Country Grouping 18 Table 3 Contraceptive Prevalence and "Unmet Need" for Contraception by Country Grouping 20 Table 4 "Appropriate" Contraceptive Use by Country Grouping 21 Table 5 Unplanned Pregnancies by Country Grouping 22 Table 6 DALYs Lost, 1990 and 2000 Baseline Estimates for STDs and HIV 24 Table 7 Incidence of and Mortality Due to Cervical Cancer per 100,000 Women, Age-Standardized Rates by Country Grouping (1990 Estimates) 26 Table 8 DALYs Lost (thousands) Selected Chronic Illnesses 1990 and 2000, Baseline Projections 27 Table 9 Prevalence of Smoking by Sex and Country 30 Table 10 Public Spending on Health and Total Public Spending on Women's Health byType of Institution, 1997 38 Table 11 Public Spending Gaps for a Basic Reproductive Health Package, 1997 40 Boxes Box 1 What increases the odds of seeking care? 35 Box 2 Other public institutions can be important actors in the health sector 39 Box 3 Chile: Women's health and decentralization 48 Box 4 Colombia 50 Box 5 Contracting: The key ingredients for success 53 Box 6 PROSALUD 54 iv ,t,/gcknowledgments This report represents the collaborative effort of Charles Griffin (World Bank) and Ana Langer (Popu- three partners-the World Bank, the Pan Ameri- lation Council, Latin America and the Caribbean can Health Organization (PAHO), and the Inter- Office) for their substantial inputs and comments, American Development Bank (IDB). It draws on and to the authorities and organizations that pro- a dozen background papers, which are avail- vided us with the relevant information. Our thanks able on the Latin America and the Caribbean also to Adam Wagstaff, Jerker Liljestrand, Sandra Region Women's Health Study Web site, at Rosenhouse, and Isabella Danel (World Bank), and http://www.worldbank.org/lachealth/. Mayra Buvinic, Tomas Engler, Isabel Nieves, and The team collaborating on the preparation Ingvild Belle (IDB), and Sylvia Robles (PAHO) for re- of this report included Ruth Levine and Miriam viewing earlier versions of the document. Marian Schneidman (World Bank), Amanda Glassman Kaminskis provided invaluable assistance in prepa- (IDB), Carol Collado, Elsa Gomez, and Marijke ration of this document; Alison H. PeFna was the Veizeboer-Salcedo (PAHO). Very special thanks to copyeditor. v bbreviations and Acronyms AIDS Acquired Immune Deficiency Syndrome BMI Body Mass Index DALYs Disability Adjusted Life Years DHS Demographic and Health Survey DTP Diphtheria, Tuberculosis, Polio Immunization DRG Diagnostic Related Group GDP Gross Domestic Product GNP Gross National Product HIV Human Immunodeficiency Virus IARC International Agency for Research on Cancer IBRD International Bank for Reconstruction and Development ICPD International Conference on Population and Development IDB Inter-American Development Bank IMSS Mexican Social Security Institute/Instituto Mexicana de Seguridad Social ISAPRE Private Health Insurance/instituto de Salud Previsional ISSSTE Social Security Institute for Public Sector Employees (Mexico)/ Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado LAC Latin America and the Caribbean Region MMR Maternal Mortality Rate NGO Nongovernmental Organization PAHO Pan American Health Organization PPP Purchasing Power Parity PSRH Public Spending on Reproductive Health PSWH Public Spending on Women's Health SSA Federal Secretariat of Health (Mexico)/Secretaria de Salud STI Sexually Transmitted Infection TFR Total Fertility Rate THE Total Health Expenditure USAID United States Agency for International Development WDR World Development Report WHO World Health Organization YPLL Years of Potential Life Lost vi (9xecutive Summary The health sector in Latin America and the Carib- ing of the issues related to reproductive health bean is under pressure to achieve better health policy in the region. outcomes, particularly among the poor, within se- The study has two main objectives: verely constrained budgets. Countries are attempt- + To analyze trends and differentials in ing to meet this challenge by establishing new women's health; examples of good practices in priorities for public spending, changing the locus delivery and financing of women's health pro- of decisionmaking, reorienting major institutions, and introducing productivity- and demand-oriented gram a nd the k enson ofoms healt that are relevant for the health reforms currently management and financial mechanisms. As this underway in Latin America. process is implemented, yields results, and re- + To provi de gu ida nce for govern ments quires adjustment, policymakers are more likely and program designers in addressing the most to achieve their objectives if they pay careful at- tenton t thetopi of omens helth,and ase pressing causes of women's ill health, within the tention to the topic of women's health, and base cneto rae etrladntoa oiis context of broader sectoral and national policies. their decisions, in part, on a solid empirical under- standing of the health, economic, and social con- ditions of women. Women's Health Conditions in This report seeks to contribute to the de- Latin America and the Caribbean bate about health policy and program design in Latin America and the Caribbean by focusing on Women's health in Latin America and the Carib- the special topic of women's health. It aims to bean tells a story of diversity. Reflecting underly- provide governments and program designers with ing differences in socioeconomic conditions and information about priority needs in the region, and policy responses, the countries of the region are on how policies can yield optimal results. The characterized by vast differentials in the status of report, which summarizes more than a dozen women's health and services. In Haiti, maternal original background studies, represents the col- mortality is estimated to be about 600 per 100,000 laborative effort of three partners-the World live births, and nearly 80 percent of women de- Bank, the Inter-American Development Bank (IDB), liver in the home. In Colombia, maternal mortality and the Pan American Health Organization (PAHO). has been reduced to 100 deaths per 100,000 live In addition, three regional consultations, spon- births, and less than 20 percent of women have sored by the IDB, were conducted in collaboration home deliveries. Still further along the broad con- with the Population Council, Latin America and tinuum, Chile's maternal mortality rate rests at 65 the Caribbean Office, to gain a deeper understand- per 100,000, and health service providers find that * The Health of Women in Latin America and the Caribbean providing cost-effective care for chronic conditions The pattern of incidence and prevalence by among older women is an increasing challenge. socioeconomic conditions is complex. Cardiovas- Looking at reproductive health indicators, cular disease, diabetes, and cervical cancer tend we see persistent, clear patterns of poor repro- to be more problematic among poorer popula- ductive health associated with poverty, and low tions. Conversely, breast cancer tends to account coverage of basic services. In the poorer coun- for a larger share of mortality among better-off tries, there is evidence of longstanding and wide- populations, probably because of patterns of re- spread poor nutritional status, high (and unwanted) productive risk factors, such as delayed child- fertility levels, high-risk childbearing, and low use bearing among richer and better-educated of prenatal services. But the majority of women in women. these countries have much in common with the poorer women in the better-off countries, who are Delivery and Financing of at equally high risk for poor reproductive health Women's Health Services outcomes, despite the good reproductive health enjoyed by a large share of the women in those Public sector provision is the most common countries. source of women's health services, although the But reproductive health is only part of the private sector does provide a sizeable share of story of women's health. Overall, the disease bur- services, even in poor communities. In a special den represented by some chronic or noncommu- analysis for this report that looked at seven coun- nicable illnesses is higher for women than for tries of the region studied, we found that, having men. The relative female burden is higher for car- perceived a medical problem, most women seek diovascular disease between the ages of 15 and care in the public sector or from publicly financed 44 and among those 60 years and older. Women private providers-from 42 percent of all visits in assume a larger overall burden for cancers. Breast Paraguay to 76 percent of all visits in Brazil. Insur- and cervical tumors in women occur at an earlier ance coverage is concentrated in the upper in- age than the most common malignant tumors do come quintiles and urban areas, is mostly public, in men (PAHO 1998). Breast cancer takes a toll on and women and men benefit equally. women from the age of 15 onward. The burden Wealthier women are more likely to seek for colorectal cancers is higher among women 45 care in the private sector, although there is sig- and older than it is for men in these age groups. nificant use of public services by the upper- Although diabetes-related mortality is increasing income households. Even in the poorest 20 among men, the disability-adjusted life years lost percent of the income distribution, women are among women are still substantially higher; the more likely than men to seek care in private health disparity is maintained from the age of 15 onward. facilities or pharmacies. The use of private facili- Musculoskeletal diseases, which can dramatically ties as the first site of care among the poorest 20 affect physical function and mental health, take a percent of households ranges from lows of 5 per- much larger toll on women than on men. The dif- cent of females in Brazil (where universal access ferential begins at age five and is maintained is mandated and the use of private facilities paid throughout the life span. for by the government is included in the category Executive Summary of "public" services) to highs of 29 percent of first ing demands on the health system-policy- visits among females in Paraguay. makers, technical specialists, advocates, commu- Our analyses demonstrate wide variation in nity leaders, and others interested in women's total health spending-it is 147 times greater in health issues can take advantage of a major op- Brazil than in Jamaica, for example-and in spend- portunity: Well-designed and well-implemented ing as a share of gross domestic product. In gen- efforts to reform the health systems in Latin eral, however, spending on women's health America and the Caribbean, which are now un- services accounts for about one-quarter of public derway, can increase the quantity of, improve the health spending and nearly half of household quality of, and stimulate demand for women's spending on health. Not surprisingly, the volume health services. At the same time, it is essential to of public spending on women's health is highly recognize that poorly designed and poorly imple- associated with a country's wealth, and its distri- mented reform initiatives-those that ignore some bution across Institutions and inputs is similar to of the critical gender-specific dimensions of the that of total expenditures on health. supply of and demand for health services-can The analyses examine the gap between cur- erode past progress in improving women's health rent spending on reproductive health and the re- in the region. This is true for both the better-off source requirements for the delivery of a package countries-where the challenge lies in greater ef- of core reproductive health services. For the seven ficiencies, better targeting, and stimulation of de- countries for which data are available, this assess- mand among the poor-and the poorer countries, ment indicates that there is little or no funding where the primary objective is directing a greater deficit in Brazil, Mexico, and Jamaica. In Paraguay volume of resources to meet persistent needs for and the Dominican Republic, marginal additional essential, basic reproductive health services. resources-from 11 to 15 percent of current pub- The first step toward using health reform lic spending on reproductive health-would be re- processes to promote improvements in women's quired to finance the core reproductive health health is to understand that women's health ad- services for the entire population. In contrast, in vocates and health "reformers" have common the poorer countries of Guatemala and Peru, pub- aims, despite differences in professional training, lic spending on reproductive health services-ex- ideology, politics, and even vocabulary. In its most clusive of external support-would have to stripped-down form, health sector reform (as increase by about 25 to 50 percent to achieve manifested in developing countries) typically the target. seeks to achieve three overarching objectives. First, it aims to improve the efficiency of Women's Health and Health the overall allocation of public resources within Sector Reform: Synergies the health sector, so that public funds are directed and Risks toward the health services that will have the greatest positive impact on health conditions, but To tackle the challenge of improving persistently that the market would not otherwise provide. Sec- poor health indicators among vulnerable women ond, health sector reform seeks to provide incen- in the face of resource limitations-and expand- tives for the efficient production of services in The Health of Women in Latin America and the Caribbean both the public and private spheres, so that a Despite the commonalities between those given level of inputs devoted to an essential de- interested in improving women's health outcomes terminant of human capital formation (and a large and the efficiency- and equity-oriented health sec- player in the national economy) yields the great- tor "reformers," communication is often limited est possible output. Third, it tries to improve the by the lack of formal channels and mechanisms lot of the poor-or at least counteract historically to involve women's health advocates in the re- regressive public expenditure policies-by focus- form processes. In a few countries of the region- ing public spending on services that dispropor- notably Mexico, Brazil, and Colombia-efforts are tionately benefit lower-income and other underway to incorporate women's health advo- vulnerable households. As demonstrated in this cates and gender specialists in the dialogue about report, meeting each of these objectives requires the direction of health sector reform. But these attention to women's health. countries are the exception. In general, formal par- Just as policymakers and others promoting ticipation mechanisms have been limited, and health sector reform can meet their objectives both national governments and development part- most effectively by focusing attention on women's ners have done relatively little to ensure that is- health, it is also the case that advocates of sues of women's rights and other gender-specific women's health can achieve their goals by recog- concerns are discussed during debates on health nizing the opportunities presented by particular sector reform. aspects of health sector reform. Many health ser- The outcomes for women of four common vices for women have long been characterized by health sector reform strategies-decentralization, poor quality and lack of responsiveness to de- public sector priority setting, financing changes, mand. Within health sector reform, instituting con- and adjustments in the roles of the public and tracting arrangements, new demand-side private sectors-can be enhanced if attention is financing mechanisms, strengthening of regula- paid during the design stage to lessons learned tory mechanisms, and decentralization of from experience, as outlined below in brief, and decisionmaking have the potential to address as further detailed in this report. these concerns. In addition, as documented in this Decentralization can have positive effects on report, finishing the reproductive health agenda women's health services when (1) women's health requires more financial resources and better use advocates (and women patients) have a voice in of those resources that already are invested in the local decisionmaking process; (2) coherent na- reproductive health. Again, health sector reform tional policies and "rules of the game" are in place initiatives that seek both efficiency and equity im- that favor the delivery of women's health services provements can serve to free up and refocus fi- of acceptable quality; (3) formula-based transfers nancial resources for this purpose. Finally, are used to ensure sufficient funding based on financing non-health services is a complex task need, and to redress historic inequities; and (4) sup- that will require mechanisms that include, but also port is provided to bolster technical and manage- go far beyond, traditional public sector-resource rial capacity at the local level. outlays. In particular, expansion of both public and Strategies for public sector priority setting private insurance systems is likely to be needed. that employ analysis of cost-effectiveness often Executive summary favor core reproductive health services. The chal- Contracting with nongovemmental organi- lenge, as seen in several countries, is to obtain zations and public-private collaboration have tre- and stimulate the use of reliable and up-to-date mendous potential to increase access to and the information about both costs and efficacy. quality of women's health services in the region, Broadening financing options to mobilize although, to date, experience is limited. The key resources, control unnecessary demand, and ingredients for success include (1) putting in place promote risk-pooling will have better outcomes a legal and regulatory framework that protects for women's health if the design takes into ac- service providers, financiers, and, above all, con- count the possibility that women have less ac- sumers; (2) minimizing transaction costs and in- cess to and control over household income corporating incentives for productivity and quality; than do men. In particular, a variety of studies (3) ensuring continuity in service provision and have confirmed that core maternal and child minimizing delays in payments; and (4) strength- health services are best funded by means other ening management information systems, monitor- than user fees. ing results, and making required adjustments. rview Chapter Summary + Health systems in Latin America and the Caribbean are under pressure to improve performance. + Improving our ability to understand and respond to women's health needs and denmands- including those not related to reproduction-is essential to achieving goals of enhanced equity and increased efficiency. + Responding to women's health needs requires recognition of gender-specific determinants of health and health-service use. Objectives and Organization gets. As a result, they are engaging in a process of health sector reform: establishing new priori- The health sector in Latin America and the Carib- ties for public spending, changing the locus of bean is under pressure. While the countries of the decisionmaking, reorienting major institutions, and region have achieved notable progress in delivery introducing new management and financial of both public health and individual health ser- mechanisms that are designed to promote pro- vices over the past several decades, the accom- ductivity and responsiveness to consumers. plishments are not as great as would be predicted As this process is implemented, yields re- by the level of spending in the sector (IDB 1997). sults, and requires adjustment, policymakers are Low-income households continue to suffer from more likely to achieve their objectives if they pay preventable diseases and are vulnerable to the careful attention to the topic of women's health, financial insecurity associated with illness. In ad- and base their decisions, in part, on a solid em- dition, health services in the region are often inef- pirical understanding of the health, economic, and ficient. The sector is characterized by wasteful social conditions of women. Just as it has been spending practices. Many countries recognize demonstrated that the aims of health sector in- these shortcomings and realize they face increas- vestment are closely tied to addressing the prob- ing demands to make the economies of the re- lem of poverty and inequity in Latin America and gion more globally competitive by investing the Caribbean, it is also the case that better out- effectively in human capital within restricted bud- comes from the health sector depend in large part 7 * The Health of Women in Latin America and the Caribbean on the extent to which the health system under- and differentials in women's health in Latin stands and responds to gender differences. America and the Caribbean, grouping countries into four broad categories according to trends in Objectives. This report seeks to contribute to the health, demographic, and socioeconomic indica- debate about health policy and program design tors. This analysis illustrates how countries have in Latin America and the Caribbean by focusing performed relative to one another over the past on the special topic of women's health. It aims to decade and suggests the priority needs at this provide governments and program designers with stage. Chapter Two turns to a discussion of ac- information on priority needs in the region, and cess, utilization, and spending on women's health, on how policies can yield optimal results. The providing the results of new analyses for seven report, which summarizes more than a dozen countries. The third chapter provides an over- original background studies, represents the col- view of the links between women's health and laborative effort of three partners-the World health reform. It emphasizes potential synergies Bank, the Inter-American Development Bank (IDB), and opportunities to integrate women's health and the Pan American Health Organization concerns in broader reform initiatives and points (PAHO). In addition, three regional consultations out risks to be avoided. The chapter includes ex- were conducted in collaboration with the Popula- amples of good practices in the provision and fi- tion Council, Latin America and the Caribbean Of- nancing of women's health services in the region. fice, to gain a deeper understanding of the issues The final chapter presents concluding remarks related to reproductive health policy in the region. and recommendations. The study has two main objectives: Background papers are available on the Web site, www.worldbank.org/lachealth/. This site + To analyze trends and differentials in includes both the background materials for the women's health; examples of good practices in women's health study and a series of cases pre- delivery and financing of women's health pro- pared for a conference on health reform in 2000, grams; and the key dimensions of women's health which focused, in part, on policy and program- that are relevant for the health reforms currently matic innovations to foster more effective deliv- underway in Latin America. ery of maternal and child health services to poor + To provide guidance for governments communities. and program designers in addressing the most pressing causes of women's ill health, within the What Is Women's Health? context of broader sectoral and national policies. Women's health constitutes a wide range of con- Organization. The report is divided into five sec- ditions, which are influenced by socioeconomic tions. This overview highlights the rationale for fo- status, educational attainment, and the availabil- cusing on the topic of women's health, along with ity, cost, and quality of services. It includes repro- a conceptual framework for understanding the de- ductive health, which was defined broadly in the terminants of women's health and the role of Fourth World Conference on Women (Beijing 1995) health policy. Chapter One describes major trends and the international Conference on Population overview and Development (Cairo 1994) as "... a state of countries are experiencing a shift in epidemiologic complete physical, mental, and social well-being patterns away from infectious diseases and to- and not merely the absence of disease or infir- ward chronic conditions. mity, in all matters related to the reproductive sys- In short, the countries of the region face tem and to its functions and processes." It also a triple challenge: (1) an unfinished reproduc- includes concerns related to chronic diseases tive health agenda, which affects dispropor- (such as cardiovascular problems, cancers, dia- tionately the lower-income countries, and the betes), mental illness, and occupational and envi- poor across all countries; (2) new infectious ronmental health problems. The following criteria diseases, including HIV/AIDS; and (3) emerging can be used to distinguish between women's health problems, including chronic and degen- health and men's health. Women's health issues erative diseases, injuries, and mental and (1) are unique to all women or some groups of occupational health, particularly in the higher- women; (2) are more prevalent among all women income countries.' While these emerging or some groups of women; (3) have more serious health concerns affect both men and women, consequences or implications for all or some women have special needs, given their greater groups of women; and (4) imply different treat- vulnerability to the HIV/AIDS infection, a vari- ment for all or some groups of women. ety of biological and social susceptibilities, and The Latin America and Caribbean region women's relatively greater representation in presents a mixed picture of women's health con- the older population. ditions. The priority attached to expanding ac- cess to family planning in many countries has Why Do we Need to Pay generated impressive results, with the total fer- Attention to Women's Health? tility rate declining from 5.0 to 2.7 children per woman, and with one-third of the countries hav- Making sound policies to improve health sector ing reached replacement-level fertility over the past 25 years (Loganathan 1999). In spite of these performance requires attention to the determi- nants and characteristics of women's health, and impressive regional gains, progress has been un- the allocation of public and private resources to even across countries: Women's lifetime risk of women's health services. This statement does not dying during pregnancy and childbirth, for ex- imply that women's health is intrinsically more ample, ranges from 1:17 (Haiti) to 1:510 (Panama). important than men's health, but rather that suc- Female life expectancy averages are about 57 cessful health policy recognizes and responds to years in Haiti, 63 years in Bolivia, and close to 80 years in Costa Rica. ~~~~gender-based differences in biology and in social and economic conditions. At the same time, new health concerns and Several features of women's health are challenges are emerging. On the one hand, the worth noting: growing problem of HIV/AIDS puts pressure on reproductive health programs to expand attention . Women are the primary beneficiaries of to specific services and populations. On the other, health services in Latin America and the Carib- coupled with an aging of the population, many bean, and particularly of publicly financed health * The Health of Women in Latin America and the Caribbean services. Women use both general services- + The equity and efficiency objectives of those services that benefit men and women-and health sector reform can be achieved only with women-specific services associated primarily with attention to women's health in general and repro- pregnancy and childbearing. As shown in chapter ductive health in particular From an equity per- three, women are more likely to experience and spective, the almost invariable association report illness and more likely to seek care than between socioeconomic vulnerability and particu- men. They interact with the health system more lar health problems experienced by women, such frequently than do their brothers and husbands, as risky childbearing and nutritional deficiencies, both as patients themselves and as the primary means that improving some types of women's caretakers of children who are patients. The out- health services will disproportionately benefit the come of virtually all policy or programmatic deci- poor. On the other hand, ignoring these prob- sions in the health sector will be determined largely lems-and failing to devote adequate resources by the response of, and the impact on, women. to resolving them-reinforces the high levels of + women's health has important exter- inequity that characterize most of the societies of nalities. Women in their own right deserve the op- Latin America. From an efficiency perspective, one portunity for excellent health and the associated of the primary means of achieving better health ability to participate in education, employment, outcomes with the same level of health sector and other endeavors. Women's health has a spending is by focusing public resources on a par- broader impact, as well. First, the health of ticular set of women's health services that are women before and during their reproductive years unlikely to be produced in adequate volume by is a powerful determinant of their children's well the private sector and are inexpensive relative to being. Women who are severely undernourished their effectiveness.3 during pregnancy, for example, are more likely to + Women's health issues represent an have children who suffer from low birth weight, opportunity for establishing a shared interest and who are physically and cognitively impaired. among diverse actors in the health sector. By look- Second, women typically are the primary caretak- ing at women's health, we can see a clear con- ers of children, and often take on the role of car- vergence of interests between individuals and ing for other household members who are sick or groups that emphasize human rights and public infirm. When these women-the caretakers-are health and those that emphasize the importance ill themselves, their dependents suffer. The death of economic criteria for priority-setting. This con- of a mother usually has catastrophic effects on vergence of interests can be an important force the physical and psychological well being of her in advancing the reproductive health agenda in young children.2 Finally, employed women tend the poorer countries of the region, and working to occupy a narrow range of occupations in the toward better health among the relatively older service sector, which brings women into direct population in the better-off countries of the re- contact with many people. The health and wel- gion. At the same time, given the overwhelming fare of a community rest, in part, on the health of importance of women as patients and health-care its teachers, nurses, food service workers, and decisionmakers, understanding how to serve childcare providers. women better is part of the agenda for both pub- Overview lic and private health-care planners and service the direct product of a set of inputs, such as food, providers. medical care, and so forth, and to identify the va- Despite this rationale, the health concerns riety of individual, household, and community or of women have not yet received adequate atten- societal factors that influence the combination of tion. Historically, the medical and public health inputs. With this type of framework, we can ana- fields have equated women's health concerns with lyze the proximate and indirect determinants of those of men, even though there are important bio- health systematically, and identify how policy logical and physiological differences that need to choices might affect health outcomes.5 6 be taken into account in identifying appropriate in- Individuals and households make choices terventions.4 From a policy perspective, the by balancing the value placed on good health overarching focus has been on women's reproduc- against the value placed on other aspects of indi- tive and maternal capacities, rather than on the vidual and household welfare, taking into account needs of women in their own right, typically to the financial, information, and other constraints.7 Each exclusion of non-reproductive health needs. day, individuals (or, in the case of children, their parents or other caretakers) must choose be- A Framework to Understand tween pursuing better health or other objectives Women's Health and Health that may also improve welfare. In other words, Policies they choose between health-generating inputs or behaviors, on the one hand, and consumption Men and women differ in their physiological vul- that creates other types of benefits, on the other. nerability to ill health, and in their interaction with For example, with growing economic pressures the health system and general environment. It is and larger numbers of women entering the labor useful, then, to identify where-in the chain of market in Latin America, women often face diffi- events from policymaking to individual health cult choices in allocating their time between practices-those differences are manifested. In income-generating activities, child-care responsi- this section, we present a framework for looking bilities, and seeking health care when ill. at the determinants of health, and then use that We see here the first instance where men framework to identify the ways in which women and women may differ. The degree to which par- may face different constraints, make different ticular inputs lead to health is affected to some choices, and experience different health out- extent by immutable individual characteristics, in- comes than men. cluding age, genetic make-up, and gender. Men and women differ in their vulnerability to different The General Framework. Health conditions are diseases; nearly all health problems have gender- a function of a combination of biological factors specific patterns of incidence and severity, and and behaviors at the individual, household, com- obviously most of the reproductive concerns of munity, and national levels. The complex chain of women do not directly affect men at all. More events leading to a health outcome can be envi- subtly, health is affected by education and infor- sioned in many ways. One way-although by no mation: better-informed individuals generally are means the only way-is to consider health to be better able to determine when a particular health The Health of Women in Latin America and the Caribbean condition requires medical attention, how to use hold. The key decisionmakers may be persons medications, and so forth. In settings where men other than those whose health is being affected. and women differ in their educational level or their The most obvious example is children, whose access to information, or both, these asymme- health is affected by decisions made by their par- tries can contribute to health differences between ents. For example, parental decisions about pre- males and females. natal care, breast-feeding, first supplemental The inputs or behaviors about which irdi- foods, and vaccinations affect children's health. viduals and households make choices can be Moreover, since household resources are limited, thought of as (1) those that are directly related to tle household may not be able to spend all it health, including medical treatment for ailments, would like on every household member and may immunization, and other preventive actions, and have to decide among activities that affect differ- others; (2) those that are health-related, yet also ent household members. provide other types of benefits, such as housing, The earliest economic models of household water source, food, risk-taking behaviors, exercise, behavior (such as Becker 1964) assumed that all and so forth; and (3) those that are generally not households jointly maximized some household thought of as health-related, including employ- level of welfare, and that the household should ment, household activities, and transportation. be treated as if it acted as a single individual. More The choices made are influenced by individual recent research has recognized that preferences characteristics, such as education; household rnay differ among members across a household. characteristics, including income; and community This research has investigated how alternative features, including the availability and prices of decisionmaking styles might affect the allocation health services, cultural norms, legal factors, en- of resources within the household (see Thomas vironmental conditions, and so forth. 1989). For example, whereas in one family mem- The relative values placed on good health bers may act unselfishly toward one other, in an- and other outcomes that people want may differ other one individual may act as a dictator, perhaps depending on gender (as well as other character- discriminating against other members, such as istics). For example, households may place less females or the aged, while another family may value on women's or girls' health than on men's engage in cooperative or noncooperative bargain- or boys' health due to discriminatory factors. Al- ing over the allocation of resources. ternately, households may expect that women will Variation in preferences and gender roles earn less income for the household than do men, within the family are important factors that affect due to characteristics of the labor market. If so, the investment that one generation will make in they might invest less time and fewer monetary toe next. For instance, an important study by Tho- resources in girls' medical care. mas (1994), using data from Brazil, showed that In this context, it is important to note that daughters were taller in households where moth- household decisionmaking may not be based on ers controlled more of the economic resources, preferences and values shared by all members. and sons were taller in households where fathers Households tend not to be monolithic-there may controlled more of the economic resources. This be disagreement over priorities within a house- comparison was made holding the overall level Overview of economic resources constant in the house- macroeconomic dynamics, play a large role in de- hold. The hypothesis is that mothers and fathers termining the constraints communities, house- have different preferences over their sons' and holds, and individuals face in reaching, using, and daughters' health. The extent to which the pref- gaining benefits from health services. erences affect decisionmaking is related to the At this level, it is possible to see some clear extent to which the parent controls resources. gender-related differentials: frequently women's The study's findings are consistent with the opin- disadvantage as participants in public life is evi- ion that strengthening the mother's hand is likely dent. However, policymakers have the potential to result in daughters being treated more fairly to minimize inequities that may be harder to within the family, tackle directly at the household and community At the community level, decisions are made levels. Some policies, such as those promoting regarding the quality of the environment (hous- girls' education, can be used to redress existing ing, sanitation, transportation, work opportunities) differentials in social and economic status, which and the nature of health services, again by mak- will have a long-lasting positive effect on women's ing trade-offs in the face of constraints. Gender health. Others, such as those which increase the differences are evident at this level, as well. effective use of public funding for women's health Women's relative social and economic disadvan- services, can have a direct and relatively immedi- tages can affect the responsiveness of commu- ately positive impact on women's access to ser- nity decisionmaking to women's needs. In some vices and health outcomes. societies, the occupations and preoccupations of The gender-specific effect of policies on women are explicitly considered less important prices of education and health services is of par- than those of men. A family member's contribu- ticular note. Some work has shown that women's tions to the formal economy, for example, may be demands for medical services and their demand seen as more important than another member's for education are more sensitive to prices than reinforcement of domestic life. In most societies, are men's demands. Alderman and Gertler (1998) women are less active and vocal participants in show that increases in the prices of primary care public life than are their brothers and husbands, lower the treatment of girls' illnesses more than so decisions taken in even nominally democratic the treatment of boys' illnesses in Pakistan; environments can fail to take women's needs and Gertler and Glewwe (1991) show that increases in demands into account. schooling costs reduce the enrollment of girls At the national or subnational level (wher- more than boys. This has important implications ever the relevant policies are made and programs for co-payment policies. Increases in direct pa- designed), decisions both within the health sec- tient costs to finance improvements in health ser- tor and across sectors ultimately affect health vices will tend to reduce access to care more for conditions. Policies related to the financing, struc- girls than for boys. Similarly, increased school fees ture, and management of health services deter- will reduce female enrollment more than male mine the availability and characteristics of care enrollment. available to the population. Policies in the realm Both studies also found that girls' demands of education and the environment, as well as in for medical care and education are more income- The Health of Women in Latin America and the Caribbean elastic than are boys' demands. Consequently, choices to make (or to have made for them, in girls' access to medical care and schooling is in- the case of children). Similarly, young adults face versely related to income and more vulnerable to different health conditions, choices, and con- economic shocks. Hence special attention is war- straints than do the elderly. Yet the human capital ranted in order to ensure girls' access to educa- investment decisions made early in life-such as tion among poorer households and during those about nutrition, education, and preventive economic crisis. In addition, it means that girls health care-have profound implications for are more likely to benefit from general economic health later in life. growth than are boys, although they start from a In Chapter One, we present an overview of lower level. women's health conditions in Latin America and It is important to see relationships as dy- the Caribbean, attempting to identify opportuni- namic, existing within the context of the life cycle, ties for critical investments that have the poten- and changing over a lifetime. Children and young tial to improve the welfare of women and their adults have different health needs and different families. CHAPTER ONE Women's Health Conditions Chapter Summary + Women's health conditions vary widely, both across and within countries of the region. Four distinct patterns can be identified. + There is an unfinished agenda for reproductive health among poorer populations, and an emerging problem of chronic diseases throughout the region. + In countries where women's health conditions are poor, policymakers should focus on general improvements in basic services that yield better reproductive health: early and reliable prenatal care; birth attendance by trained personnel; nutritional support, particularly to address iron-deficiency anemia; and appropriate contraception for women who wish to space or limit births. + In countries with better health conditions, on average, for women, reproductive health services should be strengthened in poorer communities, and governments should consider ways to counteract market failures in the provision and financing of care for noncommuni- cable diseases. Given differences in prevalence rates for men and women, gender-specific strategies may be required. Women's health in Latin America and the Carib- along the broad continuum, Chile's maternal bean tells a story of diversity. Reflecting underly- mortality rate rests at 65 per 100,000, and health ing differences in socioeconomic conditions and service providers find that providing cost-effec- policy responses, the countries of the region are tive care for chronic conditions among older characterized by vast differentials in the status women is an increasing challenge. of women's health and services. In Haiti, mater- The differentials are striking not only across nal mortality is estimated to be about 600 per national boundaries, but also within them. The 100,000 live births, and nearly 80 percent of poorest women in Haiti are about two-and-a-half women deliver in the home. In Colombia, mater- times as likely to be undernourished' as the nal mortality has been reduced to 100 deaths women from the richest households. In Colombia, per 100,000 live births, and less than 20 percent about 60 percent of the poorest women are at- of women have home deliveries. Still further tended by medically trained personnel at deliver- ies, compared to more than 98 percent of the This chapter contains contributions by Paul Gertler wealthiest women. 15 * The Health of Women in Latin America and the Caribbean In this chapter, we explore the patterns and d- Medium-low status: Bolivia, Ecuador, differentials of health conditions in Latin America Guatemala, Honduras, Nicaragua, and Peru and the Caribbean, with a primary but not exclu- + Low status: Haiti sive focus on reproductive health outcomes. First, we group countries of the region into a simple Table 1 shows the average values of the typology, based on key indicators of health status key variables for each of the country types. There and services. Second, we examine reproductive is wide divergence across all indicators, with the health conditions in several countries in the re- high status countries having conditions that, on gion for which relatively recent household-level average, are not much different from many indus- data from the Demographic and Health Surveys trial countries, and the medium-low and low sta- exist.9 Third, we present information on the preva- tus countries having characteristics of extreme lence of emerging noncommunicable diseases. disadvantage. For the most part, the country types correspond simply to levels of GNP per capita: the higher the income, the higher the status in The Typology this typology. However, several countries do not fit neatly into this pattern. Costa Rica and Panama, While each country represents unique chal- for example, have a higher status than would be lenges, there is value in attempting to catego- predicted based on per capita income alone. Good rize, or group, the countries to develop a more women's health, health resources, and health ser- generalized strategy. To this end, a typology of vice conditions place those countries in the high women's health was developed for this study. status category. Brazil is more similar in income The typology employed eight variables-GNP per to the high status group, but lower health, health capita, adult illiteracy rate, female life expectancy, resources, and health service conditions place it total fertility rate, total health expenditure, ac- among the medium-high status countries. In the cess to sanitation, births attended by trained descriptions of health conditions that follow, these health staff, and child immunization (DTP)-to country groupings are used to facilitate under- group countries, using the cluster analysis tech- standing of the information. With caution, the nique."0 The analysis incorporates 21 countries policy and programmatic inferences drawn from from the region for which sufficient data were the data for the selected countries can be ap- available, plied to others in the same country grouping. Based on data from 1990-96, the country groupings are: Poor, Rural, and Uneducated Women Face Extreme + High status: Argentina, Chile, Costa Reproductive Health Risks Rica, Panama, and Uruguay + Medium-high status: Brazil, Colom- The definitions of reproductive health outlined at bia, Dominican Republic, El Salvador, Jamaica, various United Nations conferences in the 1990s Mexico, Paraguay, Trinidad and Tobago, and the extend beyond maternal health to encompass Republica Bolivariana de Venezuela complete sexual and reproductive well being. Women's Health Conditions Average Values for Indicators by Country Grouping High Medium- Medium- Low status high status low status status Female Life Expectancy (years) 77.5 73.9 69.0 56.7 Total Fertility Rate (children per woman) 2.5 2.9 3.9 4.3 Access to Sanitation (% of population) 86.6 59.4 53.2 24.0 Illiteracy (% of population over age 15 and above) 5.1 12.9 24.0 55.0 GNP per Capita 4,944 2,650 1,210 310 Delivery by Trained Staff 95.0 70.2 40.2 40.0 Health Expenditure (total spending as % of GDP) 8.32 5.68 5.22 3.6 DPT (% of children under I year) 87.6 86.4 86.2 30.0 Source: Loganathan 1999. Given its broad definition, and as discussed in reproductive health enjoyed by a large share of chapter one, many factors influence reproductive the women in those better-off countries. health, including socioeconomic status, educa- tional attainment, cultural and social norms gov- Maternal Morbidity and Mortality. Despite erning female sexuality, power relations within a weak data sources, Murray and Lopez (1996) have marriage or other union, domestic and sexual vio- estimated that approximately 2.2 million disability- lence, and the availability, cost, and quality of re- adjusted life years (DALYs) among women are lost productive health services. In this section, our annually to conditions associated with pregnancy. scope is more limited-to describe the epidemio- Maternal mortality ranges widely in the region, logical and service utilization patterns related to from 65 per 100,000 live births in Chile, to over a set of reproductive health outcomes for which 600 per 100,000 in Haiti. Table 2 shows recent data are available, with an eye toward identifying maternal mortality estimates for several countries, key targets for policy and programmatic action. by placement in the typology. Looking at reproductive health indicators, Overall, mortality due to maternity-related we see persistent, clear patterns of poor repro- causes has dropped substantially in most of the ductive health associated with poverty and low region in recent decades. From 1980 to 1994, ma- coverage of basic services. Generally, in the low ternal mortality decreased by 42 percent in the status and medium-low status countries, there is Southern Cone, 38 percent in Mexico, 35 percent evidence of longstanding and widespread poor in Brazil, and 35 percent in the English-speaking nutritional status, high (and unwanted) fertility lev- Caribbean. However, some parts of the region con- els, high-risk childbearing, and low use of prena- tinue to struggle with persistently high levels of tal services. But the majority of women in these maternal mortality. In many Central American coun- countries have much in common with the poorer tries, for example, maternal mortality declined by women in the medium-high status and high sta- only about 4 percent between 1980 and 1994. tus countries, who are at equally high risk for poor As described in detail in the sections that reproductive health outcomes, despite the good follow, a constellation of factors-most of them The Health of Women in Latin America and the Caribbean Maternal Mortality by Country rural and uneducated. in the medium-low status Grouping and low status countries, this represents the ma- jority of women; even in the other countries of MMR (deaths per the region, at least one-fifth of the population con- 100,000 fronts serious reproductive health risks. live births), Country 1990-97 Nutrition and Reproductive Health. Poor nu- High Status Argentina 100 trition-both a cause and a consequence of ill Chile 65 health-represents a major risk factor for poor Costa Rica 55 birth outcomes for both mother and child. Iron- Medium-High Status deficiency anemia, an important problem among Brazil 160 many women of the region, is estimated to play a Colombia 100 Dominican Republic 110 contributing role in up to half of all maternal El Salvador 300 deaths (ACC/SCN 1997), and is linked to prema- Jamaica 120 ture delivery and low birth weight (PAHO 1998). Medium-Low Status Chronic protein-energy malnutrition can result in Guatemala 190 Peru 280 short stature, which in turn is a risk factor for ob- Honduras 220 structed labor. Nicaragua 160 Iron-deficiency anemia, the most common Low Status nutritional disorder in the world, affects between Haiti 600 one-third and one-half of the pregnant women in S,,urcc:Loga,.athan 1999. the Latin America and Caribbean (LAC) region. Among national surveys conducted in Belize, Bo- livia, Guatemala, Nicaragua, and Paraguay, preva- strongly associated with poverty and social vul- lence of anemia in pregnant women ranges from nerability-confer high risk of poor reproductive 26 percent in Paraguay to 52 percent in Belize. outcomes. Mothers at high risk include those at Half or more of these cases are probably due to the very beginning or end of childbearing years, nutritional iron deficiency. Anemia is also related with high parity, and who have poor past or cur- to poor iron absorption or uptake, blood loss rent nutritional status. These factors are com- trhrough menstruation and childbirth, low intake pounded when prenatal or obstetric care is of other food and nutrients that promote iron ab- inadequate. By not having access to (or not us- sorption and availability, and repeated bouts with ing) family planning methods that are consistent infectious disease (PAHO 1998). with their reproductive aims, women are also vul- Research suggests that anemia is more nerable to unintended pregnancy, and the conse- common among poor women and women who quences of an unsafe abortion, or an unplanned are lactating. National survey findings from Bo- (and potentially unwelcome) child. The data re- livia reveal substantially higher levels of anemia veal thatthe women most likelyto face these risks among less-educated and rural women, com- are those in poor households-disproportionately pared to their educated and urban counterparts. Women's Health Conditions Overall, however, levels of anemia are relatively less education and those residing in rural areas, high among all women: even one-fifth of the the rates are substantially higher. In Colombia, for most-educated women have some degree of ane- example, a country with a national TFR of 3.0, the mia (Loaiza 1997). TFR in urban areas is 2.5 children per woman and With respect to chronic energy deficiency, the rural TFR is 4.3 Among women with no edu- adolescent mothers are at the greatest risk in the cation, the total fertility rate is 5, compared with LAC region. Young Haitian mothers are particu- 1.8 among women with the highest educational larly vulnerable due to poor nutrition. Low mater- level (PROFAMILIA and DHS 1995). In Guatemala, nal height-a risk factor for various poor which has the highest fertility rate in the region, reproductive and functional outcomes-is a seri- DHS data indicate that the urban TFR is 3.8, the ous problem among mothers in Guatemala, Bo- rural TFR is 6.2, and the TFR among indigenous livia, and Peru. women is 6.8. In Latin America and the Caribbean, as else- High Fertility Levels. Although average family where, economic status is a strong and consis- size has declined dramatically in the region, some tent correlate of fertility. In Peru, the poorest 20 countries-and some populations within low- percent of women have an average of 6.6 chil- fertility countries-still have relatively high fertil- dren during their lives, while the richest 20 per- ity rates. Countries in the region where the total cent of women have, on average, only 1.7 children. fertility rate (TFR) exceeds 4 children per woman As shown in figure 1, regardless of the national include Belize, Guatemala, Honduras, Nicaragua, fertility level, across the region the poorest house- Haiti, Bolivia, and Paraguay. Among women with holds have the most children, and the best-off Figure 1 Total Fertility Rate by Wealth Quintile Children per woman 10 - -- Bolivia 1998 - Brazil 1996 8 ....... Colombia 1995 . @ ** -*Dominican Republic 6 _^s t- 1996 Guatemala 1995 4 - X **w* - Haiti 1994-95 2 _ _ *- , , - -................ Nicaragua 1998 2_____ _____ _____ ___-__ _- _ - _ Paraguay 1990 Peru 1996 0 1 2 3 4 5 Poorest Richest Wealth quintileRihs * The Health of Women in Latin America and the Caribbean segment of the population maintains relatively low of modern contraceptive methods-and the use fertility, converging across countries at around two of contraception has increased significantly over children per woman. the past 15 years or so. At the same time, large gaps exist in contraceptive use, and choice of Adolescent Childbearing. In most Latin Ameri- methods is often severely limited. can countries, between one-quarter and one-third As shown in table 3, the contraceptive of women 18 years old or younger are pregnant prevalence rate ranges from about 13 percent of or have already had a child. Contraceptive use currently married women in Haiti to more than 70 among sexually active adolescents tends to be percent in Brazil. In parallel, nearly half of all sexu- relatively low; even among those adolescents us- ally active Haitian women in the reproductive ages ing contraception, discontinuation (especially due who wish to wait more than two years before be- to method failure) is higher than among older coming pregnant, or who wish not to become preg- women. Up to half of the pregnancies in young nant at all, are not using modern contraception, women are unplanned. Many of the children are compared to only 7 percent of Brazilian women born outside of marriage, making both the moth- with this "unmet need" for contraception. ers and their babies particularly vulnerable to so- The correlation of contraceptive use with cial and economic risk (Way and Blanc 1997). age, educational level, residence, and household income is almost invariable. Higher-educated, ur- Contraceptive Use. Compared with other parts ban women are vastly more likely than their less- of the developing world, the Latin America and educated, rural counterparts to use modern the Caribbean region exhibits relatively high use contraception. Correspondingly, the women from Contraceptive Prevalence and "Unmet Need" for Contraception by Country Grouping Women 15-49 years Women 15-49 years using modern with "unmet need" Country/Year contraception (%) for contraception (%) Medium-High Status Brazil 1996 70.3 7.3 Colombia 1995 59.3 7.7 Dominican Republic 1996 59.2 12.5 Medium-Low Status Bolivia 1998 25.2 26.1 Guatemala 1995 26.9 24.3 Nicaragua 1998 57.4 14.7 Peru 1996 41.3 12.1 Low Status Haiti 1994-95 13.2 47.8 Source: DHS various years. Women's Health Conditions households with the highest incomes use mod- ately if they want to limit all future births? The ern contraceptives in higher numbers than do results, shown in table 4, indicate a substantial women from the poorer households-" mismatch between reproductive goals and meth- in many cases, the match between ods used, particularly in medium-low status and women's reproductive desires and the type of low status countries. contraceptives used (or not used) is imperfect. For example, women who do not wish to have addi- Unintended Pregnancy and Abortion. tional children may be using short-term, "spacing" Throughout the region, regardless of development methods, instead of longer-term contraception or status, unplanned pregnancies are common. The sterilization. A background analysis for this report percent of recent births women report as mistimed examined the extent to which women in selected or unwanted ranges from 29 percent in Guatemala countries were using appropriate contraceptive to 54 percent in Haiti. Of particular concern for methods. Answers to the following questions were the welfare of women and children are the un- sought: Of women using modern contraceptive wanted births (those occurring to women who methods, what proportion were using spacing later say that they wanted no more children at methods that correspond to their reproductive the time they became pregnant). In both Bolivia aims-that is, want to become pregnant in the and Peru, for example, about 37 percent of future and are using oral contraceptives, barrier women who had given birth during the five years methods, or other spacing methods? What pro- prior to the DHS indicated that they had not portion were using spacing methods but do not wanted any more children. Even in the relatively want to become pregnant at any time? And what developed Colombian setting, about 23 percent proportion were using limiting methods appropri- of women report that they had wanted to end "Appropriate" Contraceptive Use by Country Grouping (percent of women using modern contraception) Appropriate Inappropriate Appropriate Inappropriate Spacing Spacing Limiting Limiting Medium-High Status Brazil 1996 18.2 22.6 59.2 0.0 Colombia 1995 19.1 32.7 47.8 0.4 Dominican Republic 1996 14.4 24.8 25.4 0.0 Medium-Low Status Bolivia 1998 18.7 52.1 29.2 0.0 Guatemala 1995 15.4 21.9 62.7 0.0 Peru 1996 25.2 49.5 25.0 0.2 Low Status Haiti 1994-95 25.8 38.4 32.9 2.9 So.rc. DHS various years. * The Health of Women in Latin America and the Caribbean childbearing before their most recent pregnancy tating health outcomes. In LAC, an estimated one- Mistimed births tend to be more common among fifth of maternal deaths are attributed to abortion- adolescent mothers, while unwanted births are related conditions, and an estimated 40 percent more typical among older women (see table 5). of women undergoing abortions experience seri- Women seeking to terminate an unwanted ous complications. pregnancy have few safe options in Latin America and the Caribbean. Although abortion is legally Maternity Care and Caesarean Section. The restricted in all countries in the region with the proportion of women who receive adequate pre- exception of Cuba, it is common and is typically natal care-defined as being three or more visits, performed inder unsafe conditions. The most au- starting before the seventh month of pregnancy- thoritative report on this topic indicates that abor- varies dramatically among countries, from 38 per- tion is common in Peru and Chile, with almost cent in Bolivia to nearly 90 percent in the one out of every 20 reproductive-age women Dominican Republic. Throughout the region, basic each year having an abortion, on average. Mexico health services fail to reach the women who are is estimated to have among the lowest incidence at highest risk for pregnancy-related problems. of abortion in the region-about one woman in Rural women are substantially less likely to re- 40 is having an abortion annually, on average. Nev- ceive prenatal care. Prenatal care coverage is ertheless, the average Mexican woman will have lower among women with little or no formal edu- had at least one abortion by age 50 (AGI 1996). cation and among lower-income women (see fig- The high abortion rates, combined with of- ure 2). The differentials are particularly striking in ten unsafe and unregulated conditions under Bolivia and Peru: In Bolivia, only about 32 percent which abortions are performed, result in devas- of the lowest-income but more than 92 percent of the highest-income women report two or more prenatal visits. In Peru, prenatal coverage ranges by Country Grouping from about 34 percent among poor women to more than 95 percent among the wealthiest fifth Unplanned of the population. pregnancy Professional assistance during delivery, a Country (%) strong marker of adequate obstetric care, is also Brazil 1996 48.4 highly variable in the region, following roughly the Colombia 1995 45.5 same patterns as prenatal care. In Haiti, only about Dominican Republic 1996 36.8 21 percent of births are attended by a nurse- Medium-Low Status midwife or a physician; in Brazil, nearly 9 out of Bolivia 1998 51.9 every 10 births are assisted by a physician or nurse- Guatemala 1995 29.3 Nicaragua 1998 33.2 midwife. The majority of births in Guatemala, Peru 1996 58.0 Bolivia and Haiti occur at home-a phenomenon Low Status highly correlated with income (see figure 3). Haiti 1994-95 54.3 Although commonly performed, delivery by Source:DHSvariousyears. Caesarean section (C-section) is associated with Women's Health Conditions At Least Two Prenatal Visits, by Wealth Quintile Percentage of pregnant womnen 100 ..................... Bolivia1998 --- Brazil 1996 ___________ -_____ _ .. _ Colombia 1995 80 _ :-_, df ...... 5;t w_ t + Dominican Republic 1996 60 f - Guatemala 1995 _ - Haiti 1994-95 40 _ ___ _ - Nicaragua 1998 Paraguay 1990 Peru 1996 20 1 2 3 4 5 Poorest Wealth quintile Richest I _1 ~ Delivery at Home, by Wealth Quintile Percentage of deliveries 100 - - Bolivia 1998 --- Brazil 1996 Colombia 1995 _ < > *** Dominican Reputbic 60 S ~ , _ f \ 0S, w 1996 '., \ l s \ \ Guatemala 1995 Haiti 1994-95 - '*, \ s Nicaragua 1998 20 *'.*>i Paraguay 1990 .. , *.,^ ., '**.,_ l ~ ^ Peru 1996 0 1 2 3 4 5 Poorest Wealth quintile Richest higher risk to mothers-3 to 30 times higher risk morbidity also increase with C-sections. In addi- than a normal birth-and substantially higher tion, human rights and health concerns have been costs than normal births. Risks include higher in- raised regarding the overuse of medical proce- fection rates, hemorrhage, lesions to other organs, dures at the expense of women's well being (Coe and maternal mortality. Perinatal mortality and and Hanft 1993). *3 The Health of Women in Latin America and the Caribbean In a number of countries, more than 10 per- DALYs Lost, 1990 and 2000 cent of births are facilitated by C-section: in the Baseline Estimates for STDS and HIV Dominican Republic (22.3 percent), Colombia (16.9 (thousands) percent), Paraguay (13.1 percent), and Bolivia (10.6 percent). The levels tend to be higher in urban ar- Female Male eas and among women with a secondary or higher STIs excluding HIV 925 544 level of education (Stewart and Stanton 1997). (668) (255) -Syphilis 392 443 (122) (143) Sexually Transmitted Infections. Sexually -Chlamydia 389 35 transmitted infections (STIs), considered a "hid- (404) (40) den epidemic" in the United States, have a major -Gonorrhea 145 66 (142) (72) impact on women's health and well being. Poten- Cervical Cancer 705 tial health consequences include infertility, can- (483) cers, ectopic pregnancies, spontaneous abortions, HIV 375 1,283 (895) (3367) stillbirths, low birth weight, neurologic and physi- cal abnormalities in children, and death. Sexually Source: Adapted from C. 1. L. \4urray and A.D. Lopez, eds. 1996. transmitted infections, excluding HIV/AIDS, have a more severe impact on women than on men for four major reasons. First, women are more bio- related DALYs among young children, mother-to- logically susceptible to certain sexually transmit- child transmission of syphilis appears to account ted infections than men. Second, women are for much of the impact of this disease on mortal- more likely to have asymptomatic infections that ity and morbidity. Although HIV continues to ex- delay diagnosis and treatment. Third, STIs are of- act enormous costs on the male population, the ten more difficult to diagnose in women because level of burden is projected to rise among women. the anatomy of the female genital tract makes Notably, the burden for HIV is slightly higher for 5- clinical examination more difficult. Finally, women to 14-year-old females than it is for 5- to 14-year- often do not control the use of condoms and the old males (see table 6). circumstances under which sexual intercourse takes place. HIV/AIDS. According to data from 1991 to 1996, This is largely borne out in the estimated the incidence of AIDS in the region is increasing, disability-adjusted life years (DALYs) lost among especially in the English-speaking Caribbean and women for curable sexually transmitted infections. Central America. Men who are infected continue Women assume a substantially larger burden for to outnumber women: the ratio for reported cases chlamydia and gonorrhea. Cervical cancer, which in 1996 was 3.2 in Latin America and 1.7 in the is related to infection with certain types of a sexu- Caribbean. However, the "gap" is narrowing, re- ally transmitted human papilloma virus, accounts flecting the increasing numbers of HIV-positive for a higher level of DALYs lost for females than women, especially in the Caribbean. Additionally, any other single sexually transmitted infection, in- the current female prevalence estimates-based cluding HIV. Given the concentration of syphilis- largely on women in prenatal care clinics-may Women's Health Conditions underestimate the levels of infection among all (IARC).12 In general, incidence is high across many women. Some evidence indicates that levels are of the countries in the region, regardless of devel- higher among all women than they are among opment status. Mortality levels, however, tend to those in prenatal care clinics (PAHO 1998). be higher in the medium-low status and low sta- The primary transmission mechanism is tus countries. Among regions, both incidence and unprotected sexual contact. In Latin America, ho- mortality levels are highest in Central America, as mosexual or bisexual behaviors are implicated in compared with South America or the Caribbean. 45 percent of the cases while heterosexual con- According to IARC data, Haiti has the region's tact figures as the major risk factor in 75 percent highest incidence level, while Nicaragua has the of the Caribbean cases (PAHO 1998). In some highest mortality level (among the countries de- countries, intravenous drug use is having a major picted in table 7). The trends for the region overall impact. In Brazil, for example, research conducted suggest that mortality related to cervical cancer since 1990 indicates that one-third of all injecting has not declined significantly. drug users in major urban areas are HIV positive. Early diagnosis of cervical cancer is essen- The epidemic is increasingly concentrated tial for successful treatment. In North America, among the most disadvantaged population dramatic declines in cervical cancer are largely groups, especially those with low education and due to the widespread availability of routine vagi- poor access to basic health-care services. HIV nal cytology screening or Pap smears. In the Met- prevalence levels are especially high among some ropolitan Region of Santiago, Chile, 10 years of commercial sex workers; in San Pedro Sula, Hon- sustained screening have led to a decline in cer- duras, HIV prevalence among commercial sex vical cancer mortality from 13.9 per 100,000 in workers has ranged from 15 to 20 percent since 1985 to 8.7 per 100,000 in 1997. Screening pro- 1989. Research findings also suggest that HIV/ grams in Cali, Colombia, have also shown mea- AIDS is occurring among increasingly younger surable decreases in mortality. population groups, with infection acquired during Overall, an estimated 63 percent of Latin adolescence. in the Southern Cone, for example, American women have had a Pap smear at least the median age among AIDS cases was 32 from once in their lifetime. Large differences in cover- 1983 to 1989. The median has dropped to 27 years age, however, have been documented across coun- of age, according to data from 1990 to 1992 (PAHO tries. For example, survey data suggest that 35 1998). As the epidemic matures, even if it started percent of women in Nicaragua have had a Pap among intravenous (IV) drug users or men who smear at least once, compared with 70 percent of have sex with men, it moves aggressively into the women in Costa Rica (PAHO 1998). Evidence also poor and female populations. indicates large differences in Pap smear coverage by age, education, income, and residence. Various Cervical Cancer. On average, the countries of studies conducted in the region-in Brazil, Chile, Latin America and the Caribbean have the high- and Mexico, for example-indicate that women est cervical cancer incidence and mortality levels from lower socioeconomic levels are less likely in the world, according to estimates from the In- than their better-off counterparts to know of the ternational Agency for Research on Cancer Paptestortohaveundergoneatest(Robles1996). e The Health of Women in Latin America and the Caribbean Incidence of and Mortality Due at least four years (screening is often recom- to Cervical Cancer per 100,000 mended at intervals of once every three years, Women, Age-Standardized Rates by Country Grouping, after two consecutive annual negative results). (1990 Estimates) Poor or uneducated women are less likely to have had a Pap smear than better-off groups, Incidence Mortality and research indicates that mortality levels are High Status higher among poor or uneducated women than Argentina 27.60 9.50 Chile 28.52 12.13 among their better-off counterparts. In Quito, for Costa Rica 24.96 12.13 example, researchers found that less-educated Panama 42.58 13.92 women (with a primary education or less) had Uruguay 25.64 7.87 nearly twice the incidence of cervical cancer of Medium-High Status those with secondary or higher education (Corral Brazil 30.55 16.36 Colombia 31.58 16.10 and others 1996). The authors also found that Dominican Republic 23.59 20.45 women with the lowest educational levels tended El Salvador 33.99 19.34 to be diagnosed with later stages of cervical can- Jamaica 44.12 21.31 Mexico 45.32 16.19 cer (lii or IV), which are associated with poor sur- Paraguay 41.10 22.04 vival prospects. In contrast, women with higher Trinidad and Tobago 22.39 13.89 education were diagnosed earlier (PAHO 1998). Venezuela, R. B. de 26.78 15.17 Medium-LowStatus 26.19 Women Face a Large Burden Ecuador 28.45 23.46 from Chronic Disease, and the Guatemala 43.95 23.65 Poor, Rural, and Uneducated Honduras 43.95 23.65 Individuals Are Most Affected Nicaragua 61.33 32.83 Peru 39.45 21.46 Low Status The disease burden represented by a number of Haiti 91.46 21.96 chronic or noncommunicable illnesses is higher Source: Parkin and others 1999. International Agency for for women than men. The relative female burden Research on Cancer; WHO GLOBOCAN I database. for cardiovascular disease is higher for women between the ages of 15 and 44 years old, and among those 60 years old and older. Women have In Honduras, survey data also confirm that women a larger burden for cancers, with cancer DALYs from lower socioeconomic levels and rural areas peaking at younger ages for females (45 to 59 are much less likely to have undergone a Pap years old) than for males (60 years old and over). smear than are women from better-off groups. Breast and cervical tumors in women occur at an Among those who have undergone a Pap smear, earlier age than the most common malignant tu- poorer and rural women are also less likely to mors do in men (PAHO 1998). Breast cancer takes know the results of their last test. Older women, a toll on women from the age of 15 onward. The at higher risk for the disease, are more likely than burden for colorectal cancers is higher among younger women to have not had a Pap smear for women aged 45 and older than men in the same Women's Health Conditions group. Although diabetes-related mortality is in- tends to account for a larger share of mortality creasing among men, the DALYs lost among among better-off populations, probably because women are still substantially higher; the difference of patterns of reproductive risk factors, such as is maintained from age 15 onward. Musculoskel- delayed childbearing among richer and better- etal diseases, which can dramatically affect physi- educated women. cal function and mental health, take a much larger toll on women than men (see table 8). The differ- Cardiovascular Disease. Among noncommuni- ential begins at age 5 and is maintained through- cable illnesses, cardiovascular diseases account out the life span. for the highest amount of DALYs lost among The pattern of incidence and prevalence by women.3 Projections suggest that 31 percent of socioeconomic conditions is complex. Cardiovas- deaths from all causes in the year 2000 will be cular disease, diabetes, and, as seen above, cervi- due to cardiovascular diseases. cal cancer tend to be more problematic among Premature mortality from cardiovascular poorer populations. Conversely, breast cancer diseases varies from one country to another. For women, the country with the highest years of po- tential life lost (YPLL) is Argentina, followed by Trinidad and Tobago, Brazil, and El Salvador. The lowest rates for both women and men are in fiatDALYs Lost (thousands) Selected Chronic Illnesses Canada, Chile, and Costa Rica. Trend analyses con- 1990 and 2000, Baseline ducted by PAHO indicate that 6 out of 13 coun- Projections (in parentheses) tries studied have had a significant decline in YPLL: Argentina, Mexico, Chile, Colombia, Costa Female Male Rica, and Trinidad and Tobago. Rates in El Salva- Noncommunicable 33,378 33,014 dor appear to have been increasing since the Disease (26,719) (29,077) Cardiovascular 7,345 7,451 1970s. Generally, rates for cerebrovascular disease Disease (4,454) (5,323) have declined except in Cuba, El Salvador, and -Ischaemic heart 2,666 3,019 the Republica Bolivariana de Venezuela. Hyperten- disease (1,663) (2,213) -Cerebrovascular 2,404 2,267 sion is a major risk factor for the development of disease (1,502) (1,658) cardiovascular disease. In most countries, the Chronic Obstructive 779 965 PulmonaryDisease (663) (768) YPLL rates are higher for men than women. Malignant Neoplasms 4,647 3,706 Women, however, had consistently higher YPLL (3,106) (2,631) rates in Barbados, Colombia, Mexico, and Nicara- -Breast cancer 806 (552) gua (PAHO 1998). -Colon and rectum 251 204 Chile, one of the countries with the most cancers (168) (152) favorable mortality statistics, illustrates male- Diabetes Mellitus 1,450 1,032 female and socioeconomic-related differences in (832) (683) Musculoskeletal Disease 2,764 1,740 cardiovascular disease. Overall, the rate of mor- (2,370) (1,493) tality from stroke is slightly higher for men (71.2 Souirce:Adaptedfrom MurrayandLopez 1996. per 100,000) than for women (69.5 per 100,000) The Health of Women in Latin America and the Caribbean for the period 1994-96. Looking across socioeco- Risk factors for Type II diabetes include a nomic groups, however, it is clear that the overall number of modifiable factors amenable to primary male-female differential obscures some female prevention, including hypertension, obesity, a sed- disadvantage among the lowest-income (and entary lifestyle, and upper-body obesity The level least-educated) populations: On an age-adjusted of complications among those with diabetes can basis, Chilean men with no education have a be lowered by addressing risk factors such as stroke mortality rate of 84.5 per 100,000, com- smoking and high blood pressure (PAHO 1998). pared with 32.9 per 100,000 among highly edu- Diabetes-related mortality increases with age cated Chilean men. Among women, those with (Brownson and others 1998). no education die from stroke at the rate of 93.6 Primary prevention measures for diabetes per 100,000, compared to 27.4 per 100,000 among include a well-balanced, low-fat diet; weight con- women with more than 13 years of education. trol; and consistent physical activity (Brownson Hypertension, one of the primary risk fac- and others 1998). Obesity is increasingly common tors for stroke, affects an average of one-quarter among women, especially with age. In the United of adults in Latin America and the Caribbean, ac- States, research suggests that women tend to be cording to PAHO estimates. The high prevalence less physically active than men in leisure time; represents an important challenge for the health self-estimates of physical inactivity during leisure system because proper control of hypertension time are 26.5 percent for men, compared with can reduce five-year mortality from stroke by 51 30.7 percent for women. The differences are es- percent among those under age 60. pecially striking at age 75 and older, when 50.5 percent of women report physical inactivity dur- Diabetes Mellitus. The number of people with lng leisure, compared with 38.2 percent of men diabetes in the Americas-currently estimated at (Brownson and others 1998). Recent survey data 13 million-is projected to rise 45 percent by the from Chile suggest higher levels of inactivity and year 2010. Projections suggest that dramatic in- larger disparities between women and men: 93 creases will occur in Central America and the Car- percent of women reported physical inactivity, ibbean Islands (PAHO 1998). Throughout the compared to 78 percent of men. region, female mortality exceeds male mortality: the ratio is 1.2 to 1 in Latin America, unadjusted Cancers. In general, mortality levels related to for age. Two major factors are associated with cancers are rising in the region. PAHO analyses greater relative female disadvantage: First, women indicate that increases are registered at earlier are more likely to develop Type II (non-insulin de- ages (25 or 30 years old) and are more widespread pendent) diabetes than men. Second, women live among women. Population aging is implicated in longer, with a higher lifetime probability of devel- cancer-related mortality increases. In the region, oping the disease. Socioeconomic factors, however, there were an estimated 344,000 cancer-related are also probably involved. In general, persons with deaths in 1990. Female deaths exceeded male diabetes in the region are about twice as likely to deaths (176,000 and 168,000, respectively). Ac- die from the disease than are those with diabetes cording to projections for the 50-year period be- in North America (PAHO 1998). ginning in 1990, however, the number of deaths Women's Health Conditions from cancers is supposed to reach parity among percent in Costa Rica. Among subregions, breast women and men in the year 2000 (PAHO 1998). cancer mortality rates exceed cervical cancer According to PAHO, the leading causes of rates in the Caribbean and South America. cancer deaths among women in 1990 were There is still much controversy over breast colorectal cancers, followed by breast cancer and cancer screening methods, in particular their uterine cancer. Breast cancer mortality levels were cost-effectiveness and positive predictive value higher in the more developed countries in the re- in countries with low prevalence of disease. In gion, while uterine cancer was more common in industrial countries, only mammography screen- less developed countries. This may, however, be ing for women aged 50 and above has demon- partly an artifact of different recording procedures strated a significant reduction in mortality (PAHO 1998). In the region, among malignant neo- (approximately 23 percent), and there is increasing plasms, breast cancer accounts for the single evidence of the efficacy and cost-effectiveness highest number of DALYs lost for women. of treatment in early stages of the disease (Galani Breast cancer incidence is highest in and Robles 1998). Uruguay (88 per 100,000), with a level exceeding that of Canada and on par with incidence in the Multiple Risk Factors. It is now clear that risk United States. The next highest incidence levels factors tend to cluster in certain population in the region are found in the high status coun- groups, and that the behaviors to which they are try of Argentina, followed by Jamaica and Trinidad associated are complex in nature and change over and Tobago. The lowest incidence levels per time. Thus the best way to learn about the distri- 100,000 are found in Haiti (5), El Salvador (13), and bution of those risk factors in the population is Nicaragua (16). through surveillance, which by definition requires The mortality rate is highest in Uruguay (26 continuous data collection. Along the same lines, per 100,000), exceedingthe rates found in Canada interventions to prevent and control risk factors, or the United States. The next highest rates are among those both with and without associated found in Jamaica (25), Haiti (24), Argentina (22), conditions (such as diabetes and hypertension), Brazil (21), and Trinidad and Tobago (19). Despite need to be multifactorial, targeting sets of risk fac- having the lowest incidence level, Haiti-the tors in various ways, through health services region's only low status country-has one of the based on prevention as well as on health- highest mortality rates (23.61 per 100,000). Breast promotion strategies. cancer mortality is generally higher among It has been suggested that the higher rates women aged 50 and older, and increases with age of diabetes among women and the difficulties in (Gomez 1997). hypertension and diabetes control are associated Although mortality rates in the region are with higher levels of obesity and physical inactiv- generally lower than those found in North ity. Recent PAHO surveys indicate that in Bolivia America, the rates of increase are high in many 56.6 percent of males and 64.7 percent of females countries in the region. From 1965 to 1985, for are overweight, while 26.1 percent of males and instance, the mortality rate increased by approxi- 30.3 percent of females are obese."t In Chile 60.3 mately 4 percent in Uruguay and Chile and 17 percent of males and 63.1 percent of females are The Health of women in Latin America and the Caribbean overweight, and 17.3 percent of males and 23.4 In Latin America and the Caribbean, coun- percent of females are obese. tries in which the prevalence of smoking is high, Physical activity is considered to be the the male-female ratios are lower; in low preva- single behavior that can lead to modifications of lence countries these ratios are higher. Among the other two major risk factors (diet and smok- women, the prevalence of smoking increases with ing). In a survey in Chile, 93 percent of women educational status, but among males this trend is and 78 percent of men were reported to be physi- not as clear. There is evidence that the epidemic cally inactive. Physical inactivity also has eco- has taken a different course among women than nomic consequences-in the United States, the among men, which may reflect differences in mar- costs associated with physical inactivity and obe- keting strategies. Women exhibit a higher preva- sity accounted for 9.4 percent of the national lence of smoking in higher-income countries and health expenditure in 1995 (Colditz 1993). in countries with more women in the workforce, Tobacco consumption is the major risk fac- which is likely related to a greater capacity to pur- tor for noncommunicable diseases. According to chase tobacco products and the greater social available data in North America and Latin America, acceptability of women smoking (Robles 1993). between 1996 and 1999 tobacco prevalence in the population ranged from a high of approxi- What Does This Information mately 40 percent in Argentina and Chile to a low Tell Policymakers and of 22 percent in Colombia. In some urban areas, Program Managers? more than half of young people smoke. Among men, the percentage of the population who Drawing inferences for policymakers and program smokes ranges from 47 percent in Argentina and managers over a large number of countries with Chile to 26 percent in Colombia. Among women, varied health-care settings and resource con- the high is 36 percent in Chile, with a low of 16 straints (and inadequate data) is risky, but several percent in Peru. messages stand out. The foregoing review demon- strates that there are serious gaps in policies as they affect the health of women, particularly of y Prevalence of Smoking poorer and less-educated women. Simple and fairly by Sex and Country (per 100 inhabitants, for latest obvious recommendations are the following: available year) 4* Countries now falling into the low sta- Country/year Males Females tus and medium-low status categories should fo- Argentina 1999 46.8 34.0 Chile 1998 47.2 35.5 cus resources on Improving basic reproductive Uruguay 1999 38.0 26.0 health conditions. The interventions required are Bolivia 1998 42.7 18.1 relatively low cost, in general, and yet have major Colombia 1996 25.2 12.1 pay-offs in terms of health conditions and human Peru 1998 41.5 15.7 Costa Rica 1995 28.6 6.6 welfare. Provision of appropriate family planning Mexico 1993 38.3 14.2 methods to women who want to control their fer- Source: PAHO 2000. tility, providing early and reliable prenatal and es- Women's Health Conditions sential obstetric care, fostering good nutrition, and + At the same time, there is clearly room developing specially targeted services for women for specific types of public action to address the at high risk for sexually transmitted infections, growing problems of chronic disease that affect should all be very high on the public priority list. both men and women, although the nature of These services have broad benefits for house- these health problems-potentially very high cost, holds and society at large, and are arguably particularly given technological advances, and among the most cost-effective investments that with limited benefits to society at large-requires governments can make. careful thought about the level, distribution, and + In medium-high and high status coun- mechanism for public investments. For example, tries, the government also has a role in ensuring governments have an important role in promot- the availability of these core services. For the ing cost-effective screening and preventive inter- same reasons as above, the public sector should ventions, such as cervical cancer screening focus on reaching the poorest 20 to 40 percent of directed at women who are at high risk of con- the population with precisely these basic repro- tracting the disease, and supporting cardiovascu- ductive health services, to reduce the large gap in lar disease-prevention programs, particularly for women's health conditions between the poor and low-income populations that are at disproportion- the better-off segments of the population. ate risk and have few resources. CHAPTER TWO elivery and Financing of Women's Health Services Chapter Summary + Spending on women's health services accounts for about one-quarter of public health spending and nearly half of household spending on health. Thus, making this spending more effective can improve the overall efficiency of the sector. + The volume of (and growth in) spending on women's health services shows large pay-offs, particularly in reproductive health outcomes: fertility decline, more births attended by professionals, and contraceptive use. However, there are big differences in the extent to which spending meets needs by income level: women from the lowest-income households report the most illness, but taking "need" into account, poor women obtain lower levels of health care than do their better-off counterparts. + There is little evidence that women are more disadvantaged than men wiNth respect to household resources for health services, and insurance coverage is equal between men and women (although concentrated in highest-income households). + To address the unfinished agenda for reproductive health, the poorer countries will need to mobilize substantially more resources for reproductive health from outside or within the health sector-a difficult task in times of declining external support and growing attention to other public health concerns (such as HI V/AIDS), In both better-off and poorer coun- tries, the demand by poorer women must be stimulated and made effective. The information presented in the previous chap- be requirec to meet the growing demand for ter demonstrates some of the centra cha lenges women's health services.5 facing the health systems of Latin America and This analysis has both conceptual and em- the Caribbean in responding to the health-care pirical limitations, but t represents a step toward needs of womer. This chapter addresses the formulation of appropriate national and donor question of who is currently using health services, policies. Little empirical research exists in the re- now those services are financed, and how to esti- gion on the gender dimens ons of perception of mate the public anc private resources that would health prob ems, the decision to seek care, or neal:h-serv ce utilization and spenoing. Th s chap- Thrs chapter contans contributtons by Dera Carr ter seeks to employ the rich data sets provided 33 *3 The Health of Women in Latin America and the Caribbean by nationally representative household surveys, ban areas, is mostly public (except in Paraguay), institutional budgets, and expenditure studies in and women and men benefit equally. seven countries (Brazil,16 the Dominican Republic, Wealthier women are more likely to seek Guatemala,17 Jamaica, Mexico, Paraguay, and care in the private sector, although there is sig- Peru). These countries were selected because of nificant use of public services by the upper- tne availability of household survey data and geo- income quintiles. Women, even in the poorest 20 graphical representativeness; all correspond to ei- percent of the income distribution, are more likely ther the medium-high or medium-low countries than men to seek care in private health facilities in the typology. The discussion that follows refers or pharmacies. The use of private facilities as the only to data from these seven countries. first site of care among the poorest quintile ranges from lows of 5 percent among females in Brazil" Characteristics of Women's to highs of 29 percent of first visits among fe- Health Services males in Paraguay. Types of Providers and Services Provided. Need, Access, and Utilization. Recognizing the Health-care delivery systems in Latin America and complexity of using self-reported illness, in these the Caribbean can be categorized in four sectors. seven countries more females report health prob- The public sector includes government and social lems than do males, across age and income security-run hospitals, clinics, and health posts. groups, and this difference is highly significant. The not-for-profit sector includes charitable and For both sexes, health problem reporting de- nongovernmental organizations (NGOs). Private in- creases as income increases. Country effects are dividual practitioners, private hospitals, clinics, also statistically significant. Jamaica, the country and pharmacies make up the organized pr/vate with the fewest reported health problems, was sector, while an informal private sector of tradi- used as the reference country, so that all results tional healers and lay midwives also exists. Each are relative to Jamaican figures. The results show sector comprises a greater or lesser share of utili- that health problem reporting in Mexico is 8 per- zation and spending in each country depending centage points higher than in Jamaica, while in on the organization of the health system and socio- Peru it is 26 points higher. While survey question cultural practices, but all exist in every country. design may be playing a role in these results, Public sector provision is the most com- these differences in reporting also reflect under- mon source of women's health services, although lying health conditions, institutional settings, and the private sector does provide a sizeable share the availability of public and private resources. of services, even in poor communities. In the To assess how sociodemographic and eco- countries studied, having perceived a medical nomic factors influence the decision to seek care, problem, most women seek care in the public sec- the case of the Dominican Republic was exam- tor or from publicly financed private providers- ined in greater detail (see box 1). The odds that a ranging from 42 percent of all visits in Paraguay female will seek care in the event of a health prob- to 76 percent in Brazil. Insurance coverage is con- em are about 25 percent greater than they are centrated in the upper-income quintiles and ur- for her male peers. Females from 0 to 14 years Delivery and Financing of Women's Health Services old and over 65 years old, in urban areas, wealthy, women's higher levels of illness perception as a and insured are the most likely to seek care, by function of learned behavior patterns.19 large and significant proportions. Health status Nevertheless, women do report more illness, and the perceived severity of the health problem and this has an impact on the use of services: fe- also have strong and highly significant effects on males consume more outpatient and inpatient the probability the person will seek care. health services than do males across all the coun- Women's greater perceptions of illness tries studied. After accounting for pregnancy and have been viewed as a function of greater objec- childbirth,20 which generates health-service use by tive need for care. Other information, such as the most women, women consume more health care burden of disease studies and mortality data, than men of comparable age and income. shows that higher levels of morbidity and mortal- The household surveys analyzed provide ity are present among boys and men in the re- mixed evidence of higher rates of health-care use gion up to age 60. However, male reporting on during the reproductive years, which might be health problems is well below what might be ex- partly related to data deficiencies. In Peru and pected, given these statistics. This may reflect that Jamaica, women in the 15- to 45-year-old age the male burden of disease has different charac- group are most likely to use services, after chil- teristics (accidents and violence), which may lead dren who are 0 to 15 years old. However, in Para- to health problem reporting or, as will be seen guay, Brazil, and the Dominican Republic, women later on, which may lead to more intensive use of between 15 and 45 years old are the least likely health services. Alternative explanations interpret to seek care. Explanations for females' more intensive use of health services are similar to those pre- sented for health-problem perception, with the addition of a hypothesis regarding the health-care What increases the odds delivery system. The health-care delivery system of seeking care? may contribute to women's greater perception To assess how sociodemographic and and use of health services through, for example, economic factors influence the decision to funding mechanisms supporting specific women's seek care, the case of the Dominican services or increasing "medicalization" of men- Republic was examined in greater detail. The dds hat femle seks are n th struation, pregnancy, birth, and menopause. A tra- The odds that a female seeks care in the event of a health problem are about 25 dition of vertical programming in maternal and percentgreaterthantheoddsthathermale child health and family planning in the region may peers will seek care. Females aged 0 to 14 years old and over 65 years old, in urban encourage greater utilization of services by fe- areas, the wealthy, and the insured are the males. Moreover, if females make more visits, most likely to seek care, by large and they are also exposed to more opportunities for significant proportions. Health status and the perceived severity of the health problem also have strong and highly significant positive test results; and iatrogenic conditions, all effects on the probability of seeking care. of which may, in turn, contribute to greater sub- sequent utilization. V The Health of Women in Latin America and the Caribbean As suggested in the first chapter, several fac- Another means to explore the need- tors determine whether or not women have ac- utilization relationship among females is in the cess to and take advantage of health-care services: analysis of equity,2' using methods developed to household income, opportunity costs, cost of ser- rneasure whether persons with equal health vices and transport, availability and quality of ser- "need" are obtaining similar amoints of care.22 vices, cultural preferences, and an awareness of Figure 4 illustrates the degree of inequality in the the need to seek treatment. Reasons for non-use distribution of medical care among women in are one means to explore access constraints and Brazil, a pattern that holds in the other countries explain utilization patterns. In response to ques- studied. Controlling for the effects of age and tions on reasons for non-use given the presence health need, women in the lowest-income of a health problem, most women reported that cuintile use fewer services than their need would they considered treatment unnecessary, presum- suggest. The opposite is true of upper-quintile ably because the severity of the health problem women who use more services than they "need." did not warrant a visit, or because they were un- Need-based use is most equitable in Jamaica, aware of the need to seek treatment. The excep- followed by the Dominican Republic, Paraguay, tion to this pattern is in Paraguay, where self- Peru, and Brazil. medication was given as the most important reason In the countries studied, household sur- for non-use, perhaps due to the limited availability veys offer little evidence of gender bias unfa- of services. The cost of services and transport were vorable to girls and women as a group, in terms the second and third most common reasons for of access to and utilization of health services, a non-use in all countries studied. However, the im- finding that has been confirmed by other re- pact of cost, transport, availability, and quality of search in the region.2" However, the results dif- care on the likelihood of health-service use appears fer somewhat from those found in studies to affect women and men equally. carried out in other regions,24 particularly with Upper income groups are much more likely regard to spending, as will be seen in the next to seek care in the case of a health problem. This section. Across age and income groups, females highly significant difference is about 18 percent- report more health problems (chronic and in the age points on average for the sample of coun- last 30 days), and seek treatment for these tries studied. This phenomenon is observed in problems, more often than do males. However, both sexes, though a significant difference exists the profound differences in access to care re- between women and men in the lowest-income lated to income, place of residence, and insur- quintile, and it is like y that access and cost are arice coverage set the gender issue in context. factors driving this differential. Place of residence Females in the lowest-income group report the also has a dramatic effect on the decision to seek highest burden of health problems relative to care, with rural females 11 percent less likely on both males and females in other income average to use services once a health problem quintiles. Although a greater proportion of these has been identified. The greatest gaps in use be- women have a health problem, they are the tween rural and urban residents exist in Peru, the least likely to seek treatment. Inequity is con- Dominican Republic, and Jamaica. centrated in this group: at the same level of Delivery and Financing of Women's Health Services Differences in Women's Use-for-Need Brazil Kakwani index 0.06 0.04 0.02 0.00 Use-for-neec, -0.02 -0.04 / -0.06 1 2 3 4 5 Poorest Richest Wealth quintile need, poor women do not receive similar levels tially, government spending accounts for 60 per- of care. cent of the total. These changes include women's health services. Financing of Women's Health Services Public Spending on Women's Health. For our purposes, public spending on women's health Total Health Spending and Its Impact on consists of public spending on services and prod- Spending on Women's Health. The analysis of ucts among whose objectives are the mainte- health expenditure should be interpreted in the nance or improvement of women's health. This context of a regionwide transition, in which the includes programs that target women specifically, role of the state as a service provider is being such as maternal care, as well as any curative or modified to a regulatory role, and many political preventive care utilized by women. On average, it and administrative functions are being decentral- accounts for 24 percent of all health spending in ized. Public health expenditure in the countries the seven countries studied, ranging from 16 per- studied has fallen to a weighted average of less cent in the Dominican Republic to 35 percent in than half (44 percent) of total health expenditure. Guatemala (see table 10). In the Dominican Republic, public expenditure is Public spending on women's health per fe- least important, which may be associated with male inhabitant shows marked differences, from recent growth in private care-seeking, especially US$150 to US$25 in the extreme cases, with per private hospital care. In Guatemala, where health capita spending six times larger in Brazil than in reform has increased public spending substan- Guatemala. The growth of public spending on * The Health of Women in Latin America and the Caribbean 3 e Public Spending on Health and Total Public Spending on Women's Health by Type of Institution, 1997 PSWH Percent Public as per- PSWH PSWH PSWH Health PSWH cent of per per provided Spending (millions PSWH Public woman woman by Social as percent of US as percent Health (US (US$ Security Country of GDP dollars)a of GDP Spending dollars) at PPP) Institutes Brazil 3.0 12,045 1.6 24 151 201 100 Mexico 2.0 3,960 1.2 23 84 166 77 Peru 2.0 705 1.1 26 59 104 33 Paraguay 2.5 131 1.3 18 55 75 38 Dominican Republic 1.8 144 1.1 16 53 111 34 Guatemala 1.4 139 0.8 35 34 89 51 Jamaica 2.7 68 1.4 20 25 61 NA l'SWH: public spending on women's health; GDP: gross domestic product; PPP: purchasing power parity dollars. Soturce: Hernandez and others 2000. a. Includes expenditure on reproductive and non-reproductive health. women's health is strongly and significantly asso- but provide a group of interventions including, but ciated with fertility decline, greater coverage of ob- not limited to, health services. These institutions stetric care by trained medical professionals, and account for 14 percent of public spending on contraceptive use up to a certain level of spending. women's health, on average. Public spending on health primarily in- cludes two types of institutions-ministries of Unmet Needs and the health and social security institutes-which to- Spending Gap gether execute approximately 85 percent of all public spending on women's health. Frequently, If many countries in Latin America and the Carib- other public institutions provide services to spe- bean are spending large sums on women's cific population groups, but the amount of their health-and they are-and if, as shown in chap- resources and services is much smaller This is ter two, significant portions of the female popula- the case with institutions whose primary function tion experience poor health and are not using is not the production of health services, but that basic health services, then the question arises: provide coverage to workers through their own Should governments in the region spend more to infrastructure or through contracting mechanisms increase coverage, or should they allocate their (see box 2). Similarly, there are special funds for current spending differently, or both? The ques- activities or coverage of specific population tion can perhaps best be answered by looking in groups (such as indigenous peoples, the elderly, depth at a specific country's spending and ser- and the poor) which form part of public budgets vice delivery patterns, health conditions, and Delivery and Financing of women's Health Services population characteristics. The question can also be addressed, in a limited way, by comparing what is currently spent on women's health services with Other public institutions can be the recommended amounts for a package of core iportant actors in the health sectr. reproductive health services.25 + In the Dominican Republic, the For the countries included in the present presidency of the republic finances 16 analysis (see table 11), this "rough" assessment percent of PSWH through infra- of the spending gap indicates that there is little or structure investment and equipment purchases for health facilities, and the no funding deficit In Brazil, Mexico, or Jamaica, all Program of Essential Medications is of which are medium-high status countries. Fi- responsible for the purchase, storage, nancing of the core reproductive health services26 and distribution of medication to ministry of health hospitals, the might require reallocation and Improved efficiency, primary care network, and the but no significant influx of funds. In Paraguay and "popular pharmacies." the Dominican Republic, also medium-high status + InMexico,inadditiontotheministry countries (although with lower GDPs), marginal of health, there are four institutions additional resources-from 11 to 15 percent of that provide services to the unin- sured, and social security is offered by current public spending on reproductive health- five institutions. These latter organi- would be required to finance the core reproduc- zations (SSA, IMSS, and ISSSTE) tive health services for the entire population. In represent 88 percent of public health expenditure in the country. The contrast, in the medium-low status countries of institutional complexity of health Peru and Guatemala, public spending on repro- systemsdoesnotnecessarilygenerate ductive health services would have to increase higher levels of expenditure. by about 25 to 50 percent in order to achieve the target. It is important to note that these estimates do not fully take into account the current and ex- spending on reproductive health is on the in- pected declines in external assistance to repro- crease, but does not fill the financing gap caused ductive health services. The LAC region received by withdrawal of multilateral and bilateral repro- 13 percent of international reproductive health fi- ductive health funding from the LAC region to nancing in 1996, amounting to approximately support more economically disadvantaged re- US$195 million, with half of the funds going to gions. For instance, USAID, a major player in the NGOs. A third was channeled bilaterally, principally health field and one of the principal supporters of through the U.S. Agency for International Devel- reproductive health in the LAC region, has re- opment (USAID), and 16 percent was provided duced health funding to the region as a whole through multilateral agencies, such as the United and closed down its health, nutrition, and popula- Nations (UNFPA 1996). tion programs in several countries. Funding for About half of reproductive health spending population and reproductive health programs in in the LAC region is financed through external as- the LAC region declined by 15 percent between sistance. National spending as a share of total fiscal years 1997 and 1998, and has remained The Health of Women in Latin America and the Caribbean m ml Public Spending Gaps for a Basic Reproductive Health Package, 1997 Public Spending on Reproductive Health Package as per woman percent of Country (PPP US$) 1997 PSRH Gap (millions US$) Brazil 34 52 No gap Mexico 33 63 No gap Paraguay 8 139 15 Jamaica 11 94 1 Peru 12 100 23 Dominican Republic 27 117 11 Guatemala 26 170 54 PSRH: public spending on reproductive health; PPP: purchasing power parity. Source: Hernandez and others 2000. stable since then (from US$74 million in 1997 to In this sample of females and countries, the US$63 million in 1999). In contrast, funding for percent of income spent on health care falls as child survival programs in the same period first income increases. The wealthiest quintiles spent declined by 26 percent but later was replenished between 1 and 2 percentage points less on health in full, to begin and end with approximately US$53 out of their total househoid budget than does the million. Furthermore, USAID closed all of its health first quintile, while the second and third quintiles operations, with the exception of HIV/AIDS, in are not significantly different from the poorest. Mexico and Colombia. Aid to Brazil ended in 2000 This result may reflect the confounding effects of and health support to Ecuador will end in 2001. insurance coverage, which is most prevalent Retrenchments by USAID will continue in future among the upper-income quintiles. Most other years in countries that have not yet been studies have found health care to be income- identified. elastic, which is reflected in a rising share of ex- penditure on health as income increases. Private Spending on Women's Health. To de- As a share of total household expenditure, termine the variations in the share of spending low-income households spend slightly more for that can be attributed to sex, income level, and health-care needs of females than do households country of origin, group averages were analyzed. in higher-income quintiles. In the Dominican Re- Independent of income level or country, house- public and Paraguay, this effect is more pro- hold spending on female health exceeds that of rounced, perhaps due to the limited coverage of males by about 1 percentage point of total house- public subsidies in these countries. hold spending. Women report more health prob- The composition of health spending by lems, and seek care for those problems, more women 15 to 45 years old shows that women in often than men. All else being equal, household this age group are most likely to spend on medi- expenditure should be higher for females. cines, from 48 percent of all expenditures in Brazil Delivery and Financing of women's Health Services to a high of 92 percent in Paraguay.27 In all coun- percent goes to private facilities, though this ratio tries studied, the share of expenditure allocated is reversed in the upper-income quintiles. to medicines is highest in the lower-income Households at all levels of income are uti- quintiles. There are several possible explanations lizing public and private health services, and for this phenomenon. it may reflect higher levels households at all levels of income are receiving of self-medication but may also show that medi- some level of subsidy in the public sector. This is cation is less likely to be subsidized at the point due in part to the participation of social security of service as compared to the costs of the visit services in the public sector, which include upper itself. This is the case for uninsured and low- income groups; it is also related to the fact that income women, for whom relative expenditures often the most complex and technologically ad- on medicines are thus likely to be higher. vanced services are available only at large public Outpatient and inpatient expenditures are hospitals. the next largest categories of spending, and vary greatly depending on the health system. In Jamaica and in the Dominican Republic the great- What Does This Information est share of expenditures is allocated to out- Tell Policymakers and patient care, largely due to the importance of the Program Managers? private sector in the provision of outpatient treat- ment. In Jamaica, 64 percent of expenditures went These analyses, although limited, carry both good to outpatient care, 37 percent specifically to pri- news and bad. The good news is that in many vate providers, reflecting that public outpatient countries in the region the public sector is dem- services are heavily subsidized through the Na- onstrating the priority it gives to improved tional Health System. In the Dominican Republic, women's (and particularly maternal) health by de- 74 percent of expenditures are in outpatient care, voting a considerable share of all government with 67 percent going to private providers, reflect- spending to women's health programs. Good ing a different phenomenon of lack of availability health conditions for women-and particularly of services and quality of care in the public sector. dramatic improvements in reproductive health The share of expenditures devoted to hos- outcomes over the past 15 years-demonstrate pitalization is relatively small, a surprising finding the effectiveness of such spending. The absolute within the reproductive ages. On average, hospi- levels of spending on reproductive health are likely talization consumes less than 15 percent of out- to be close enough to finance a relatively com- of-pocket spending in Brazil, Jamaica, and the prehensive set of cost-effective services that are Dominican Republic. In Peru, hospitalization rep- unlikely to be provided by the market without gov- resents the second largest expenditure category ernment action. In addition, although insurance after medicines, but the share rises sharply from coverage is concentrated in the upper-income 9 percent of expenditures in the first quintile to groups, there is little evidence that it is biased 27 percent in the fifth quintile. Of the 21 percent against women. These are indications that poli- of private spending going to hospitals in Peru, cies of both donors and national governments in about two-thirds goes to public hospitals, while 8 much of the region have had positive outcomes. * The Health of Women in Latin America and the Caribbean The bad news is twofold. First, in the coun- in such health programs will soon amplify this tries where spending on women's health services Droblem. For these countries,28 close analysis is and service utilization is relatively high, the evi- required to determine the feasibility of, and dence shows that poorer women are missing out imechanisms to achieve, a significant expansion to a large extent. A combination of inadequate of total resources for the health sector or a shift targeting mechanisms on the supply side, and im- of existing resources toward the most cost- portant demand-side constraints, leads to serious effective and needed reproductive health ser- and systematic gaps in coverage, and poor health vices, or both. outcomes. Reinforcing the actions that result in the Second, most countries in the region 'good news" and redressing the policy lapses that underspend on reproductive health (and non- lead to the persistent "bad news" are potential reproductive women's health) services, relative outcomes of health sector reform efforts currently to what would be needed to achieve coverage underway in the region. The following chapter dis- of a core package of cost-effective interventions cusses the links between health sector reform ini- that are unlikely to be provided if left to the mar- tiatives and women's health generally, and ket alone. The diminution in donor investments reproductive health specifically. ()3/7U CHAPTER THREE //,/omen's Health and Health Sector Reform: Synergies and Risks Chapter Summary + To mobilize resources to complete the reproductive health agenda in poorer countries in the region, to better target reproductive health initiatives in better-off countries, and to finance chronic and emerging women's health problems require attention to the current direction of health reform. + Health reform actions have better results when women's health concerns are carefully considered. + Decentralization, public sector priority-setting, reorientation of financing arrangements, and modification in the roles of the public and private sectors all have the potential to benefit women's health, if appropriately designed. The previous chapters highlighted the achieve- progress in improving women's health in the re- ments and remaining challenges in improving gion.This is true for both the better-off countries- women's health in Latin America and the Carib- where the challenge lies in greater efficiencies, bean. To tackle those challenges, policymakers, better targeting, and stimulation of demand technical specialists, advocates, community lead- among the poor-and the poorer countries, where ers, and others interested in women's health is- the primary objective is directing a greater vol- sues can take advantage of a major opportunity: ume of resources to meet persistent needs for Well-designed and well-implemented efforts to essential, basic, reproductive health services. reform the health systems in Latin America and This chapter focuses in two ways on the the Caribbean, which are now underway, can in- relationship between women's health and health crease the quantity of, improve the quality of, and sector reform. First, it provides a brief conceptual stimulate demand for women's health services. overview of the links between the two issues. Sec- At the same time, it is essential to recognize that ond, it draws upon regional (and international) ex- poorly designed and poorly implemented reform periences to extract insights about how four initiatives-those that ignore some of the critical common elements of health sector reform-de- gender-specific dimensions of the supply of and centralization, public sector priority-setting, financ- demand for health services-can erode past ing changes, and adjustments in the roles of the 43 * The Health of Women in Latin America and the Caribbean public and private sectors-can have either posi- efit lower-income, and other vulnerable, house- tive or negative effects on women's heath. holds. Meeting each of these objectives requires attention to women's health: Women's Health and Health Sector Reform Are Two Sides Ilil health among women, and particu- of the Same Coin larly problems associated with reproduction, con- stitute a large share of the preventable morbidity and mortality in developing countries, and yet Differences in professional training, ideology, poli- tics, and even vocabulary between women's many of the health-care services to address those problems wili not be provided in sufficient volume health specialists and advocates, on the one hand, and health sector reform specialists anid advo- by the private sector, under current conditions. ± Many health interventions that fall into cates, on the other, often have had the unfortu- the category of reproductive health are highly nate effect of limiting the discourse between two cost-effective. This is particularly evident when groups that have much in common. In this sec- tion, an explicit argument is made for the interde- taking into consideration both direct and indi- rect effects of maternal ill health on the woman pendence of women's health and health sector reform. ~~~~~~~~~and her family. reform. Poor women are disproportionately af- fected by ill health, and targeting specific types of Why Should "Health sector Reformers" Pay services serves as a relatively straightforward Attention to Women's Health? In its most means of focusing resources on poor populations. stripped-down form, health sector reform (as In addition, given the intergenerational effects of manifested in developing countries) typically poor maternal health, appropriate targeting to seek to chiee tree verachig obecties, women's health services can have enduring posi- First, it aims to improve the efficiency of the over- tive effects in reducing poverty, or at least in re- all allocation of public resources within the health sector, so that public funds are directed toward clucing its effects. the health services that will have the greatest Why Should "Women's Health Advocates" positive impact on health conditions, but would Pay Attention to and Participate in Health not otherwise be provided by the market. Sec- sector Reform? Just as policymakers and oth- ond, health sector reform seeks to provide incen- ers promoting health sector reform can meet their tives for the efficient production of services in objectives most effectively by focusing attention both the public and private spheres, so that a on women's health, it is also the case that advo- given level of inputs devoted to an essential de- cates of women's health can achieve their goals terminant of human capital formation (and a large by recognizing the opportunities presented by par- player in the national economy) yields the great- ticular aspects of health sector reform: est possible output. Third, it tries to improve the lot of the poor-or at least counteract historically + Many women's health services have regressive public policies-by focusing public long been characterized by poor quality and lack spending on services that disproportionately ben- of responsiveness to demand. Within health sec- women's Health and Health Sector Reform tor reform, instituting contracting arrangements, ners have done relatively little to ensure that is- new demand-side financing mechanisms, sues of women's rights and other gender-specific strengthening of regulatory mechanisms, and de- concerns are discussed during debates on health centralization of decisionmaking all have the po- sector reform. tential to address these concerns. Finishing the reproductive health The Links Between Four Elements agenda requires more financial resources and bet- of Health Sector Reform and ter use of resources that already are invested in Women's Health in Latin reproductive health. Again, health sector reform America and the Caribbean initiatives that seek both efficiency and equity im- provements can serve to free up and refocus fi- This section highlights the relationship between nancial resources for this purpose. women's health and four elements of health sec- + Financing nonreproductive health ser- tor reform that are prominent in the region of Latin vices is a complex task that will require mecha- America and the Caribbean-decentralization, nisms that go far beyond traditional public sector priority-setting, financing changes, and adjust- resource outlays. In particular, expansion of both ments in the roles of the public and private sec- public and private insurance systems is likely to tors. The examples provided present a clear be needed. As insurance coverage is extended, picture of the ways in which health sector reform the benefits packages need to be reviewed for can successfully address women's health needs inclusion of reproductive health services and cost- in both better-off and poorer countries. At the effective care for women. Financial incentives to same time, there are cautionary tales regarding reduce unneeded procedures, such as inappro- the problems that can emerge when gender- priate Caesarean sections, need to be reviewed specific financing and service delivery issues are as well. not taken into account during policy formulation. Despite the common interests of those in- Decentralization. A common feature of reform terested in improving women's health outcomes programs is an emphasis on decentralization, and the efficiency- and equity-oriented health sec- which is intended to improve responsiveness to tor "reformers," communication is often limited local needs, ownership, and accountability. How- by the lack of formal channels and mechanisms ever, whether these goals are realized and to involve women's health advocates in the re- whether decentralization can have a positive im- form processes. in a few countries of the region- pact on women's health care depend on why de- notably Mexico, Brazil, and Colombia-efforts are centralization occurs, how it is carried out, and underway to incorporate women's health advo- who is involved in its design and implementation. cates and gender specialists into the dialogue Decentralization in Latin America, as in the rest of about the direction of health sector reform. But the world, is often motivated by political consid- these are the exceptions. In general, formal par- erations rather than by the need to improve effi- ticipation mechanisms have been limited, and ciency and equity in the health sector. As Kutzin both national governments and development part- (1995) argues, this may exacerbate inequities, * The Health of Women in Latin America and the Caribbean because power is transferred from the center to reflects patterns of disease and takes into account regional elites, wealthier districts are able to raise cost-effectiveness criteria, this can also have a more funds, and central governments transfer the potentially positive impact on women's health ser- burden of financing to lower levels of government, vices. By contrast, where the definition of or a combination of the three. women's health-care needs is left to the discre- Decentralization in the LAC region has tion of local authorities, this may not necessarily taken on different forms. In Chile, primary health yield good results. Conservative attitudes among care has been devolved to municipalities, while local leaders and reluctance of health workers hospital and public health programs have been may impede the integration of some interventions deconcentrated to autonomous health-service ar- (such as STI screening and treatment) with other eas (see box 3). Nicaragua has deconcentrated reproductive health services. responsibilities to lower levels of the health sys- Fourth, in cases where decentralization tem. Colombia has devolved responsibilities to de- has resulted in increased NGO participation in partments and municipalities, while transforming service provision (such as Brazil or Mexico), this hospitals into public corporations. The strategies opens up opportunities for expanding women's and instruments used in conjunction with decen- health services.30 tralization are critical to averting the risks men- The active participation of those who rep- tioned above, and to facilitating the attainment of resent women's interests is also critical to attain- women's health objectives. ment of women's health objectives. The issue First, formula-based transfers have an im- relates to whether women's interests are repre- portant potential in redressing inequities in health- sented on local health committees, and whether care access, and in improving coverage of primary their preferences and needs are reflected in re- health care, including women's health services. source allocations. Evidence suggests that The use of transfer mechanisms varies tremen- women's views are often not well represented, dously across the region .29 Mechanisms for trans- particularly in local settings.31 While local authori- ferring resources do not always take into account ties are, in principle, closer to beneficiaries and existing service capacity, which may leave some more responsive to their needs, evidence sug- facilities poorly funded and unable to deliver the gests that local preferences may favor curative required package of women's health services. For care rather than longer-terms gains from preven- example, in Bolivia the use of a simple per capita tive and public health interventions, which tend formula left tertiary referral hospitals in some re- to form the majority of women's health services gions short of funds (Aitken 1999). (Standing 1999). In cases where women's interest Second, decentralization has also involved groups are actively involved, these issues emerge strategies aimed at diversifying sources of fund- high on government agendas, even in decentral- ing and improving resource mobilization, strate- ized settings (Aitken 1999; Langer and others gies which appear to have generated important 2000). For example, in Brazil the feminist move- benefits in primary heaith care. ment promoted the establishment of state and Third, when resources are targeted for a municipal women's councils, with a mandate for well-defined essential package of services, which a broad range of women's issues. This repre- Women's Health and Health Sector Reform sented the first true involvement of the state in surate resources for these activities. Finally, coun- women's health and resulted in expanded col- tries may lack coherent population, reproductive laboration with the NGO sector and greater atten- health and/or women's health policies that would tion to increasing coverage and quality of a wide help to guide local action, and set the framework range of women's health services. In Nicaragua, for national-level laws and regulations. Such is the community participation through social audits has case, for example, in Paraguay and Argentina given the local population an effective voice in (Langer and others 2000). health care (Langer and others 2000). - Poor local capacity. Transfer of respon- Decentralization may not necessarily pro- sibilities to lower levels of government is also ren- vide an enabling environment for women's health dered difficult by the variable quality of technical programs, which have traditionally been organized and managerial capabilities, which runs the risk in a vertical fashion. Some of the main issues that of compromising the provision of primary health have emerged include: care, including women's health services. In Mexico, for example, capacity weaknesses at the + Fragmentation. Decentralization runs local level have proved a serious hindrance to the the risk of leading to fragmentation in national decentralization of a system that has a long his- health programs to the extent that it increases tory of having power concentrated at the central the number of institutions and stakeholders in- level (Langer ano others 2000). These shortcom- volved. First, there may be a loss of economies of ings underscore the importance of setting up or- scale, particularly for the relatively small munici- ganizational and management structures and palities. Some functions (such as procurement, providing staff training to decentralized authori- staff training, strategy development, and norm and ties. While it may be in the interest of women's protocol design) may need to remain centralized health programs to slow down the pace of de- in order to reap economies of scale and benefit centralization to allow time to strengthen these from a stable flow of resources.32 Centralized pro- capabilities, this is often not possible. curement may also avoid some of the liquidity + Skewed incentives. Decentralization problems of a large number of decentralized units. may impede the functioning of the referral sys- Second, responsibility for primary health care may tem and the integration of primary health services be fragmented between state and central govern- with secondary level hospital care, which are es- ments witnout effective power to manage person- sential for the provision of a comprehensive range nel (such as Colombia, Mexico, Bolivia) at the of women's health services. Experience has regional level. In Bolivia, previously well-developed shown that service providers may face skewed systems of integrated regional and health admin- incentives, to the extent that provider payment istrations were broken down by decentralization mechanisms are not consistent across levels of so that the referral hospitals ended up as part of care in decentralized settings. While these issues a separate local government from the primary may not be unique to decentralized systems, they care services (Aitken 1999). Third, there may arise become more complex to tackle since responsi- situations where central level mandates are para- bility for different levels of health care is spread chuted onto decentralized units without commen- across administrative lines. For example, in cases * The Health of women in Latin America and the Caribbean where primary health facilities are remunerated vices, particularly as the majority of women's on a per capita basis and secondary level facili- health interventions are cost-effective. The effec- ties operate on a fee-for-service structure, this will tiveness of such packages depends on whether create perverse incentives to shift costs to the women's health needs are adequately reflected, secondary level of care. In situations where fees whether this theoretical benefit actually trans- are not well differentiated by levels of care, lates into effective access, and whether it is fi- women may tend to bypass the primary level, nancially sustainable. The definition of needs is which overburdens the secondary level. often carried out by technicians. There is scope for improving the participation of women's health Priority Setting. Many health reform programs specialists in validating these results. In some in the region have defined minimum health-care cases access may not necessarily translate into packages along the lines spelled out in the 1993 improved use, either because the financial in- World Development Report. The introduction of centives are not in place to provide the services, such packages as part of broader health reform or because service capacity and quality have not programs has potentialiy positive implications for kept pace with the increase in benefits. Incorpo- the provision and financing of women's health ser- rating women's health concerns into essential Chile: Women's health and decentralization Chile offers an interesting case for looking at the links between women's health care and health reform, and highlights the types of issues that may arise. Nevertheless, it also suggests that it is virtually impossible to establish causality, particularly as many of the health gains predate the launching of the decentralization process in 1979. Chile's outstanding record in improving maternal and reproductive health can be largely explained by the following factors: a national health system with high coverage and a strong emphasis on primary health care and on public health interventions; a policy of targeting the most vulnerable groups, using clinical audits to tackle maternal mortality; providing free access to preventive and promotional activities, and using food supplements to address nutritional problems and to increase attendance at health facilities. Decentralization appears to have permitted better adaptation of programs to local conditions and has facilitated the introduction of innovative interventions. Following the munici- palization of primary health care in the 1 980s, the maternal health program received a new boost, with a substantial infusion of resources and an expansion in coverage. Decentralization has led to a new set of issues: (1) the lack of coordination and frag- mentation across institutional boundaries; (2) resistance at the central level to defining a basic package of services and assigning resources according to need and sex; (3) possible perverse effects of provider payment mechanisms, which encourage shifting of costs to the next level of care. For example, concerns have been raised about the financial incentives to screen for cervical cancer at the municipal level, which is paid on a capitation basis and hence does not cover the financial cost for cancer treatment; (4) risk of the central level establishing new programmatic areas without providing commensurate resources, effectively resulting in an unfunded mandate; (5) a generally low level of community participation, including limited involvement of women's groups. Women's Health and Health Sector Reform packages will imply a move away from free- Some researchers have found that prices are not standing or vertical programs toward integrated important determinants of utilization of medical health-care delivery. care (Birdsall and Chuhan 1986; and World Bank This will involve setting up new support 1987). Others have documented that prices are systems and management structures, providing important, and that the poor are more sensitive staff training, and overcoming resistance to to price changes (for example, price elasticity of change. The Brazilian experience in making the demand falls with income). Gertler and van der transition from providing a basic reproductive Gaag (1990) cite empirical evidence from Peru and health package in a vertical program to deliver- Cbte d'lvoire, illustrating that the demand for ing it in a decentralized context suggests that these medical care is very price-sensitive for individuals problems are not insurmountable.33 Governments in the lowest-income groups, and quite inelastic have also found that often they cannot sustain for those in the highest-income groups. The data the required level of financing, with reproductive also found that user fees seem to have a greater health programs competing more explicitly for negative effect on children's utilization than on scarce public and donor resources in an envi- adults'. Gertler (1999) argues that there is also ronment of growing needs. Colombia presents some evidence substantiating that women's de- one of the single most interesting reform sce- mand for medical care is more price-elastic than narios, because the introduction of the essential men's, implying that increases in user fees will health package was accompanied by mutually reduce access to care for females more than reinforcing changes in the way the package was males. Other evidence also substantiates these delivered and financed (see box 4). findings. One survey carried out in 70 countries found that fees were mentioned as the most seri- Financing Options and Payment Modes. An- ous obstacle to reproductive health services other key feature of health reform programs is (WEDO 1999). In the sample of countries cited broadening financing options (such as user fees, above, Henderson and others found that up to 35 co-payments, and insurance) to mobilize re- percent of respondents mentioned cost of ser- sources, control unnecessary demand, and pro- vices and transport problems.34 Controlling for age mote risk-pooling. The justifications for user and health need, women in the lowest-income charges are well known. Worldwide evidence has quintile use fewer services than their need would shown that individuals in most developing coun- suggest, implying some access problems. tries spend substantial amounts on private health These findings suggest that while user fees care and are willing to pay for quality services. are a potential source of substantial revenue for They recognize that free care may in fact involve the health sector (particularly as willingness to pay hidden charges and implicit rationing. Critics of increases with income), care must be taken in reforms argue that the introduction of user their design to ensure that the poor are not de- charges has impaired access to health care for nied access. Particular attention will need to be poor women (Langer and others 2000). given to poor women (and children), who use ser- The empirical evidence on the demand for vices more often than men, and who sometimes medical care in developing countries is mixed. use a larger share of household expenditures on * The Health of Women in Latin America and the Caribbean Colombia Law 100-the cornerstone of the reform-provided for universal access and introduced the concept of demand-side subsidies with money following the patient. The goal was to promote competition, efficiency, and solidarity. Competition was promoted on both the insurer and provider sides, with beneficiaries free to select their organization of choice. Insurers are reimbursed for the provision of a basic package of services based on a risk-adjusted premium (that is, age and sex) that follows the enrollee to her chosen plan. Basic health-care packages were designed, differentiating between those in the contributing scheme and those in the subsidized scheme. A solidarity fund provided for cross subsidization of the two schemes. The essential package was initially defined using standard burden of disease and cost-effectiveness criteria (Plaza 1999). Following a broad-based consultative process, this "basic" package was substantially expanded with the final version covering most health interventions, including a wide range of women's health services (such as reproductive health, complications from pregnancy, Caesarean sections, and cancer). Complementary public health interventions involving large externalities were targeted to women and children and delivered and financed by the ministry of health. To reduce unnecessary demand and mobilize additional resources, user fees and co- payments were introduced, taking into account the ability to pay. Since the introduction of the reform there has been a large rise in health spending and a dramatic improvement in access and equity. Nationwide, the proportion of insured increased from roughly 20 percent in 1993 to nearly 60 percent in 1998. The subsidized scheme now covers some 8 million Colombians who previously did not have access to insurance. This expansion has benefited vulnerable groups, such as women, who are less healthy on average than their counterparts in the contributing scheme, and who have greater perceived needs. The proportion of insured households in the two lowest income quintiles rose from less than 12 percent in 1993 to roughly 53 percent in 1998. Improved access to insurance is reflected in increases across the board in utilization rates during 1993-97. The introduction of demand-side subsidies has been the lynchpin in improving targeting and raising equity in health spending. These subsidies have had an important redistributive effect. Subsidies as a percent of GDP rose from .4 to 1.3 percent for those in quintile 1, while they dropped from .4 to -.2 percent for those in quintile 5. These positive developments are tempered by evidence that highlights difficulties facing the poor in taking advantage of the new benefit package. First, information asymmetries have prevented consumers from making good choices about insurers, and practices such as hoarding of funds or partial commissioning of the basic package have precluded access to quality services and resulted in relatively lower rates of utilization for those in the lowest income quintiles. Regulatory capacities have not been developed at a sufficiently rapid pace to offset these problems. Second, while the capitated premium should create incentives to provide promotional and preventive care, which are an essential part of women's health services, high turnover of beneficiaries has created disincentives to some providers. Third, fragmentation of reproductive health services amongst a large number of providers has been cited as an additional concern. Fourth, evasion of payments and underreporting of salaries have resulted in financial shortfalls for the contributing scheme. This raises concerns about the financial sustainability of the system and the government's ability to expand both the range of services in the subsidized package to coincide with the contributing one as well as to provide access to the 17 million Colombians who remain uninsured. Perhaps one of the key lessons emerging from the Colombian reform is the need to design an affordable package of services which can be provided to a large number of beneficiaries rather than a generous package which remains within the reach of a few. Related to this point, the process used in the Colombian reform highlights the importance of managing the sociopolitical dimensions of a process that is otherwise technical, by bringing key stakeholders to the table at an early stage. Women's Health and Health Sector Reform health (Henderson and others 1999). Gertler and In situations where private insurance mar- van der Gaag (1990) stress that clinics in poor kets have been developed, it is critical to ensure areas cannot survive unless they are heavily sub- appropriate regulation. The risk of unregulated or sidized.35 They argue for gradation and differen- poorly regulated for-profit private insurance mar- tiation (for example, by level of care) in the kets can be serious. For example, the ISAPREs in application of user fees, and continuous monitor- Chile charge women higher contributions because ing to assess impact and compliance with guide- of the additional risks associated with reproduc- lines and regulations. In Ecuador, for example, tive health and the higher expected utilization despite a law mandating that maternity care be rates. Langer and others (2000) emphasize the provided at no cost, facilities offering obstetrical importance of determining whether the regulatory services continue to levy fees to maintain and im- role of the public system is effective in ensuring prove service quality (Langer and others 2000). that reproductive and women's health issues are The implications of introducing user fees for adequately addressed by private insurance com- women's health services need to be assessed in panies, whether these are included in packages, different reform settings to ensure that user fees and how much they cost. will not have an adverse impact on poor women's Many programs have also supported modi- ability to utilize services, and to offset these ef- fications to provider payment mechanisms in an fects through the introduction of appropriate ex- effort to improve efficiency and raise accountabil- emption policies and cross subsidies. ity. There is little empirical evidence on the effects The introduction of insurance can improve of provider payment mechanisms on the provi- access to women's health services and redress sion of women's health care. A notable exception inequities. Countries have often introduced insur- is the impact of alternative provider payment ance as a way to pool risks for events that have a mechanisms on the rate of Caesarean sections. relatively low occurrence but that result in a sub- Data from a sample of hospital records in Brazil stantial burden to households (such as treatment revealed that physicians were more likely to per- of complications from pregnancy and some ob- form C-sections on women who could pay for the stetric care; treatment of cancers of the repro- service, illustrating how financial incentives can ductive system; and treatment of chronic adversely affect decisions that should be based conditions such as hypertension and osteoporo- on medical need (Janowitz and others 1983).36 In sis). Empirical evidence has shown that insurance principle, a move away from traditional payment can substantially improve access to care. mechanisms (such as salaries or fee-for-service), Henderson and others (1999) found that, in the as has occurred in numerous reform programs, Dominican Republic, insured women were 60 per- has the potential to benefit women's health pro- cent more likely to seek care than uninsured ones. grams. For example, the increased emphasis on Bolivia's Mother and Child Health Insurance Pro- capitated formulas should produce incentives to gram also illustrates how access can be improved provide preventive and promotional health ser- to the poorest women as part of a health reform vices that are essential to women's health, as- effort to decentralize decisions, maintain national suming that it does not result in undertreatment. priorities, and have money follow patients. When the capitated payment is in the form of a The Health of Women in Latin America and the Caribbean demand side subsidy, such as in Colombia, this creasingly used to improve efficiency and quality, can empower women to select their provider or to provide highly specialized services that require insurer of choice, or both. costly equipment, and to expand coverage. Within The move away from salary payments for publicly funded systems, servce agreements have physicians (which tend to encourage absentee- been introduced in some countries (such as Costa ism and poor productivity) toward capitation tied Rica, Colombia, and Chile) in an effort to enhance to performance improvements may also improve transparency, improve decisionmaking, and trans- quality of women's health services and increase fer risks to providers. accountability of personnel. For example, an in- The expansion in contracting of private sec- novative program in sao Paulo, Brazil, relying on tor providers can have potential benefits for the health-care workers organized under cooperative- provision of women's health services. In many de- type arrangements and using capitated reim- veloping countries women often prefer private bursement mechanisms, has produced impres- practitioners because of the convenient and flex- sive reductions in waiting times, hospital stays, ible hours of service and perceived high quality of and overall costs, while generating a substantial care, including the strong emphasis on privacy increase in patient satisfaction (Harmeling 1999). and respect. The private sector is a heterogeneous The introduction of case-based payments group, consisting of both nongovernmental orga- (for example, DRG type), which cover all service nizations and for-profit organizations. tests and treatments for a specified diagnosis, The main focus of this section is on the provides incentives to standardize care and disin- potential role of nongovernmental organizations centives to perform unnecessary procedures and in expanding access to quality services for poor could be used effectively in some situations. For women-either through expilcit contracts or more example, to curb the frequency of Caesarean sec- general collaborative arrangements with the pub- tions, which have reached epidemic proportions lic system. While NGOs have a longstanding in- in the region, case-based payments, in combina- volvement in catering to the needs of poorer tion with second opinions, could be used to dis- households and women, in particular, they have courage unnecessary use of this procedure. As received a major boost following the Cairo con- discussed above, one of the key issues that will ference and are now playing a critical role in need to be addressed is the coherence in pro- partnering with the public sector. To date, there vider payment mechanisms across levels of care, has been relatively little public-to-NGO contract- which is particularly important in the provision of ing for health services in Latin America, and even an integrated package of women's health services. less systematic analysis of the impact of using NGOs on access to and utilization of women's Reorienting Public and Private Roles Through health services. However, given the positive po- Contracting and Private Sector Collaboration. tential of this mechanism-particularly for The Latin America region has seen a large expan- women's health services-this section attempts sion in contracting, both within public health sys- to highlight some positive features of this collabo- tems and among public financing agencies and ration, identifying examples of good practice private sector providers. Contracting is being in- where poor women appear to be well served by Women's Health and Health Sector Reform a hospital and a number of dispensaries, catering to lower- and lower-middle-income families. Suc- Contracting: The key ingredients cessful features include use of a strong manage- forsuccess ment information system; reliance on bonus + Putting in place an appropriate legal payments to motivate personnel; and creative use and regulatory framework and a of income-generating activities to stimulate nutri- conducive political environment. tion interventions. Notable results include a drop + Minimizing transaction costs and getting the incentives right. in the infant mortality rate from 150 to 66 per + Ensuring continuity in service pro- 1,000 during 1980-95, and an increase in the con- vision and minimizing delays in traceptive prevalence rate from 15 percent in 1993 payments. . Strengthening management informa- to 38 percent in 1998. tion systems, monitoring results, In some countries, introduction of compe- learning from mistakes, and making tition between public and private providers has required adjustments. opened up new opportunities for NGOs and of- fered women a greater range of choice among providers. A notable example is Colombia's the NGO sector. It also highlights the types of is- PROFAMILIA, a world-renowned NGO, which has sues that are emerging in promoting public- an impressive record of achievements in provid- private partnerships and in using contractual ing reproductive health services. PROFAMILIA has arrangements (box 5). been taking advantage of the opportunities of- The nature and scope of this collaboration fered by the new legal framework by contracting have varied tremendously across countries, de- its services to both public and private sector in- pending on the political will of governments to stitutions. This has allowed the organization to di- use the capacity of NGOs. The arrangements be- versify its risks and lessen its dependence on tween the public and private sectors range from donor funding, which declined from 30 percent of informal collaboration (such as in Bolivia and Haiti) the organization's total budget in 1993 to only 5 to formal contracts (such as in Colombia and percent in 1999. Abramson (1999) found that the Costa Rica). The PROSALUD model, which is based increased competition provided incentives to on the principle of promoting sustainability PROFAMILIA to modernize its technology and im- through cost recovery, appears to represent a prove the efficiency and quality of its services and promising approach to catering to some low- to fill important service delivery gaps. income segments of the health-care market Some of the key issues that have emerged (box 6). This model has been replicated in other in contracting are similar to those found in other low-income settings, such as Haiti, with positive countries: payment delays by purchasers, diffi- initial results (Baer 1999). City March is a large culties in complying with information require- Haitian NGO that participates in mixed manage- ments of various players, greater risks assumed ment of health facilities with the government, pro- by the organization as a result of the payment viding curative care with a strong cost recovery modalities used, and high transaction costs of component. The organization owns and operates administering to patients who belong to different The Health of Women in Latin America and the Caribbean PROSALUD PROSALUD has made impressive progress in providing an integrated package of primary health services to low-income populations in urban and periurban areas of Bolivia, operating a network of facilities with a high degree of autonomy. The package includes access to free preventive services (such as prenatal and postpartum care; and health education) as well as to a wide range of curative services on a fee for service basis (such as obstetric and gynecological care, deliveries, and family planning; and ambulance service and emergency care). PROSALUD uses an effective one-stop shop- ping approach, whereby most services are available on a 24-hour basis, and laboratory exams and prescriptions are handled at the same facility. The overriding principle of the PROSALUD model is to promote sustainability through cost recovery, by using revenues generated from curative care to fund operating costs. The goal is to provide quality services at high volumes, thereby keeping unit costs low. Fees are set according to costs and ability to pay, with indigenous groups being exempt from payments. To discourage unnecessary use, women who self-refer to the reference hospital pay a significantly higher fee than those who are referred. Other important features of the PROSALUD model include its strong emphasis on: privacy and respect, particularly during childbirth (such as partos humanizados); community participation and outreach; demedicalization of service delivery; and monitoring and evaluation. With the launching of the decentralization process and the introduction of the Popular Participation Law in 1994, PROSALUD aimed to work closely with the government by expanding its network nationally through agreements with municipalities, whereby the government agreed to contribute infrastructure and supplies for priority programs while the NGO was delegated respon- sibility for service provision. By contrast, PROSALUD and other NGOs have not elected to partici- pate in the government's maternal and child health insurance scheme, because the reimbursement rates for most procedures are set considerably below cost. Moreover, lengthy processing delays for reimbursements have created further disincentives. In some PROSALUD health centers births at- tended by professionals have declined, but the overall number appears to have remained fairly steady. This situation highlights the importance of getting the incentives right in building effective partnerships between the public and private sectors. insurance schemes. While PROFAMILIA's strong fi- enting financial arrangements, and modification nancial situation and its diversification strategy of the public-private roles-both positive and have enabled it to cope with payment delays, negative aspects of the reforms for women's NGOs in other countries have found themselves health have been pointed out. It is important not vulnerable to the unpredictability of donor fund- to dwell on the negative, because for the most ing, which has seriously impeded service provi- part the goals of the reforms can and should be sion.37 This highlights one of the key lessons for consistent with higher quality and more effective NGOs-the need to reduce dependence on donor health efforts. Many, but not all, of the negative funding and to adopt sustainable strategies such aspects can be corrected by being aware of the as cost recovery and revenue generating activities. problems and tweaking the reforms to be friend- lier to women's health needs. As the reform Conclusion. In each of the areas of reform-de- agenda moves forward, it is time to become more centralization, public sector priority setting, reori- precise about these issues and actions. CHAPTER FOUR onclusion Inescapably, health sector reform efforts, as is true to health services directed to women, but obvi- for health programs and policies, will be more ef- ous coverage gaps remain. For example, while in fective if the well-known biological and socioeco- absolute terms many countries of the region nomic differences between men and women are spend "enough' on reproductive health care to taken into account in their design and implemen- ensure full population access to a core package tation. Empirical information on women's health of services, in those same countries the poorest status and access to services, as well as analyses 20 percent of the population is only able to obtain of patterns of spending on women's health can services that are limited in coverage and quality inform good policymaking. In the poorest countries of the region, a large- Despite the vast diversity across the coun- scale mobilization of financial resources is re- tries and populations of Latin America and the quired to support basic care for most women. Caribbean, the information compiled for this study + Strategies commonly associated with points toward several conclusions: health sector reform-including decentralization, public sector priority-setting, financing changes, + Most women in poor countries, and the and adjustments in the roles of public and private poorest women in rich countries, are suffering scoscnb anse oipoewmn unnecessarily from inattention to the fundamen- health outcomes. At the same time, they carry risks tal services that would make pregnancy and child- for women if done without the active participation becareing saf. Te fixedeinathentionhi unecessangry of individuals who are aware of gender-related dif- because it can be fixed either within existing re- ferences in biological and social vulnerabilities. source constraints or with feasible changes in re- Ten policy guidelines fall logically from this source allocation. study, which will, of course, need to be adapted + As the population ages, as some com- to specific country situations. municable diseases decline in importance, and as tobacco use, obesity, and other "lifestyle" factors take an increasing toll, a growing share of women Expansion of Reproductive in the region are at risk for diseases that erode Health Services quality and length of life, including cardiovascular + To improve the health status of disease, diabetes, and cancer. For the most part, women, given tight budget constraints, countries the women most negatively affected are those now falling into the low status and medium-low with the fewest resources. status categories should focus resources on im- + Both governments and households de- proving basic reproductive health conditions. The vote a considerable share of financial resources interventions required are relatively low-cost, in 55 The Health of Women in Latin America and the Caribbean general, and yet have major pay-offs in health effective screening and preventive interventions, conditions and human welfare. Providing appro- such as cervical cancer screening directed at priate family planning methods to women who women who are at high risk of the disease, and want to control their fertility, providing early and supporting cardiovascular disease prevention pro- reliable prenatal and essential obstetric care, fos- grams, particularly for low-income populations that tering good nutrition, and developing specially are at disproportionate risk and have few resources. targeted services for women at high risk for sexually transmitted diseases should all be very Tweaking Health Reform high on the public priority list. + In the seven to ten countries in the re- + Women's health advocates and health gion that underspend on reproductive health (and sector reform advocates have common inter- probably other women's health) services, close ests-one group cannot achieve its goals without analysis is required to determine the feasibility of, the other-yet the absence of a common vocabu- and mechanisms to achieve, a significant expan- lary and mechanisms for participation and com- sion of total resources for the health sector, or a mnunication impedes dialogue. Both national shift of existing resources toward the most cost- policymaking bodies and international agencies effective and needed reproductive health services. can play a role in bringing women's health advo- External donors can play a valuable role both in cates into the dialogue on health policy. the mobilization of resources and in providing in- + Decentralization can have positive ef- formation for better priority setting. fects on women's health services when (1) >I- In the countries of the region where women's health advocates (and women patients spending on women's health services and service themselves) have a voice in the local decision- utilization is relatively high, poorer women will rnaking process; (2) coherent national policies and only benefit from the relative abundance of re- ,rules of the game" are in place that favor the sources with better targeting mechanisms on the delivery of women's health services of acceptable supply side, and a concerted effort to address im- quality; (3) formula-based transfers are used to portant demand-side constraints. ensure sufficient funding based on need and to * In medium-high and high status coun- redress historic inequities; and (4) support is pro- tries, governments should ensure that the same vided to bolster technical and managerial capac- basic reproductive health services reach the poor- ity at the local level. est 20 to 40 percent of women. This initiative would + Strategies for public sector priority set- be a cost-effective way to reduce the large gap in ting that employ analysis of cost-effectiveness of- women's health conditions between the poor and ten favor core reproductive health services. The the better-off segments of the population. challenge, as seen in several countries, is to ob- tain reliable and up-to-date information about Addressing Noncommunicable both costs and efficacy, and to minimize the im- Diseases pact of interest groups seeking to use political + Particularly in better-off countries, govern- influence to capture budgetary resources for spe- ments have an important role in promoting cost- cific programs. Conclusion +F Broadening financing options to mo- tremendous potential to increase access to and bilize resources, control unnecessary demand, the quality of women's health services in the re- and promote risk-pooling has better outcomes gion, although experience to date is limited. The for women's health if the design takes into ac- key ingredients for success include (1) putting in count the possibility that women have less ac- place a legal and regulatory framework that pro- cess to and control over household income tects service providers, financiers, and, above all, than do men. In particular, a variety of studies consumers; (2) minimizing transaction costs and have confirmed that core maternal and child incorporating incentives for productivity and qual- health services are best funded by means other ity; (3) ensuring continuity in service provision and than user fees. minimizing delays in payments; and (4) strength- + Contracting with nongovernmental or- ening management information systems, monitor- ganizations and public-private collaboration have ing results, and making required adjustments. otes 1. Mortality due to chronic and degenerative disease and Pande and Gwatkin 1999. some text in this chapter is estimated to be 10 times higher than deaths from is taken from Dara Carr's report, which was prepared as infectious and parasitic disease. background for this study 2. For example, studies show that surviving children 10. Out of the full range of possible variables, these are three times more likely to die within two years than were shown to have the greatest ability to discriminate children who live with both parents; and many mother- among country groups. For more information on data less children, particularly girls, receive less health care and methods, please see Loganathan (1999). and education as they mature. 11. Modern contraception excludes periodic absti- 3. World Bank 1993 documented the cost-effective- nence and other traditional methods. it includes hor- ness of these interventions, including prenatal and de- monal and barrier methods, as well as sterilization. livery care, childhood illnesses, family planning, and STI 12. It is important to note that, while the IARC pro- (sexually transmitted infections) treatment, in the mini- vides the most comprehensive data on cervical cancer mum package. Financing this package could reduce the incidence, the data are far from complete or fully reli- burden of disease by more than 30 percent in low- able. They are based on population-based cancer regis- income countries and by about 15 percent in middle- tries, which are usually incomplete and restricted to income countries. urban populations. Readers are encouraged to keep in 4. For example, researchers have identified impor- mind shortcomings in the quality of information when tant differences such as height and weight, fat ratios, interpreting the data presented. and metabolism that can alter the effectiveness of drugs. 13. Cardiovascular diseases include a group of con- To the extent that most clinical trial testing of new drugs ditions affecting the circulatory system, including or treatments has excluded women, this exclusion can ischaemic heart disease, cerebrovascular disease, and have a potentially negative impact on women. hypertensive disease. 5. This section draws primarily from the background 14. obesity typically is defined as having weight for paper by Gertler 1999. Some text is taken from that paper. gender, age, and height at +2 standard deviations from 6. This framework is fully consistent with the a reference population. Overweight is between +1 and conceptualization articulated in World Bank 2000. +2 standard deviations. 7. it is important to note that the word "choice" does 15. This chapter is based on the following back- not mean that all options are open, or that the choice is ground reports: Hernandez, Glassman, and Poullier 2000; unconstrained by limited resources (money, time, infor- and Henderson, Montes, and Glassman 2000. mation, and others). For poor families, and for women 16. Brazil's household survey is subnational. Addi- who may have little access to financial resources, the tional details on the surveys are available in the back- set of options may be very limited indeed. ground reports. 8. Defined as having a body mass index (BMI) of less 17. Guatemala was not included in the household than 18.5. The BMI is an indicator that combines infor- spending analysis, as a nationally representative mation about both height and weight. household survey that included expenditure and utili- 9. Information for this part of the chapter was de- zation questions was not available at the time of the rived from four sources: Carr 1999; Loganathan 1999; study. 59 * The Health of Women in Latin America and the Caribbean 18. included in the category of "public" services are reproductive health services) and is estimated to cost situations where universai access is mandated and the approximately US$135 per woman n the Latin America use of private facilities is paid for by the government. and Caribbean region. 19. According to this view, women perceive morbid- 27. The Paraguayan figure is likely to be somewnat ity and use more services than men because tney have inflated because information on hospital expenditure is been socialized to acknowledge and articulate bodily nct available for Paraguay. However, even after account- signs and symptoms, and to seek the help of others, ing for this omission, the figure is still large. including health-care providers and informal sources of 28. Using the typology established for this purpose, care, more readily than do men (Hibbard and Pope 1986). these countries are: Bolivia, Ecuador, Guatemala, Hon- 20. Care during pregnancy and delivery in public hos- duras, Nicaragua, Peru, and Haiti. pitals accounts for a large proportion of health-care uti- 29. Most transfer formulas in the region have a large lization in the public sector For example, obstetric care population-based weighting. In Colombia the transfer represents 44 percent of inpatient stays in the Domini- mechanisms are adjusted for unmet need and local fis- can Republic and 40 percent in Brazil. cal effort. in Chile transfers to municipalities, which are 21. It should be noted tnat the analysis of the equity responsible for primary health care, are based primarily of need-based utilization only provides insight into the on a per capita allocation, which is complemented wth distr bution of utilization and says nothing about the ab- an allocation for the provision of public goods. solute levels of service available in each country. 30. In Brazil, BEMFAM provides a good example of 22. Wagstaff and van Doorsiaer 1998. collaboration, with the municipality providing facilies 23. A study conducted in Mexico found no evidence and staff, while the NGO provides training, contracep- of gender bias unfavorable to girls (see Langer and tives, and technical support. Lozano 1998). 31. Hanson and McPake (1993) found a notable ab- 24. A study of the equity of public expenditure on sence of women on local health committees despite health in Egypt (Berman and others 1998), for example, the emphasis on promoting the healtin of women and showed that males received three times the amount of children. major program subsidies as compared to females, yet 32. For example, costs of drugs, contraceptives, and exhibited lower service-ut lization rates. Women were medical equipment-which are essential to women's found more likely to use services, although they were health services-can be kept lower if the government perhaps less expensive services, and to spend out-of- takes advantage of its purchasing power Therefore, the pocket more frequently. procurement of tnese items should probably remain 25. There are obvious shortcomings to this approach. centralized in most settings, although tne government (1) The package of reproductive health services does not may wish to contract out the procurement function to constitute all of women's health services, although it the private sector does include many of them-and certainly most tnat 33. The government's Programa Assistencia Integral are likely to be financed by the public sector, for at least a Saude de Mulher (PAISM) was set up in 1984 to pro- some popu ations. (2) There s an implicit assumption vide for a comprehensive range of women's health ser- that funds could be reallocated without significant tran- vices (prenatal care, delivery, and postpartum care; sition costs, and that countries could deliver services boeast and cervical cancer screening; STI care; infertility efficiently enough to achieve the unit costs upon which services; and family planning education and services). the cost of the package of reproductive health services By 1995 implementation remained patchy, and it became is based. irncreasingly evident that this vertical program needed 26. The package recommended at the International to be integrated into municipal-level primary health care. Conference on Population and Deve opment includes As a result, basic interventions such as prenatal and ma- family planning, prevention of sexually transmitted in- ternity care, fami y planning, and cancer screening have fections (including HIV/AIDS), research, and other basic irproved dramatically For example, prenatal consulta- Notes m tions increased by over 50 percent and cervical and cost of medical care takes no more than 2 to 3 percent breast cancer screening increased from 14 percent to of a household's nonfood budget. 44 percent during 1995-97 (Harmeling 1999). 36. Study findings indicated that the rate of Caesar- 34. This figure varied widely across countries: Brazil ean sections increased with payment status of women, 6.6 percent; Peru 34.5 percent; Paraguay 5.3 percent; with 75 percent of private patients, 40 to 50 percent of Mexico 29.5 percent; and the Dominican Republic 11.6 insured patients, and only 15 to 30 percent of indigent percent. In this study the impact of cost, transport, avail- patients having had a Caesarean section delivery. Re- ability, and quality of care on likelihood of use appeared searchers found that differences in medical conditions to affect women and men equally, were too small to explain these rates. 35. They point out that user fees at levels of half and 37. For example, as a result of an abrupt loss of do- full marginal cost recovery would price most poor resi- nor funding, PROFAMIL in Haiti suffered a major blow to dents out of the market. They find that fees can be its operations and was forced to rationalize its services charged without a significant drop in utilization if the (Baer 1999). 0-:/Oeferences Cited Abramson, Wendy. 1999. "Asociaciones entre el Sector Brownson, R., P Remington, and J. Davis. 1998. "Chronic Publico y las Organizaciones no Gubernamentales Diseases Epidemiology and Control." 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Washing- the Delivery of Health Care: Methods and Results ton, D.C. for Jamaica." Prepared for the Human Development . 1993. The World Development Report 1993. Department, World Bank. Washington, D.C. Way, A., and A. Blanc. 1997. "Contraceptive Knowledge ---. 2000. "Health, Nutrition, and Population and Use and Sexual Behavior: A Comparative Study Sourcebook for Poverty Reduction Strategy Papers." of Adolescents in Developing Countries." Unpub- Washington, D.C. How=do the needs of women fit into the changing health systems of Latin America and the Caribbean? In The Health of Women in Latin America and the Caribbean,theWorld Bank,the Inter-American Development Bank, and the Pan American Health Organization explore advances and challenges in women's health in the region. Starting with a review of health conditions, the book identifies key health service delivery gaps in the region. It provides new analyses of public spending on women's health and highlights funda- mental ways in which health sector reform strategies-from decentraliza- tion to resource mobilization-affect women's health outcomes. TheWorld Bank Inter-American Development Bank 1818 H Street, N.W. 1300 NewYork Ave., NW. Washington, D.C. 20433, U.S.A. Washington, D.C. 20577 Telephone: 202-477-1234 Telephone: 202-623-1753 Facsimile: 202-477-6391 Facsimile: 202-623-1709 Internet: www.worldbank.org Internet: www.iadb.org/pub E-mail: feedback@worldbank.org E-mail: idb-books(iadb.org Women, Health and Development Program 1 4 9 3 0 Pan American Health Organization 525 23rd Street, N.W. Washington, D.C. 20037 I Telephone: 202-974-3405 Facsimile: 202-974-3671 9 780821 349304 Internet: wrww.paho.org ISBN 0-821 3.4930-9