Demographic Patterns in Rwanda at War: Part 1 - Impacts on Population Size, Gender Imbalance, Fertility and Marital Status

Andre Medici
Adriana Correa Alves

Rwanda was the scenario of one of the bloodiest armed conflicts in the modern African history. From April to July of 1994 an episode of ethnic violence between the Hutu and the Tutsi ethnical groups killed more than one million people (mainly Tutsis and moderate Hutus) in only about 100 days causing massive displacement (about 2 million people) to neighboring countries. The war and genocide took significant impact on the population structure and economy. The genocide responded to about 150,000 widows and 300,000 abandoned children. Rape and HIV infection increased in large proportions. The United Nations estimates that at least 250,000 women were raped during the genocide and a large number of those women were subsequently executed.

Although Rwanda suffered a major loss of human life during the genocide, the population size after the war remained essentially the same because over a million former refugees who were living for years in exile returned at the end of the war. Currently, Rwanda’s population structure is more stable with less displacement. People were settling fast and many are already reintegrated into the social and economic life while peace and security has been progressively assured. Many health facilities were destroyed during the genocide and even some units not affected by the conflict became without adequate staffing and equipment.

The demographic census data shows that Rwanda reached a population of 8.128,553 people in 2002 and 83% of this population was living in the rural areas. The urbanization increased substantially between 1978 and 2002. Estimated in 3.6% in 1978, the urbanization rate reached 6% in 1991 and 17% in 2002. Part of Rwanda’s population is concentrated in the capital Kigali, with 603.049 habitants in 2002 representing 44% of the country urban population. After the administrative reform of 2000 Rwanda counts with a total of 11 Provinces and the city of Kigali (see map).

Rwanda has the highest population density in Sub Saharan Africa, estimated in 321 inhabitants per square kilometer in 2002. The population is essentially young, with 67 percent of all Rwandans under the age of 20. Poverty remains a major barrier to development in Rwanda. Currently 60% of the population is below the poverty line and the poverty rates increased in the last 30 years.



The consequences of armed conflict in the size, composition and dynamics of the population are difficult to quantify. Armed conflicts often disrupt the vital statistical systems, the statistical offices and the possibilities to conduct censuses and household surveys. As a result, good and reliable data during the wartime years are usually unavailable for most countries affected by armed conflicts.

In order to present evidences about the demographic impacts of the Rwanda’s war we accessed a mix of official data sources, research findings and administrative records. Some data sources such as the Rwanda Demographic and Health Survey (DHS) and the National Census 2002 provide more robust demographic information. Demographic trends were built by pooling the DHS data in three moments: 1992, 2000 and 2005. The data sets covered a sample of 6,551, 10,421 and 11,321 women in the age group 15-49 years in each of these years, respectively. Details on the survey procedures and sampling design are available in individual survey reports.

The population structure by gender and age is crucial to the demographic and socio-economic analysis related with post-conflict contexts. During the 1994 war, most of deaths were concentrated in men and boys feeding the current Rwanda’s gender imbalance. The war led to an over proportion of females in all provinces, excepting Kigali city, where women represent only 46% of the population.

Figure 1 shows the Rwanda’s population distribution by age and gender in 2002. This demographic pyramid reflects the age and gender structure six years after the war. It has a very large basis and numerous irregularities in the demographic structure in several age groups as consequence of the war.

Figure 1
Rwanda Population Pyramid 2002



The pyramid base narrows rapidly as it reaches the upper age limits, indicating that fertility rates increased after the war and genocide. In 2002 the total fertility rate was estimated in 4.1 children per women in reproductive age. It indicates a resumption of previous procreation patterns following the reconstitution of the families and new unions’ formation. However, general mortality is still high. The total mortality rate in 2002 was estimated in 154 deaths per thousand inhabitants.

It is important to observe an unexpected irregularity in the number of children in some specific ages such as one, three and four years old. It could be attributable to an-over mortality lead by malnutrition and transmissible diseases in some bad years due to waves of famine and epidemics in the post-war context.

There is a significant population fall-off in the ages between 6 and 12 years old, indicating that the generation born in the war period (1990-1996) was affected by an over mortality (probably due violence and the lack of water, sanitation, nutrition and health care) and by the decrease in the fertility rates following the separation of the couples during the war. On the other hand, the disproportionately increase in the population between 11 and 20 years old is associated with the massive return of refugees which were sheltered in other countries during the wartime.

The huge gender imbalance produced by the war could also be observed in all ages at the demographic pyramid, but more extensively among the populations over 45 years old with an excess of women due the over-mortality of men during the war.

The sex ratio (measured as the proportion of men per women) is an indicator to evaluate the demographic balance between males and females. According this indicator Rwanda had 91 men for 100 women in 2002, mostly due by the effects of war and genocide. In urban areas the proportion of men is higher, but the inverse is observed in rural areas where the ratio reached 87.5 men per 100 women in 2002. The urban/rural differences in the sex ratio resulted mostly from the farming exodus of the mainly masculine populations in search of education and job opportunities in the cities, sometimes hopeless, contributing to inflate the urban poverty .

At the provincial level, sex ratios in 2002 oscillated between 87.1, in the Province of Kibuye, and 93.3, in Umutara. Inversely, in urban areas as the city of Kigali, where the male population is predominant, the sex ratio reached 117.5 in 2002.

Figure 2 represents the sex ratio at national level by residence - urban and rural - and age. The total sex ratio is bellow 100 in all age groups of 20 years old and more. This reflects the impact of war and genocide in 1994 that caused higher levels of male mortality in adult ages and mass emigration of males to neighbor’s countries.

Figure 2
Sex Ratio according age groups and residence area - Rwanda 2002




On the other hand, in urban areas the sex rate reaches an over proportion of males between the ages 20 and 60, as result to a massive demand for job opportunities by the male population.

Fertility in Rwanda plays an important role on population growth. Socio cultural values, mostly linked with conservative interests defend a pro-natality attitude. The data from DHS 2005 shows that the total fertility rate (TFR) among Rwandan women remains very high: 6.1 children for women in reproductive age, 4.9 in urban areas and 6.3 in rural areas. Data also shows that after the war context, between 2000 and 2005, TFR increased from 5.8 to 6.1 (figure 3) breaking a historic context of fertility decreasing experienced since the early eights.

Figure 3
Total Fertility Rates in Rwanda: 1983-2005




Existing literature explores the hypothesis of fertility decline during periods of armed conflicts, but does not discuss what happens after the conflict. As can be shown, the TFR in Rwanda was reduced during the war period (from 6.2 in 1992 to 5.8 in 2000), increasing again in the after-war period, when TFR returns to 6.1 in 2005. The analysis of the age specific fertility rates in 1992, 2000 and 2005 (Figure 4) demonstrates a similar pattern of the fertility rate: a decrease of the TFR in the ages between 25 and 39 during the period 1992/2000 and a return to an increase pattern, between 2000 and 2005, for the same age groups. So, armed conflicts lead to a fertility decline during the conflict time and to a fertility increase after the conflict. Even so, figure 6 shows a persistent decline in the fertility in the youngest (15-19) and oldest (40-49) age groups between 1992 and 2005.

Figure 4
Total Fertility Rate in Rwanda by Women Age: 1983-2005



Another interpretation to the present high fertility rates in Rwanda is associated with the persistent unwanted fertility in this country. Women in developing countries often have more children than they desire. A birth is considered “wanted” if the number of living children at the time of conception of the birth is less than the ideal number of children, as reported by the respondent. Bongaarts (1997) argues that unwanted fertility is typically higher in countries at intermediate levels of their fertility transition.

The Total Wanted Fertility Rate is the same as the Total Fertility Rate, only if unwanted births are omitted. If all unwanted births were avoided by the adequated supplies of contraceptive means for Rwanda's women in reproductive age, the TFR for Rwandan women should be 4.6 children in 2005, rather than 6.1 children. The TWFR is higher in rural areas (4.8) than in urban areas (3.6) and in the City of Kigali (3.4).

However, the data about the unwanted fertility in 1992 (before the war) is not available. If considered that the access to family planning was better in 1992 than it is in the present, probably the unwanted fertility in 1992 should be lower than in 2005. Rwanda has the second higher TFR among 12 sub-Saharan countries in which a DHS survey has been conducted since 2000. But if the reduction of the TFR between 1992 and 2005 had kept the same pattern observed between 1983 and 1992 the Rwanda's TFR probably would reach 4.6 in 2005, standing among the lowest levels in the Sub-Saharan Region on the early 2000’s. Based on that, certainly the armed conflict has an important role in the delay of fertility rate reduction in Rwanda.

Figure 5
Total Fertility Rates in 12 Sub-saharan African Countries in the Early 2000's




The age at which childbearing begins is an important demographic indicator because it has a direct effect on a women’s cumulative fertility, particularly when contraceptive means are not available. The younger a woman is when she begins childbearing, the greater her likelihood of having many children. At the same time, having children at too young an age can have negative repercussions on the mother’s health and can put her children at risk of dying. In Rwanda, in 2005, the median age at first birth of 22.0 years for women age 25 to 49 is identical to the median age observed for women the same age in the 2000.

Another important fertility indicator is the age of marriage for women. In low income countries, the women who marry earlier tend to have their first child earlier and give birth to more children, contributing to higher fertility rates. The duration of exposure to the risk of pregnancy depends primarily on the age at which women first marry. In Rwanda, where pre-marital fertility is uncommon or very low and the efforts to control fertility are not expressive, delays in marriage can cause a reduction in the number of women under risk of childbearing. The average age at first union is 20.7 years and first sexual relation is 20.3 years, which is relatively late compared with other African countries and has remained unchanged since 1992, when the median age at first union was around 20 years. On the other hand, men in Rwanda tend to marry at an older age than women. The median age for the first marriage is 25.0 years and the median age of first sex is 20.8 years. Even having the first marriage and first sexual relation later than other developing countries, Rwanda presents high fertility rates due the little space between pregnancy and the lack of contraceptive goods and services to the poor families.

Marriage remains practically the sole context of procreation in Rwanda. Among the women age group 15-49, 49 percent declared they were in a union at the time of the 2005 DHS. The proportion of never-married women decreases as age increases and it is rare to find a woman over 45 years old who has never been married (2 percent). In addition, 12 percent of Rwandan women live in polygamous households. Rwandan women tend to marry late: only 19 percent of those between the ages of 25 and 49 had married before they were 18 years old.

Of the 11,321 women surveyed in 2005 by DHS, 49 percent were in union (29 percent formal marriages and 20 percent in informal unions). The proportion of women who never married is 38 percent. Divorced women make up only 0.9 percent of women, separated women make up 9 percent, and widows are 4 percent. The proportion of never-married women has increased since the RDHS-II, from 34 percent to 38 percent.

Apparently the war does not present a strong impact in the marital status of women. The largest increase occurred in the 15 to 19 age group, of whom 90 percent were never married in 1992, 93 percent in 2000, and 97 percent in 2005 showing the trend to increase the first marriage age mentioned before. The number of married women has remained relatively stable during the last two surveys. The proportion of widowed women has dropped by half, from 8 percent in 2000 to 4 percent in 2005, given that the 2000 data was inflated by the armed conflict effect on the men’s disproportional mortality.

The second part of this article (to be published in the next post) will address the impacts of the Rwanda armed conflict in the use of contraceptive methods, infant, child and maternal mortality, orphanhood and migration.

Armed Conflicts and Demographic Transition in Developing World:

Andre Medici
Adriana Correa Alves (1)


Introduction

In the last twenty years armed conflicts intensified in many of the poorest areas in the world, with severe consequences in mortality, human displacement, famine, destruction of public infrastructure and losses of physical and social capital. Armed conflicts reverse the benefits of the development process. Their devastating economic and social consequences are deep, remaining for years after the end of the conflict.

Many armed conflicts are associated with demographic imbalances. In fact, the persistency of high fertility rates, the rise of youth population, chaotic urbanization and migration processes, beside the scarcity of natural resources as cropland and freshwater supply, are frequently associated with the origins of civil wars in low income regions.

Armed conflicts generate direct consequences in mortality due war violence. All the three demographic dynamic components – mortality, fertility and migration – could be affected by armed conflicts and civil wars. Mortality in all age groups increases due direct human losses by the conflicts. Even affecting all age-groups, direct mortality in the conflicts is higher among adolescents and young adult male population. As consequence, armed conflicts multiply the number of orphans and widows, creating life disruption and increasing poverty among the survivors, especially women and children.

On the other hand, armed conflicts have also indirect impacts in mortality and morbidity accelerated by the increasing malnutrition, the disruption of family structures and family support to youth and children and the destruction of farmlands and public infrastructure. Health services, water supply and epidemiological surveillance generally don’t work properly during armed conflicts times. Increasing morbidity is one of the biggest consequences of civil wars and it is associated with the higher incidence of transmissible diseases such as AIDS and malaria during the conflicts and in post-conflicts contexts. The burden of diseases increases as consequence of the rising of physical disabilities and chronic diseases, especially those associated with stress and mental disorders.

Fertility generally increases as result of lack of access to family planning and other factors as rape and sexual violence against women. Some authors associate increases in fertility during and post-conflict with the women’s will to compensate the loss of children due to the war, but this argument still needs evidence to be proved.

International and internal migration intensifies due the generation of large waves of war refugees affecting family arrangements and family composition. In areas where displaced population is accommodated in refugees’ camps, family structure is disrupted because these camps are organized according gender and age groups. Family members are separated and children are not allowed to live with their parents. Age structure and gender ratios also change and turn imbalanced, due to disproportionately mortality of men and youth/adults. Men and women also may be differentially affected by the challenges and opportunity to reorganize their lives, to find households and to reinsert themselves into social networks and economic activities in the aftermath of armed conflicts.

Women and children suffer the most. Gender specific consequences include increased gender ratios, female-headed households, changes on the fertility patterns and unmet needs of reproductive health programs due the disruption of health systems and destruction of health facilities. Women often become caregivers for injured combatants and find themselves, as a result of conflict, unexpectedly cast as sole manager of a household, sole parent, and caretaker of elderly relatives. Children, especially the orphans, miss opportunities to attend school and health programs. Women and children are easy targets to sexual and gender-based violence and exploitation to the point of depression, mental illness and suicide. Women are disproportionately vulnerable to war associated risks such as human trafficking, forced labor or slavery, HIV/AIDS and other SDT and lack of access to education and health care. The violent environment during the conflict and post-conflict contexts reduces access or eliminate health information and health services, especially in outlying areas.

Demographic transition: balance and trends

Although the demographic transition is accelerating in most developing contexts, in low income regions, such as Sub-Saharan Africa, fertility and mortality are still high. Since the 1960s, population programs, especially those financed by international organizations or bilateral technical cooperation, have played a significant role in enabling couples to choose smaller families and to reduce fertility. However, armed conflicts could stop the spectrum of collaboration between these programs and the governments, slowing the gains in fertility reduction. In addition, two thirds of children in many Sub-Saharan African countries are projected to have HIV infection by the time they have reached age 50 (or die from HIV before).

The demographic transition is a generic concept associated with demographic changes from a context of high mortality and fertility rates to another of low mortality and fertility rates. Historically, the first classic demographic transition refers to the declines in mortality and fertility, as witnessed from the XVIII Century onward in several European populations, and continuing at present in most developing countries. The final stage of the first demographic transition was supposed to be an older stationary and stable population corresponding with replacement fertility (i.e. just over 2 children on average), zero population growth, and life expectancies higher than 70 years. The European demographic transition process was accelerated by the immigration. European countries intensively exported population to the Americas and other regions between the second half of XIX century and the first half of the XX century.

A new concept introduced by R. Lesthaeghe (2002) and others (2) in developed countries is the second demographic transition (SDT). The traditional concept implies that, at the end of the first demographic transition process, would be in place an ultimate balance between deaths and births and no “demographic” need for sustained immigration. The second demographic transition, on the other hand, sees no such equilibrium as the end-point. New social behaviors and changes in cultural norms bring new patterns such as a multitude of living arrangements other than marriage and the disconnection between marriage and procreation. These new social behaviors lead the fertility to sub-replacement levels and consequently to a no stationary population.

Instead, populations would face declining sizes if not complemented by new migrants (i.e. “replacement migration”), and they will also be much older than envisaged by the first demographic transition as a result of lower fertility and additional gains in longevity. Migration streams will not be capable of stemming aging, but only stabilize population sizes. Nonetheless, the outcome is still the further growth of “multicultural societies.” On the other hand, the SDT brings new social challenges, including those associated with further aging, integration of immigrants, less stability in family arrangements and high levels of poverty or exclusion among certain household types (e.g. single persons of all ages, lone mothers and illegal immigrants).

The demographic transition process tends to be much faster in developing countries. In Latin America, improvements in preventive health and medical care in recent decades lead to a fast to infant mortality reduction and increased life expectancy. Fertility has also declined faster, resulting in a quick transition from unprecedented population growth to low birth rates. Migration (both national and international) also affects the demographic transition in Latin American Countries. Colombian migrants, expulsed by the guerrillas, went to Amazon areas of Brazil and Salvadorians went to Guatemala, Honduras and Belize as consequence of armed conflicts.

One of the principal criticisms of the demographic transition concept is the questionable applicability to developing regions such as Africa, where the prerequisites for wealth, governance and information access to reduce both mortality and fertility are limited, especially in war and post-conflict contexts. The creation of good governance and sustainable economic growth, with increased provision of social rights as health, education, good jobs and social welfare, could pave the road to a stable process of demographic transition in these regions.


Armed conflicts and Demographic Dynamics: a brief literature review

The empirical literature on conflict and demography is scarce. Despite the relevance of the impact of armed conflicts on demography dynamic in poorest countries, especially due high mortality and forced migration, this subject is a new field of study (3). There is little structured analysis about the consequences of armed conflicts in the demographic patterns and most of the conclusions are anecdotic and could not be generalized. In most cases it is hard to found general patterns. Most of the consequences depend on the interaction between economic, social, cultural and political variables existing before, during and after the conflicts.

Conflict and violence have been referred as one of the principal causes for the erosion of physical, social and human capital in many countries. In a recent search for evidence about the demographic consequences of armed conflicts, Randall (4) analyzing the post-conflict demography of the Malaian-Tuareg, found mixed evidence of the effects of war on reproduction, mortality and family arrangements in three different stages: disorder, limbo and new order. Each one of the three phases has particular complexities and the armed conflicts could work as a catalyst to generate demographic change or to accelerate previously established demographic trends. The different escalation processes presented by the author’s framework serve to identify the related degrees of a conflict’s development and the peculiar forms of involvement by those experiencing the conflict.

The disorder takes place at the beginning of the conflict and may include violence and displacement according different environments. In the disorder phase could be observed biological and psychological impacts of the conflicts such as nutritional crisis, emergence of diseases, social stress, increased infant mortality and curtailed breast-feeding. The fertility and nuptiality tend to fall as a result of spousal separation, lack of privacy, abortion and reduced fertility due to under nutrition. The risk of rape also tends to increase.

During the limbo stage, that happens when conflict is established, people have no clear direction for the future. The population has few opportunities for sustainable self-reliance and generally suffers economic restriction and basic logistic problems associated with food distribution, security, health care and sanitation. This phase can last for several years and entire generations can grow up and matured under these uncertain conditions. In the third stage named new order, which take place during the post-conflict reconstruction, the main characteristic is the re-establishment of social and political order and the restoring of the semblance of normal life. The new order does not represent necessarily a return to the past patterns but generates an entirely new social, economic and demography dynamic.

Verwimp and Van Bavel (5) explain the cumulated fertility of Rwanda women and the survival of their children during and after the conflict through the theory of risk insurance or old-age security approach of reproductive behavior. This theory implies that fertility rises among refugee women as a response to lower chances of surviving. The refugees compensate the loss of children by having more children. Such behavior was particularly observed among the Palestinian population under armed conflicts by decades, where fertility is substantially higher than would be expected from their level of socio-economic development, according DellaPergola (6).

Girls’ survival in the first life-year is naturally bigger than boys’ survival in regular demographic contexts, but in armed conflicts areas the newborn boys have more chances of surviving than girls due family behavior and social norms. During armed conflicts boys are valued because they are early incorporated to fight as soldiers. Other social norms could also explain the over-value of boys by families. In many African countries, as Rwanda, only boys are heirs of land property. Families composed by girls have the risk to lose land property and access to food and water sources in the future.

Avogo and Agadjanian (7) explore the influence of the end of war and the postwar rebound in Angola’s fertility patterns. They show that the impact depends on the degree of exposure to the war and also the women’s socio-economic status. Ghobarah, Huth and Russett (8) analyzed several cross national World Health Organization dataset on 23 major diseases in population distinguished by gender and age groups and they found evidences that civil war increases the risk of death and disability through the breakdown of norms and practices of social order. The study also found that if a neighboring country recently experienced a civil war, women and girls are disproportionately affected by disability and death from AIDS.

In Latin America, where societies count on higher income and governance levels among other development regions, the existing literature shows that armed conflicts have impacted less the demographic trends and women and girls than in Africa. In Central-American Countries as Guatemala, Honduras and El Salvador, armed conflicts triggered intense migration flows and had demographic impacts such as delays in the reduction of fertility rates. For example, in the wake of the ensuing Honduran agrarian reform, in which only native Hondurans were allowed to own land, as many as 130,000 Salvadorans were forced to give up whatever jobs or land they had acquired and return to El Salvador. The exodus of Salvadorans from Honduras contributed to the so-called "Football War" between these two countries, in 1969, and the large number of returning Salvadorans worsened social and economic tensions within El Salvador itself.

In the next edition of this blog we will discuss some examples about how armed conflicts had affected demographic and health trends in some developing countries.

Notes

(1) Adriana Correa Alves is a Consultant of the Inter-American Development Bank and hold a PhD in Humans Right in Salamanca University (Spain).
(2) Lesthaegue, R., (2002) Second Demographic Transition, Vrije Universiteit Brussel (VUB).
(3) Brunborg, H., and E. Tabeau, (2005), Demography of Conflict and Violence: An Emerging Field, European Journal of Population, 21: 131–144.
(4) Randall S. (2005), Demographic Consequences of Conflict, Exile and Repatriation: a Case Study of Malian Tuareg. European Journal of Population 21: 291-320.
(5) Verwimp P. and Van Bavel J V (2005), Child Survival and Fertility on Refugees in Rwanda after the Genocide. European Journal of Population (2005) 21:271-290.
(6) DellaPergola, S. (2001). Demography in Israel/Palestine: Trends, Prospects, Policy Implications. Paper presented at IUSSP General Conference. Salvador, Brazil.
(7) Avogo W. and Agadjanian V. (2007). Reproduction in crisis: war, migration and fertility in Angola. A paper presented at the Population Association of America 2007 Annual Meeting Program. March 29-31, 2007, New York.
(8) Ghobarah, H. P. Huth and B. Russett (2003). Civil war kill and main people – Long term after the shooting stops. American Political Science review, 97(2), 189-202

Some Reasons to Reform United States Health Care System

Andre Medici

1. United States - A country that does not get what it spends on health


The United States is a country sui generis in their spending on health. And it didn’t start today. In 1960, while the OECD countries spent around 4% of GDP on health, the United States spent 5%. In 2007, the OECD average had reached the 9% but the United States was at 16%. Moreover, while the other countries mentioned have achieved universal health coverage for its population, about 16% of Americans (46 million people) declared themselves without coverage that year and the coverage has not increa sed over the past fifteen years.

Looking more closely a data set of six OECD countries OECD 2007 that includes the United States, it appears that the U.S., spending an average of $ 6.102 U.S. dollars per-capita per year, of which $ 878 go solely to pay for medication, suffered from the worst performance in the indicators of quality, access, efficiency, equity. Suffered also from shorter lives and least productivity when compared with countries that spent between U.S. $ 2,083 (New Zealand) and $ 3.165 (Canada) per capita-year in health.

Even paying more for health, the Americans had worse access. In 2008, the chronic patients in the United States shared with Canadians the fact that only 26% could get medical appointments for the same day, a percentage that ranged between 60% and 36% in the Netherlands, New Zealand, Germany, France and Austria. Given the same set of countries, the U.S. had more problems getting healthcare at night or on weekends and had the biggest reported problems associated with coordination of care and medical errors on prescription and medication administration. Only 28% of doctors have patients electronic medical records, compared with rates higher than 80% in the Netherlands, New Zealand, England and Austria. In short, 54% of Americans with chronic illnesses said they had problems of access to medical care because of the high costs and administrative constraints. That percentage was down to 30% in the other OECD countries mentioned.

As a result, besides spending a lot more and being treated a lot worse, the Americans also die a little earlier than their peers in OECD countries. Life expectancy at birth in the United States in 2006 was 78.1 years, compared with 78.9 on average in other OECD countries. Countries such as Australia, Canada, France, Iceland, Italy, Japan, New Zealand, Norway, Spain, Sweden and Switzerland had in the same year a life expectancy at birth greater than 80 years. The infant mortality rate is also higher in the United States than the average of OECD countries (6.7 per thousand compared with 5.1 per thousand). Mortality rates from causes that could be treated if they had better health care reached 110 per 100 thousand inhabitants in the United States, values higher than those found in at least 14 developed countries.

The United States spends 49% of global health expenditures, but its population is only 5% of the world and yet this care is linked to all the problems mentioned above. Among OECD countries, it is the one with the highest share of private spending and household spending on total health expenditure.

The lower health coverage can be explained by a number of reasons: a) Being that health insurance is voluntary for most of the U.S. population, there is an increase in number of persons without financial access to health plans whose cost increases each year at rates higher than inflation, b) the number of companies that offer health benefits to their employees is shortening over time c) individual health insurance plan markets limit coverage of pre-existing conditions and reassuring the health plans may reject patients based on their individual risk.

As a result, health insurance became too expensive for individuals (and small and medium businesses) and 62% of family bankruptcies in 2007 was associated with the high health costs in the United States.

Among the factors that are associated with higher health costs in the United States there are: (a) high administrative costs (7.4% compared to 4.4% in average OCDE5 (b) high wages and salaries of doctors; (c) high use by professionals of specialized procedures or intensive care as a percentage of health services and (d) low use of processes to reduce cost and risk sharing between insurers and providers such as capitation payments.

2. What can the international experience teach us?

The challenge of the United States is to achieve greater coverage and quality for less money. This situation has aroused discussion in many countries. Some even say they can teach the Americans out of the rut and other blame, once again, the wild capitalism and privatization model for the failure in the American health. But the reality is far from it.

From the economic point of view, health is a unique industry and from the writings of the Nobel Prize Kenneth Arrow in the sixties, health economists have highlighted the economic peculiarities of this sector that do differ from others. Health expenditures are relatively inelastic and the costs of the sector grow primarily due to external factors (income levels and population aging) and internal sector behavioral trends (use of medical technology and management models).

For all these reasons, some countries have learned that without proper regulation they are not likely to increase the economic efficiency of the health sector. This regulation is increasingly complex, and must act not only to reduce market failures but also to avoid major failures of state, under the monopoly of public provision. In this context, it is worth sorting out what other countries may have to teach the United States, according to their degree of development.

a) Developed Countries

European countries, Japan, Australia, Canada and New Zealand, do not usually tell the Americans what to do. In fact, their health systems have also been improved by importing innovations from the U.S. experience in health management (as of diagnostics Related Groups - DRG - and separating the management of health service provision) in order to allow its statist models to correct their flaws through more state-regulated competition. These countries (with the possible exception of Canada), after seeing their models of welfare state skate on gigantism state, learned that corporate governance has its advantages and sought to balance their goals of universal coverage, equity and public ownership with transparency, out-sourcing and market incentives.

From the standpoint of regulation, developed countries have used market incentives and competition managed to avoid the pitfalls of the State in the health sector. They learned to use risk pooling and incentives to control costs and to negotiate better prices using procurement mechanisms for services with different providers. They work in a more structured system of information technology to streamline the use of personnel, material resources and clinical infrastructure.

European countries, for example, have as a basic criterion the regulation of the insurance market to ensure competition and managed risk-adjusted. Many make coverage compulsory and not voluntary and provide subsidies for those who cannot afford an insurance plan.

Many developed countries, where one important exception is the United States, have done better by using public health, primary care and models of health promotion and prevention in order to avoid the catastrophic costs of chronic diseases. They more effectively promote changes in risk behavior of their people, encouraging them to practice healthier habits, reducing sedentary lifestyles and reducing the number of other factors that lead to increased costs of medical care. Countries such as Chile, for example, after the dictatorship, succeeded in establishing a public coverage option for health plans and appropriate regulation to prevent cream skimming, social discrimination and denials of coverage by health plans.

Most developed countries have used models of care and more integrated health networks, as the example of general practitioners in England and the frequent use of regulation in health networks, facilitated by information technology and regulation and control the processes of reference and counter reference in health.

Last but not least, developed countries have advanced greatly in the use of epidemiology and perceptions of users about their health status in setting health priorities, based on studies of burden of disease. In setting priorities for health, they also define the protocols, the lines of care and delivery mechanisms of these services, study their basic costs and establish procedures to purchase public or private services that are based on these parameters.

Many of these studies, processes and ways of integrating medical care, even if they have been developed and tested by institutions and American universities, are not widespread in the country and are implemented on time and on a voluntary basis (as can be seen in the successful Kaiser Permanente experience). In other developed countries where public regulation of the sector is more present and strengthened, this development has been accelerated in recent years.

b) Developing Countries

Some developing countries, proud of their models, say they can teach the Americans what to do, but in fact, the success of these countries is conditional on passing situations without coverage for a reasonable offer of basic health services. Their challenge, therefore, was not to reduce costs through improvements in coverage and quality, but instead increase spending to cover a population largely lacking in services. Much of the struggle of so-called "sanitary reform movements" in developing countries is to increase rather than reduce spending on health.

Developing countries, especially in Latin America showed great strides in increasing the coverage, reducing infant and maternal mortality, structuring primary care and interdisciplinary teams of health and thereby, and improving the primary health care in the last twenty years. But health indicators (with some exceptions such as Chile) are still far from reach developed countries standards of quality. The challenge of quality and the gap of inequality in access are even greater in Latin America, for example, than in the United States.

Innovative models of public administration started a short time ago and can cheapen and improve the quality of the public health services (such as Social Organizations and State Health Foundations in Brazil) but are threatened or numbed by the action of justice and union movements of health professionals, which defend their work stable status and, at least, act against the needs of the poor. These, in the name of combating the specter of privatization of health, have actually privatized public resources in the hands of the corporatism of health professionals, leading the public system to work less and benefit those who have more access to control health time-schedules, access and health information.

They end up arguing (even implicitly) for the use of public institutions of direct administration in favor of the private interest of themselves and not in favor of common sense and for the interest of the neediest population.

Some successful strategies for primary care visits and health in remote areas and models of securing more regulated use in developing countries may be transferable to experiences in the United States, allowing for greater coverage and best supply regulation. However, given the epidemiological differences between the United States and these countries, issues such as quality and training would have to be reworked in the American context for these experiences in order to deliver better results.

3. The reform proposed by President Barak Obama

President Barak Obama was not the first to propose a major reform in the American Health Care System. Other U.S. presidents have also done so, including most recently Bill Clinton.

The Clinton Plan, between the earlier initiatives of health reform, was what came closest to an effective process to tackle the challenges of inequality and lack of access to health care in the United States, but the resistance from various sectors of society did not allow the plan to survive. However, it was the embryo of several reform initiatives and coverage extension initiated at the level of U.S. states, especially that of Massachusetts - the first statewide initiative to propose a plan for universal health coverage with mutual responsibility of the employers and families. These state reforms in recent years have cemented the consensus, albeit partial, that something should be done and some successful experiences - both the public and private sectors - has been able to demonstrate paths that could be taken to achieve greater coverage and quality at lower costs.

The current proposal to reform the U.S. health has been presented in public debate on the need to face five challenges: (a) extending coverage to all, (b) organization of care around the patient, (c) financial incentives to reduce costs, (d) medical care quality and efficiency, (e) public regulation and integration between public and private systems.

a) Making coverage accessible to all

The challenge here is to extend (making mandatory) coverage for all citizens, including the 46 million Americans who do not have health insurance. For this challenge to be won, some measures are being proposed by the Government and discussed by the U.S. Senate. Below is a summary description of the proposals in effect until October of this year.

As for individuals, tax incentives, such as deductions of up to $ 750 per person covered in the income tax would apply. At the same time, individual fines of up to $ 750 per person would also be applicable in case of no coverage be proved, excluding those who, due to lack of income, cannot afford to pay for health insurance;

Private companies, as originally proposed by the government, with more than 50 employees, will have to pay, as of 2013, a fine per employee not covered by health insurance. Small businesses (with fewer than 50 employees) will receive incentives such as tax relief for workers to join their health plans. The Senate has proposed, alternatively, that firms with more than 25 employees would pay 60% of the premium for employee and that the fines for part-time employee not covered would be only $ 375 per employee per year. Small businesses, instead of having tax deductions receive public subsidies to affiliate its employees.

The Health Insurance Market would be subject to regulatory processes on managing private plans and would offer new options, including public sector option and cooperatives. The plans must have a minimum set of benefits that will be reimbursed between 70% and 95% of its actuarial cost estimates. The plans must be differentiated by age groups (three to four groups, including the Senate proposal to create a special health policy for young adults) and should have portability to allow options of exchanging carriers and plans for patients without disqualification coverage.

The state would offer a public choice, based on the creation of a government agency that would offer health plans, and the ability to capture those people not included or accepted in the private health plans because they can not pay or because, due to their level of risk, would be rejected by the private sector. This agency does not subsidize the price of the plans, but would seek efficiency and prevent abuses by the plans in the search for patients that are easily profitable due their lower risk. Like Medicare, the agency does not provide direct health services, but will hire private providers. This could increase coverage for many of the 46 million uninsured and provide some option for their specific health problems, even if they were rejected by the existing health maintenance organizations.

b) Organization of Care around the Patient

The proposal, in this subject, is to create incentives to increase preventive care and healthy behavior of patients and encourage primary care services. In the first instance, the Federal Government proposes to develop a national strategy to promote prevention and health, investing and giving donor resources to support prevention programs in the communities, as well as financial incentives to individuals and health plans to improve strategies for promotion and prevention.

Some elements of the proposal are: (a) to eliminate the user’s co-financing for actions of promotion and prevention programs given that they have proven necessary in the public option, Medicaid and Medicare, (b) encourage the same practice in private health plans and, (c) establishing patients’ health promotion routines and encourage scheduling medical visits for prevention and risk assessment of health.

In the case of primary care services, the proposal is to increase the value of the primary care visits remuneration in Medicare at rates higher than the salaries received by the specialized doctors. Since large amounts of curative services to chronically ill older persons are increasing spending on Medicare, this proposal would encourage further promotion and prevention to reduce program spending in the public and most expensive U.S. health care sector. Some of the amendments proposed by the Senate are to raise bonuses to primary care physicians in up to 10% of the amounts billed during the first five years of reform, along with cuts in payments to other specialized medical services at 0.5%.

c) Financial Incentives to Reduce Costs

In this area, the Government's proposals and the amendments that the Senate is working are pilot projects of innovative payment providers. The innovations in the payment system appear in proposals for family clinics (medical homes), more transparent organizations of providers (more accountable health care organizations) and hospitals dedicated to cross reference and post-acute care.

These innovations will test cheaper and integrated ways to pay providers that, since they will prove functional, are applied to mass public systems such as Medicare and Medicaid. To increase incentives to these experiences, the government could establish special funds (grants) for its financing.

d) Efficiency and Medical Care Quality

Proposals related to this field would be structured as improvements in system productivity, comparative clinical effectiveness and improving the quality of services.

Improvements in productivity may arise aligning financial incentives to the more cost-effective procedures, constantly updating medical protocols and prospective payment systems in accordance with these principles and making up the basket of procedures recommended by these criteria;

Comparative Analysis of Effectiveness would be made possible through the establishment of research centers that allow assessing the clinical outcomes of different types of health interventions, allowing you to select those that best demonstrate proven results for cost incurred.

Improvements in Quality of Service would be achieved through the creation of the Center for Quality Improvement which will identify, evaluate, disseminate and implement best clinical practices, research and define the national health priorities to improve performance of health institutions promoting evaluations indicators and measures for quality in health. To this end, they also will discuss funding to improve the efficiency of services. This policy is expected to work with same way as the criteria used by government to establishes a national strategy for quality development in health.

e) Public regulation and integration between public and private systems

The Public-private mix of health services in the United States has existed since the time when public programs like Medicare and Medicaid came into existence, in the eighties, private health plans in some contexts, to perform the services, either through contracting for risk (capitation) or through direct purchase (fee for service).

However, the Obama plan goes a step further in this process, when establishing regulations in the markets for health standards that define new services, requiring health plans and providers to disseminate results and performance. The Obama plan also creates a public insurance option as a way of marking the market in accordance with the expectations of the government and to force private companies to have a performance close to that established in the new framework of regulating the system.

4. Impact and financial prospects of approval

Although the reform has not yet defined all of its elements and many changes still may modify the current proposed measures, it is expected that it would reduce the number of uninsured from 50 million to 17 million between 2012 and 2019. It is also expected to bring a cost reduction in the expansion of the system.

Without reforms, total spending on health in U.S., estimated at $ 2.5 trillion in 2009, could range between $ 4.4 and $ 5.0 trillion in 2020 (based on trend growth rate of 4.4 % to 6.5% per year), implying an annual increase in health spending between $ 173 and $ 227 billion, representing over 20% of GDP in 2020.

With the reforms, an optimistic scenario, health care spending in the United States would, on average, be reduced by $ 81 billion between 2009 and 2020 ($ 7 billion per year) or raise only $ 239 billion in the same period (U.S. $ 22 billion per year) 9. With this, the per-capita spending on health could stagnate or even shrink, considering as baseline a moderate recovery of the U.S. economy in the same period.

More importantly, is the fact that, besides the reduction of expenditures, it would improve a population's health, increasing coverage, quality, satisfaction and health outcomes and re-placing the country on a track for rapid increased life expectancy, as has occurred in other OECD countries.

However, there are many tough issues in American society to reform health care:

a. Resistance by the population (or a substantial part of the middle class) who believes in a model where the freedom of choice is an unquestionable value and that would be willing to pay more to keep it. Health reforms tend to limit the freedom of customers to choose professionals and health facilities of their choice;

b. Resistance by doctors and other health professionals who prefer a model that does to standardize their knowledge and also give you the freedom to offer alternative treatments, differentiated pricing and charging for it freely. The strength and corporate power of the American middle class causes these providers to handle well the autonomy of their profession by making care lines, protocols, DRGs and clinical evaluations far from their aspirations, especially in the east coast;

c. Resistance by medical companies, for reasons similar to those of physicians, and also by the need to act freely in the sale of services, having the freedom to reject contracts with health insurers or with corporations;

d. Resistance by insurance companies and health management (HMOs) that will not submit to public regulation the several aspects that negatively affect the financial health, such as rates or insurance premiums, use of co-payments, use of pre stocks-to limit the range of services offered or the possibility to refuse patients if they do not make actuarial;

e. Resistance by the health law firms who want to maintain a free market trading of court orders (and their free interpretation by the court) when patients feel the consequences of pain and suffering, psychological and medical errors.

All of these resistors are worth trillions of dollars and have made it increasingly difficult to manage the public pocket and the family finances to pay the amount of resources they represent. The result has been to increase the public deficit as a function of progressive underfinanced public programs such as Medicare and Medicaid, but also the families and underfinanced companies can no longer afford the health plan, reducing the coverage and quality of services delivered by health plans.

But there is an expectation that the proposed reforms can be passed in Congress and at the moment, several conservative segments of American society, including Republicans, have positioned themselves favorably. This fact is associated with some special features of the reform. It keeps the spirit of that health duty to preserve pluralism and competition, and freedom of choice in a capitalist society like the United States. However, it emphasizes the role of the state as regulator of a theme which is notorious for information asymmetry by increasing the COMPLIANCE of basic human rights and implementing the subsidies to socially disadvantaged groups.

In his presidential inaugural speech, Baraka Obama said he was not the first U.S. president to try a Democratic health reform, but he said he would be the first to not give up and ensure that reform is made during his tenure. What is now expected not only in the United States but throughout the World is that this promise is fulfilled.