Latin America and the Caribbean Region: Champion in Reducing Child Mortality

André Medici 

Introduction

Despite the existence of pessimistic analyzes, health in Latin America and the Caribbean has improved significantly in recent years. This improvement should be attributed overall to the regional economic development, to the massive public investment in social policies and to the social and demographic dividends characterized by increasing rates of urbanization, better educational levels (especially for women) and improvements in water and sanitation systems . Between 1990 and 2008, life expectancy at birth in Latin America increased from 68 to 73 years old, reaching higher levels than the world average (69 years) and all other developing regions.


The good performance of Latin America in extending life span is evident when compared with Eastern Europe and Central Asia countries, where life expectancy at birth in the same period increased by only one year (69 to 70 years old), starting from a higher level but getting a lower level than the Latin American Region at the end of the period. Childhood malnutrition (measured by low weight at birth) reached in 2008 only 4.5% of children under five years old - the lowest value across all Development Regions, including Eastern Europe and Central Asia. In contrast, 7.2% of Latin American children at this age group became overweight - a factor that may contribute to the early incidence of chronic diseases.

In 2010, immunization rates for DPT3 and measles reached more than 90% of the target population. The prevalence of HIV-AIDS reached only 0.5% of the population between 15 and 49 years old, lower than the world average (0.9%) and the Eastern Europe and Central Asia Regions (0.6%), although higher that of high-income countries (0.3%). The incidence of tuberculosis had fallen to 47 per 100 000 inhabitants and almost 80% of cases are reported regularly by health services, value which is surpassed only by the countries of the Middle East and North Africa, among all developing regions.

However, maternal mortality is still high in the region. In 2008 it reached 130 per 100,000 – a higher level than those in Eastern Europe and Central Asia but lower than all other Development Regions. About three-quarters of Latin American women used regularly contraceptives, which is an equivalent level of high-income countries. Thus, fertility rates were reduced dramatically and many LAC countries, achieved levels below the replacement rates.

Access to water and sanitation reached 78% of the Latin American population in 2006, a figure surpassed only by high-income countries (100%) and countries of Eastern Europe and Central Asia. Through it all, the main health problems in the Region are no longer the diseases associated with poverty (malnutrition, maternal and infant causes and transmissible diseases) and became to be the chronic conditions. Population aging is accelerating as well as the demand for more sophisticated and expensive health services and, in many countries, such as Chile, Uruguay and Costa Rica, avert infant mortality depend more of efficient and well equipped hospitals.

But better health indicators performance in Latin America in recent years is not due only to achievements in health policies. It results also from a combination of successful policies of macroeconomic stabilization, economic growth and social development implemented in the last twenty years. On the health policy side, it also responds to actions focused on improvements in primary care. This set of factors has not been able to eliminate the deep inequality that is still reflected in health indicators but turn possible sound improvements in health outcomes in the region. Among these results it could be highlighted the fast reduction of infant mortality, which has been the focus of attention of international organizations and institutions as a way to fight against poverty in the developing countries.

 

Reducing Infant Mortality in Latin America and the Caribbean 

Between 1990 and 2008, the Latin America and the Caribbean Region got a fast reduction in the mortality rates for children under five years old, with an annual decrease of 4.53%. Keeping the same pace, the Region will be one of the few that will reach the Millennium Development Goal target of reducing child mortality by two thirds in 2015 (see table 1). The high-income countries, even reaching lower infant mortality rates, are not keen to achieve this target of the Millennium Development Goals. 

Table 1 - Mortality Rates of Children under 5 Years Old:

1990-2008 (per 1000 live births)

The infant mortality rates in Latin America presented big disparity among countries in the early 60s’. Countries like Bolivia and Haiti, for example, in 1960 had rates close to 160 per thousand, nearly four times higher ​​than those for Cuba, who always had lower infant mortality rates throughout the Region. Graph1 shows the infant mortality rates reduction over a half a century (1960-2010) in the five countries with higher levels of this indicator in 1960, which were Bolivia, Haiti, Peru, Guatemala and Honduras.

During this period, despite the fantastic reduction of child mortality in these five countries, the disparity in the level of infant mortality was increased. Haiti was the country with the lowest reduction turning from the second position in 1960 to the highest infant mortality rate in the region in 2010. Even so, the reduction was from 154 to 64 per thousand live births. Bolivia, which had the highest infant mortality rate in the region in 1960, showed a significant reduction (almost four times) - from 155 to 40 per thousand deaths in 2010. However, Peru, Guatemala and Honduras had the largest reduction, lowering their rates between four and six times, passing from 140 per thousand to levels between 20 and 35 per thousand live births.

Another way to see the evolution of infant mortality in LAC is to analyse  to the countries that had the lower infant mortality rates (Cuba, Uruguay, Jamaica, Argentina and Trinidad and Tobago) in the sixities, it could be shown in Graph 2  the reduction on the infant mortality rates between 1960 and 2010.

Cuba, the country with the lowest infant mortality rate in 1960 (40 per thousand) - continued to hold this position in 2010. Its rate was reduced by almost ten times during the period, as result of a health policy focused on mother and child primary care. The infant mortality rate in Cuba in 2010 (4.4 per thousand) is similar to the countries of the European community. Countries like Argentina and Uruguay, with infant mortality rates between 50 and 60 per thousand around 1960, also suffered significant reductions in this indicator, with their rates reaching in 2010 11 and 13 deaths per thousand live births respectively. However, the same did not happen with the largest countries in the English Caribbean - Jamaica and Trinidad and Tobago. In these two countries, infant mortality rates not only decreased slightly (around half) and stagnated (Jamaica) or even increased (Trinidad and Tobago) in 1985. Another way of analyzing the infant mortality trends in the region in recent 50 years is to compare countries that delivered minor and major efforts to reduce this indicator. 

Let us begin by countries that undertook major efforts. The top five are Chile, Cuba, El Salvador, Costa Rica and Peru (see chart 3). Infant mortality rates in these countries, which in 1960 presented large discrepancies (between 40 and 140 per thousand live births) began in 2010 to converge to values ​​located between 5 and 20 per thousand live births.

In Chile, the reduction was more than 13 times, from 106 to 7 per thousand over 50 years. Chile, in 2010, reached the second highest position in the regional ranking of this indicator. In Cuba, as already noted, the reduction was ten times. In other LAC countries, such as Peru, El Salvador and Costa Rica, the reduction was also quite significant. 

On the other hand, some countries apparently struggled and had worse results in the fight to reduce child mortality: they are they Trinidad & Tobago, Jamaica, Haiti, Paraguay and Bolivia (see chart number 4). Trinidad & Tobago and Jamaica - countries that in the sixties were among the five who had lower rates of infant mortality in the region, had the worst performance in reducing this  indicator compared with other in the Region. Another country with equally performed poorly in this indicator is Paraguay, which even with relative high infant mortality rates in 1960, did not registered good results in the reduction of this indicator over the past 50 years.

Haiti and Bolivia are among those with the five highest infant mortality rates in the LAC Region. However, they are also among those with the worst results in the infant mortality rates in the last fifty years. Also are included as worst performers, countries such as Trinidad and Tobago and Jamaica. Although, some of the five members of the group with lower rates in 1960 were not able to maintain this position in 2010. 

Accordingly, the champions in maintaining low infant mortality rates in Latin America and the Caribbean between 1960 and 2010 are Cuba (4.4), Chile (7.0), Dominica (8.1), Bahamas (8.5) and Barbados (9.8). But with the exception of Chile, all of them had relatively low rates in 1960. 

What matters, therefore, is to know what could be associated with the effort made ​​in reducing child mortality. Reviewing the last fifty years performance, it is undeniable that Chile has been the Latin American champion in the reduction of infant mortality. For this purpose, health policy makers, since the eighties, prioritized the strengthening of primary health care strategies at the local level, transfering responsabilities from central to local governments to fight infant mortality and giving technical and financial support to municipalities for this purpose.

Health in Venezuela: Over a Decade of Missed Opportunities

André Medici

Introduction

Hugo Chavez was one of the most innovative populist presidents of recent times in Latin America. He managed to circumvent the rules of representative democracy and tried to perpetuate himself in power. He made permanent the possibility of re-election and changed the electoral rules, co-opting congressmen eager for handouts, controlling the media, violating freedom of expression, taking the space of political opposition, arresting political adversaries and spending fortunes on propaganda and dissemination of his image and ideology at the expense of the public pocket.

Despite all his efforts, Chávez’s economic and social policies had not brought the expected results for the half of the population that has learned to love him during the period 1998 - 2013. His death on March 5, 2013, on the one hand creates a feeling of abandonment for the half of the population that revered him as one more of the fathers of Latin Americans’ poor, but on the other hand renews the hope of the other half of the Venezuelan population, embarrassed by the failure of recent past years and eager to return the country to gain traction in the race for social and economic development.

Chávez was able to give affection to the poor Venezuelans and increased their self-esteem through the cult of national roots and of hatred between classes in a highly polarized and fragmented society. His government silenced the voice and denied the rights to the majority of the middle class and business elites of the country, creating political space for his followers to enlarge disproportionately the state and to hijack the productive sector through nationalizations of private companies, controlled by few, in the name of socialism of the XXI century.

With his bragging behavior, he used the space gained in the international media to bluster poorly educated words against the governments of developed countries and twisted desperately, but in vain, so that they respond strongly, as a way to feed his political speech in favor of a late and meaningless third-worldism.

Chavez policy improved a little the income distribution in the country, illiteracy was reduced and the share of poor declined from 49% to 30% of the population between 1999 and 2011, but other countries in the region had even better results in these areas. Moreover, improvements in income distribution do not always entail better quality of life, especially when there is no adequate economic growth.

The country had not progressed in bringing economic development and quality jobs for the suffered Venezuelan population. Chavez used the country’s public money and natural resources to support other governments that might compose a world hub with its Bolivarian resistance against the policy of developed countries. The billions of dollars spent in aid to the allies could have been used in concrete policies for economic and social development in their own country.

Moreover, cheap international capital that could be transferred to Venezuela to feed productive investments shifted to other Latin America neighbors. The international capital was treated as an enemy and transaction costs to do business and create jobs became unsustainable. The inefficiency lead to increasing cost of life and inflation soared, reaching 32% in 2012. Growth rates of Venezuelan GDP remained among the lowest in Latin America over the last five years and the future perspectives are still hazy given the lack of investments in strategic areas and qualified human resources (1).

Despite the favorable international conjuncture, as the past decade, many opportunities were lost in the country during the three governments of Hugo Chávez. And the poor Venezuelans, to venerate his populist speech, exchanged their entitlement of birthright for a mess of pottage.

Health Indicators 

Health conditions in Venezuela stagnated over the past decade relatively to other countries in the region. The data below, based on the World Bank development indicators (2), shows how Venezuela stayed behind compared to some countries of similar level of development, with regard to some Millennium Development Goals (MDGs) health indicators. Maternal mortality rates in Venezuela stagnated in the period 1990-2010, while it decreased in Brazil, Chile, Colombia, Peru and Mexico. In 2010, Venezuela was carrying the highest maternal mortality rate among this group of countries (Chart 1). Peru and Colombia, who presented higher maternal mortality rates than Venezuela prior to Chavez consecutive turns, had made ​​significant progress during the last two decades leading their citizens to a better situation than the Bolivarian neighbor's in 2010.

High levels of teenage pregnancy over Chávez’s government corroborated with the maintenance of elevated rates of maternal mortality in the country. In 2008, Venezuela suffered the highest rates of teenage fertility (15 to 19 years old) among the group of countries analyzed (Chart 2). Countries like Colombia, with worse teenage pregnancy than Venezuela in the beginning of Chavez’s government had significantly better results in 2008.

It is worth mentioning that between 1990-2 and 2004-6, the percentage of the Venezuelan population consuming less than the acceptable minimum level of dietary energy increased from 10% to 12% (MDG indicator 1.9). Countries such as Mexico and Chile already had ratios below 5% regarding this indicator in 2006 and Brazil, Peru and Colombia, showed reductions from 10% to 6%, from 28% to 13% and from 15% to 10%, in the same period, respectively. Vaccination rates in Venezuela stayed behind all the countries analyzed. In 2008, neonatal tetanus vaccination rate for pregnant women was only 50%, compared with 92%, 86%, 83% and 87% in Brazil, Chile, Peru and Mexico, respectively. Regarding DPT3, used to immunize children less than one year against diphtheria, pertussis and tetanus, the rates were 83%, compared with 99%, 96%, 93% and 89% in other four countries, respectively.

Measles vaccination rates in 2008 for this set of countries displayed the same pattern regarding previously analyzed vaccines: 83% in Venezuela compared with 99%, 96%, 91% and 95% in Brazil, Chile, Peru and Mexico respectively. This poor performance led Venezuela to be one of the few countries where incidence of measles among children increased in the past decade, situation considered unacceptable for any public health policy.

Infant mortality rates in Venezuela, in the past decade were reduced on 25% - almost the same behavior performed by Chile. However, the rates of infant mortality in Venezuela are more than double that of Chile in 2008, which reached 8.5 per 1000 live births. Nevertheless, this reduction was not comparable to the 39%, 47% and 35% observed in Brazil, Peru and Mexico, respectively. Besides measles, many other diseases are bringing problems to Venezuela. Chart 3 shows the rates of tuberculosis incidence in selected countries between 1998 and 2008.

It is clear that, while significant progress has occurred in Brazil, Mexico, Chile and Colombia in the fight against tuberculosis, in Venezuela the incidence rates remained virtually the same between 1998 and 2008 (around 32-33 per 100 000 inhabitants). And the situation will only get worse, given that among all these countries, Venezuela is the one with the lowest detection rate of new TB cases (around 64%) compared with 91%, 79% and 100% in Brazil, Chile and Mexico, respectively.

Health and Violence

Besides the deterioration of public health, the confrontation policy encouraged by Chávez increased class struggles and encouraged the poor to seek a reckoning veiled. Militarization and encouragement of a gun culture was explicit, through the creation of the Bolivarian Militias who followed the same steps of Defense Committees deployed by Fidel Castro at the beginning of the Cuban Revolution. Under the aegis of The People in Arms slogan, the government trained 120 thousand civilians in the use of heavy weapons, creating a parallel organization to protect the people against the International Imperialism. According the Brazilian Epoca Magazine story (1), there are over one thousands of these armed battalions under these conditions and it is difficult to prevent heavy weapons from falling into the hands of criminals or drug traffickers.

Data from United Nations Office for Drugs and Crime - UNODC (3 ) show a rapid increase in crime rates during the last ten years - reverse the trend that has occurred in other countries with high rates of violence, such as Colombia and Brazil (see chart 4). However, information from national human rights organizations claims that homicide rates have tripled over the Chavez’ governments. The impact of violence on the health of Venezuelans had increased in alarming proportions and it must go far beyond the health policies to try to solve them.

Final Remarks

Much of the health policy failures during the Chávez government lies in the neglect of public health strategies and in the raise of a welfare policy that served for political purposes. The first Bolivarian government in 1998 promulgated a new constitution that guarantees to the Venezuelans a health system organized by the State, free of charge for all, providing comprehensive care that seek to attack both biological and social determinants. The organization of services would be decentralized to states and municipalities and community participation would be ensured in the services administration, integrating health teams with communities, families and individuals.

It resembles the proposed health charter at the Brazilian Constitution of 1988. However, the reality was far from what happened in Brazil. The key changes in the Venezuelan health system should occur within the framework of the Strategic Plan Salud y Desarrollo Social (PES) 2000-2006. This Plan had been placed as the axis of the changes in the primary care health system and it is intended mostly to tackle the needs of the vulnerable groups of the population. However, between 2000 and 2003, this plan was not implemented followed by complaints and the population made clear their dissatisfaction with the emptiness of health policies in the country.

Thus, in February 2003, the City of Caracas (guided by the national government) has contacted the Embassy of Cuba to request a Cuban Medical Mission to the country, which landed in the city in April of the same year. This contact initiated the Plan Barrio Adentro, which in December 2003 was extended to the entire national territory and, by presidential decree, became a Social Permanent Mission. It was the birth of a parallel health system, not integrated in terms of technical and administrative services with the Ministry of Health.

The political bases of Chavez applauded, in early 2004, Las Misiones Barrio Adentro (MBA), but already in 2007, according to the Medical College of Venezuela, the satisfaction levels of the MBA users fell 27% compared to 2004 ( 4). Many claim that the MBA program had as its main objective to transfer oil to Cuba, as compensation for the services of Cuban health professionals, including doctors. In this sense, despite counting with unlimited (and not transparent) fiscal resources, the system only achieved coverage of 17% of the Venezuelan population by 2008.

The program had been recognized as a failure by authorities like the Chairman of the Metropolitan Medical College and the President of the Bolivarian Society of Integral Medicine. The failures relate not only to their physical goals (less than half the 8500 primary health units proposed at the beginning of the program had not been built on schedule until 2008). Many of the health units built remain empty of physicians and medical supplies. In 2008 the Program had only one doctor for every 3000 inhabitants, when the target was 1 to 1200.

Many claim that the MBA program did not comply with the purposes of promotion and prevention for which it was created. It lacks the basic supplies such as vaccines and medicines. Despite the affection received by the population for those doctors and health teams visiting the households, the effectiveness of care ended up being very low. Moreover, Cuban doctors were unprepared to meet the health needs of a population with a profile of health risks far more complex than what exists on the Island. The mixed risk factors' framework combining communicable diseases, chronic diseases and violence is too complex for the Cuban doctors' expertise, especially because Venezuela still have a disabled and outdated epidemiological information system.

NOTES

(1) See Gorczeski, V and Coronato, M., The Lost Age of Venezuela , Revista Época, São Paulo, March 11, 2013.

(2) World Bank, World Development Indicators, electronic version on http://www.worldbank.org .

(3) UNODC 2011 Global Study on Homicide: Trends, Context and Data, UNODC, New York, 2012.

(4) Medical Federation of Venezuela, LXIII Reunión Ordinaria de la Asembléa, Diagnostico del Sector Salud en Venezuela: Estudio de las Enfermedades Emergentes y Reemergentes , Punto Fijo-Edo. Falcon, del 27 al 31 Octubre del 2008.