Most Latin American and Caribbean countries have constitutional mandates that define healthcare as a right. Nevertheless, despite important efforts in recent years to achieve effective universal or near-universal coverage, inequities still persist in access to quality services for the very poor, who are the hardest to reach. Thus, while some citizens have reliable access to up to three types of healthcare institutions (e.g., public, social security, and private hospitals), others are left without any options.

Typically, there are multiple types of health care providers, with overlapping responsibilities and little coordination of care, which increases the difficulty of achieving improved population health. For example, the public sector may provide healthcare services through hospitals and clinics managed by social security institutions and partially funded with contributions from workers and employers, while also providing similar services in public hospitals that are fully funded by tax revenues. Private hospitals often serve patients who have private insurance as well as those that are insured by the state. However, in most cases there are few mechanisms to coordinate care among the various providers, which leads to imbalances in access to services.

The increasing unit costs of health care procedures coupled with the socioeconomic implications of the epidemiological transition adds relevance and urgency to the need to improve health systems organization and performance. Meanwhile, there is important room for improvement in health systems financial management; continuous, system wide, evidence-based evaluation of health technology; and the integration of primary, secondary, and tertiary levels of care.

The increase in informal labor in Latin America and the Caribbean poses great challenges to achieving universal health care coverage. In the past three decades, the region has seen important reforms that seek to reduce fragmentation and segmentation in risk pooling arrangements in most countries (for example: in Brazil, Costa Rica and Chile). However, mixed and fragmented models in which contributory and noncontributory health insurance systems coexist are still the norm.

The implications of this situation for health systems are: inefficiencies associated with multiple risk pools that rarely complement each other; lack of portability of benefits for individuals when they transfer from one insurer to another; potential adverse selection as people try to move between risk pools, depending on their health status; lack of transparency in the allocation of public subsides; reduced capacity of health systems to effectively and efficiently provide quality services, due to redundancies in the allocation of human resources and infrastructure; lack of accountability—(including in the context of decentralized service delivery if the national/sub-national interface does not work smoothly); and low financial protection for the individuals.

Moreover, this fragmentation reduces the incentives for long-term investment planning and systemic improvements, which are necessary to address both the unfinished agenda of maternal and child health, and infectious disease prevention and control; and the emerging challenges of chronic non-communicable diseases.

The IDB works together with the national governments to adopt measures to dissolve systemic bottlenecks that hinder access to and contrain its quality and sustainability healthcare. The Bank also provides technical assistance to inform decision-making on the country-specific path towards strengthening health system integration and reducing fragmentation.

Eliminating barriers to healthcare entails the introduction of programs to expand coverage of high-quality health benefits. Such expansions, however, must be integrated with quality and sustainability dimensions through: improving the capacity of human resources; better distribution of health workers and funding; modernizing systems for purchasing and distributing drugs and other health supplies; establishing service protocols; updating infrastructure and equipment; and enhancing performance incentives and measurement of clearly defined results, among other activities.

Our work:

• “Pay for performance” mechanisms for the provision of healthcare to underserved populations.
• Strengthening service networks through investment in equipment and health infrastructure as well as the implementation of innovative delivery models.
• Integration of levels of care with the aid of information technology tools.
• Improvement of the healthcare workforce through capacity building initiatives, incentive schemes, and other initiatives.
• Development of surveillance instruments to assess current and emergent patterns of disease.