Here, Galileo Pérez-Hernández, Board Member of IFIC and Nieves Ehrenberg, Senior Researcher discuss the value and importance of the Foundation’s work in Latin America and the efforts to develop a regional hub to support capacity building around integrated care across the region.
What Latin America’s massive protests tell us about the future integrated care agenda?
2019 will be remembered for an unprecedented wave of massive protests across Latin America. In Bolivia, Chile, Colombia, Ecuador, and Honduras protesters have taken to the streets demanding economic well-being, public education, an end to corruption and better health care. There is no single explanation for the political and social tremors across the region. The countries unsettled by protests have vastly different economic and political circumstances. However, social inequality is a historical and structural feature that societies in these countries have in common. As Professor Sir Michael Marmot suggested during his keynote speech in the 19th International Conference on Integrated Care in Spain in 2019, high levels of inequality are a significant obstacle to development and to people’s ability to exercise their rights, including their right to health and care.
In the past year we have been collaborating with various Latin American partners, visiting different countries and learning from citizens, patients, care practitioners, academics and policymakers about integrated care in the region. We observed how structural inequalities have in effect led to two parallel health and care systems, one for the rich (who tend to have a lower disease burden and access to services) and one for the poor (who tend to have higher disease burdens and face various barriers to access). Public health expenditure from many countries is still below the benchmark of 6% of gross domestic product (GDP). There is a clear and urgent need to tackle the inequalities that affect millions of people and governments in these countries are being compelled to rethink their social and health agendas.
Building on the United Nations Sustainable Development Goal of achieving universal health care, the Pan American Health Organization/ World Health Organization is calling for the reform of the provision of health services underpinned by a coordinated people-centred approach. Clearly, the challenge of achieving people-centred integrated health and care services will require fundamental changes to the current systems. The provision of strong primary care is fundamental to the required transformation. It is embedded in the community and as such can coordinate the care of the people, taking people’s needs and preferences as a start point and focusing on the interrelated aspects of physical, mental and social health. Yet despite significant political efforts and progress in achieving better health outcomes, such as life expectancy, primary health-care systems in the region tend to be weak. We also know that local governments are a crucial player in helping to address the broader determinants of health. Yet this is not a relationship that is well defined or established in most places.
The social upheaval we are experiencing in the region is an indication that the time is ripe for this significant transformation in the way we think about, design and deliver care services. Although countries may have cultural differences, population needs are similar everywhere. The massive protests, in a way, act as a compass for action on how to improve health and care services in the region. Another way of looking at this is – health and care services in the region must heed the protesters’ calls… or risk missing the target again.
So what do the massive protests tell us about the future of health and care services in the region?
A) Speed up transformation towards more person-centred integrated care
As in other regions, there are already several initiatives across Latin America that are wholly or partially aligned with the principles underpinning integrated care – although they might not necessarily be described as such. Several examples from Argentina, Brazil, Chile, Costa Rica, Mexico among others were presented during the 3rd World Congress on Integrated Care in Mexico City in 2015. The current protests demonstrate that transformation requires time and that probably there has not been enough progress made in transforming health and care systems in the region so that they meet people’s needs and expectations. There is an appetite – indeed, a responsibility to ensure services are person-centred and integrated. A crucial part of this is to strengthen community-oriented primary care.
B) Engage and empower people and communities now
Citizens are making their voice heard loud and clear through these protests and probably the message is ‘no more decisions without us’. During the recent Asia Pacific Conference on Integrated Care in Australia in late 2019, a number of new ideas echoing this sentiment have emerged that challenge our understanding of the scope of integrated care and its role as part of the wider complex system and context. There is growing evidence to demonstrate that engaging and empowering local communities is essential for citizens’ wellbeing and for the care system to function effectively. To achieve this we need to foster the creation of local alliances among all actors involved in the production of health and wellbeing in the community.
Population-oriented strategies that are focused on promoting health and wellbeing, for example by bringing together health and social care with other players such as housing, schools, community groups and industry are proving to be most successful in reducing health inequalities. To achieve this it is crucial to create a shared vision, a strong narrative and everyone’s active involvement at all levels in the community and society. We must purposefully and actively strive for balanced power relations and mutual trust within these alliances. There is no one way to achieve this and what works in one place will not necessarily work in the next, but it is in essence about joining forces to take collective action to meet people’s needs, taking the assets and resources available in each community into account.
C) Reallocate resources to facilitate the transformation
Resources need to be managed transparently and redirected to drive transformation and enable integrated and collaborative working between social services, health, housing, and the third and independent sectors; to test new approaches and service delivery models that support the principles of integration; to evaluate and learn from each other. This endeavor needs to be based on best evidence available on what works in integrated care to achieve maximum impact, considering local contexts.
D) Learn from each other
Many Latin American countries have made considerable efforts to develop education and training programs related to integrated care. Unfortunately, these programs have limited coverage and tend to be underappreciated. There is a lack of contextualized knowledge and a scarce research on effective and acceptable approaches to integrated and people-centred primary health care in the region. To remedy these, it is important to build capacity and capability through knowledge building and sharing activities so as to build an environment of change in health systems and societies.
In summary, transforming health systems towards integrated and people-centred care in the region requires more than ever bottom-up, collective action. According to IFIC´s mission and experiences in other regions a shared platform that connects everyone to facilitate action among citizens, policy makers, health and care practitioners, patients, families and carers, could be a significant insight to connect the practices, policies and lessons learned across the region. In the quest to achieve the global development agenda 2030, momentum for Latin American reforms towards integrated care for and with citizens appears promising on the horizon. The time for action is now.
Dr. Galileo Pérez-Hernández
IFIC Board Member
IFIC Senior Researcher