This report provides a status update on the human resources for health (HRH) sub-system in six Latin American and Caribbean countries: Colombia, Costa Rica, Jamaica, Panama, Peru, and Uruguay. The report structures its discussion around how the health workforce is financed, organized, managed, regulated, and performing. In the area of financing, the study presents the variety of contracting mechanisms, salary levels, and financial incentives offered across the countries and their role in being able to attract and retain health workers. On the organization of the HRH sub-system, the report looks at the skill-mix, training, and distribution of health care workers concluding that although the countries have made progress towards achieving key HRH targets and in making education more accessible, there continues to be limited absorption capacity for graduates, the Primary Health Care focus of training programs needs to be strengthened, and strategies to encourage rural service have not been able to fully address the gap in the distribution of health workers. In reviewing management strategies for HRH, the report presents how all countries have adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel to recognize foreign-trained professionals to help address shortages and fill gaps of health worker presence in rural, remote areas. However, the countries continue to struggle with putting self-sufficiency policies in place to meet HRH needs such as the lack of promotion plans, limited non-monetary incentives, and the shortage of personnel for recruitment and eventual placement. In the area of regulation, the report presents the countries' efforts to reduce precarious employment and introduce HRH safety policies and legislation to regulate disputes and negotiations. On performance, the report found mixed results in the areas of access/availability to health workers and quality of care, factors discouraging dual practice, and unjustified absenteeism of health workers.

The health workforce is the foundation of care and affects quality and outcomes; human resources for health(HRH) constitutes the largest portion of the health care budget of most countries. Latin America and theCaribbean has been challenged by imbalances in workforce composition, distribution, and skill mix, as wellas by variations in productivity and quality.The Health Workforce in Latin America and the Caribbean: An Analysis of Colombia, Costa Rica, Jamaica, Panama,Peru, and Uruguay provides an update on HRH in these six countries. The discussion is structured around fivekey areas of the workforce: financing, organization, management, regulation, and performance.** Financing: The authors present the variety of contracting mechanisms, salary levels, and financialincentives, and their roles in attracting and retaining health workers.** Organization: The countries have made progress toward achieving HRH targets and making educationmore accessible. However, the absorption capacity remains limited for graduates, the primary health carefocus of training programs needs to be strengthened, and the strategies to encourage rural service havenot effectively addressed the distribution gap of health workers.** Management: All six countries have adopted the World Health Organization's Global Code of Practice onthe International Recruitment of Health Personnel to recognize foreign-trained professionals to helpaddress shortages and fill gaps in rural and remote areas. However, the countries continue to strugglewith implementing self-sufficiency policies to build the capacity to meet needs. Such policies includepromotion plans, nonmonetary incentives, and personnel for recruitment and eventual placement.** Regulation: The countries are working to reduce precarious and unprotected employment, introducesafety policies to decrease occupational diseases and workplace accidents, and enact legislation toresolve disputes.** Performance: Mixed results have been achieved in health outcomes, access and availability, quality ofcare and patient satisfaction, professional practice, and productivity and efficiency.

The health workforce must be able to cope with shifts in the pattern of causes of death and disease that are being seen worldwide—particularly with the rise in noncommunicable diseases (NCDs). This requires health personnel to have a set of skills and competencies that can adapt to meet the population’s growing and changing health needs. This report examines the status of the nurse workforce in the Eastern Caribbean, assessing how best to strengthen its capacity to respond to the growing burden of NCDs. The report is based on four Eastern Caribbean case studies conducted in Dominica, Grenada, St. Lucia, and St. Vincent and the Grenadines. The case studies showed that, although overall nurse staffing levels seem to be sufficient across the four countries in terms of numbers, there are nurse shortages at hospitals and health clinics, as well as in the availability of specialists. Better management of the nurse workforce is needed to ensure adequate coverage at the hospitals and clinics is maintained. In terms of specialists, while the quality of education is generally reported to be good, there are barriers to accessing specialized training which include the high-cost of seeking specialized training due to non-existing or very limited local options and the lack of built-in incentives for completing additional education. To help address the capacity constraints faced by the nurse workforce in the Eastern Caribbean to respond to NCDs, the report generated knowledge in support of two critical areas: (i) provide an understanding of the educational and training opportunities available to nurses to strengthen their capacity to meet the NCD challenges, and (ii) assess whether there is a supportive policy environment in place for nurses to play a role in addressing NCDs. As part of the study, a toolkit was developed, which can be used to strengthen the capacity for HRH planning and management with respect to NCDs.

World Bank Technical Paper No. 274. The preparation of the World Bank's World Development Report 1993: Investing in Health (WDR) included an effort to assemble internationally comparable statistics on a broad range of health and health system indicators. Data had to be compiled from existing sources while analytical efforts were made to improve the quality and comparability of the data. This paper presents an expanded and updated version of the WDR estimates of 1990 health expenditures for the countries of Latin America and the Caribbean. Whereas the population cut-off for inclusion in the WDR was 3 million, these tables include almost all countries in the region. This update of the expenditures results in a substantial upward revision in the estimated percentage of GNP spent on health in the region in 1990 from 4 to 6%.

Over the past three decades, many countries of Latin America and the Caribbean have recognized health as a human right. Since the early 2000s, 46 million more people in the countries studied are covered by health programs with explicit guarantees of affordable care. Reforms have been accompanied by a rise in public spending for health, financed largely from general revenues that prioritized or explicitly target the population without capacity to pay. Political commitment has generally translated into larger budgets as well as passage of legislation that ring-fenced funding for health. Most countries have prioritized cost-effective primary care and adopted purchasing methods that incentivize efficiency and accountability for results, and that give stewards of the health sector greater leverage to steer providers to deliver on public health priorities. Evidence from the analysis of 54 household surveys corroborates that investments in extending coverage are yielding results. Though the poor still have worse health outcomes than the rich, disparities have narrowed considerably - particularly in the early stage of the life course. Countries have reached high levels of coverage and equity in utilization of maternal and child health services; coverage of noncommunicable disease interventions is not as high and service utilization is still skewed toward the better off. Catastrophic health expenditures have declined in most countries; the picture regarding equity, however, is mixed. While the rate of impoverishment owing to health-care expenditures is low and generally declining, 2-4 million people in the countries studied still fall below the poverty line after health spending. Efforts to systematically monitor quality of care in the region are still in their infancy. Nonetheless, a review of the literature reveals important shortcomings in quality of care, as well as substantial differences across subsystems. Improving quality of care and ensuring sustainability of investments in health remain an unfinished agenda.

'Beyond Survival' breaks new ground in the ongoing debate about health finance and financial protection from the costs of health care. The evidence and discussion support the need to consider financial protection, in addition to health status, as a policy objective when setting priorities for health systems. This book reviews the Latin American experience with health reform in the last 20 years and the fundamentals of health system financing, using new evidence to show the magnitude and mechanisms that determine the impoverishing effects of health events (diseases, accidents, and those of the life cycle). It provides options for policy makers on how to protect, and help household to protect themselves,against this impoverishment. The authors use empirical evidence from six case studies commissioned for this report, on Argentina, Chile, Colombia, Ecuador, Honduras, and Mexico. This book provides policy makers with a solid conceptual basis for decisions on the contents of mandatory health insurance benefit packages, choices of financing mechanisms, and the roles of public policy in this field. 'Beyond Survival' provides an in-depth analysis of, and organizational alternatives for, risk pooling and health insurance for financial protection. It analyzes the urgent need to extend risk pooling to the informal sector, the challenges for current social insurance arrangements, and options for policy makers to effectively extend risk pooling to the informal sector.

Countries that have made the most progress toward universal coverage have public expenditures in health equivalent to at least 6% of their gross domestic product (GDP), which is the percentage established in PAHO's universal health strategy as the benchmark for the countries. However, while higher expenditure is a prerequisite, it is not enough to combat inequities and advance toward universal health. In addition to greater resources, the quality of the expenditure must be improved, reducing health system inefficiencies. Moreover, public expenditure in health should be sustainably increased in a fiscally responsible manner. The concept of fiscal space for health refers to the ability of governments to provide additional budgetary resources for the health system without affecting the financial position of the public sector or supplanting other socially necessary expenditures. Any analysis of fiscal space, therefore, will attempt to identify the prospects for increasing health expenditure in the short and medium term to address a series of clearly established health needs. These efforts are under way at a critical time in the Region of the Americas, particularly in the countries of Latin America and the Caribbean, which are engaged in a singular health system reform process. For the first time in history, these countries have formalized their intention of increasing public expenditure in health, putting themselves firmly on the path to real and effective access to health care through the universal health strategy. Without achieving basic well-being at this level, it will be impossible to improve social cohesion and social development in the countries of the Region. This publication brings together and summarizes PAHO's studies on fiscal space for universal health in the Americas and draws on the contributions of the regional forum held in Washington, D.C. on 7-8 December 2015. With this publication, whose target audience is the technical personnel responsible for policy development, decision-makers, and authorities, PAHO hopes to contribute to the analysis and discussion of health financing policies on the path toward universal health.

This study highlights the interaction between social protection programs and labor markets in the Latin America region. It presents new evidence on the limited coverage of existing programs and emphasizes the challenges caused by high informality for achieving universal social protection for old age income, for health, for unemployment risks and for anti poverty safety nets. It identifies interaction effects between SP programs and the behavioral responses of workers, firms and social protection providers, which can further undermine efforts to expand coverage, summarizing evidence from recent work across the region. It argues for a re-design of financing to eliminate cross subsidies between members of contributory programs and subsidies that effectively tax income from formal employment. Instead, it advocates well-targeted, tax-funded tapered subsidies to provide incentives to the savings efforts of low income workers, coupled with an effective safety net for the extreme poor who have no capacity to contribute to financing their own social protection arrangements. It also argues for the consolidation of programs and harmonization of benefits packages across different insurers. The book develops an overall conceptual framework and presents in-depth analysis of the main SP sectors of pensions, health, unemployment insurance and safety net transfers.