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.

Portraits of Labor Market Exclusion presents profiles or portraits of individuals who have limited labor-market attachment. It is widely accepted that those with limited attachment to the labor market are a highly heterogeneous group (including, for instance, recent job losers, long-term unemployed, school leavers with no labor-market experience, those close to retirement age, or people with caring responsibilities), and that understanding their circumstances and potential barriers is an essential prerequisite for designing and implementing a tailored and effective mix of policy support and incentives. The report takes a comprehensive view, focusing on both the labor market attachment of a country's out-of-work population and the social assistance package and poverty profile of the same segment of the population. In essence, the report looks at individuals through the lenses of both poverty/welfare status and labor market indicators, and, in doing so, the portraits helps move the dialogue from a purely labor market-centric view to a broader dialogue that includes social policy as a whole. This is an important shift; for instance, social protection programs, such as family benefits and maternity benefits, and broader social policy issues such as retirement ages, often have a great impact on who remains inactive. Specifically, the report presents portraits of the out-of-work population of six countries (Bulgaria, Estonia, Greece, Hungary, Lithuania and Romania) in terms of distance from the labor market, human capital, and labor supply conditions, as well as demographic conditions. The analysis relies on the European Union Statistics of Income and Living Conditions (EU-SILC) surveys for the years 2007 to 2011. Latent class analysis methodology allows multidimensional profiling of the out-of-work population, and identifies classes or groups of out-of-work individuals that are as homogeneous as possible within each class according to a set of observable characteristics, and as distant as possible between classes. Consequently, this analysis provide a much richer glimpse of the very different barriers to labor market integration that these various groups experience, considerably augmenting the limited amount of information contained in traditional descriptive statistics.

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.

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens—with defined and enlarged benefits packages—and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

This book is about 24 developing countries that have embarked on the journey towards universal health coverage (UHC) following a bottom-up approach, with a special focus on the poor and vulnerable, through a systematic data collection that provides practical insights to policymakers and practitioners. Each of the UHC programs analyzed in this book is seeking to overcome the legacy of inequality by tackling both a “financing gap†? and a “provision gap†?: the financing gap (or lower per capita spending on the poor) by spending additional resources in a pro-poor way; the provision gap (or underperformance of service delivery for the poor) by expanding supply and changing incentives in a variety of ways. The prevailing view seems to indicate that UHC require not just more money, but also a focus on changing the rules of the game for spending health system resources. The book does not attempt to identify best practices, but rather aims to help policy makers understand the options they face, and help develop a new operational research agenda. The main chapters are focused on providing a granular understanding of policy design, while the appendixes offer a systematic review of the literature attempting to evaluate UHC program impact on access to services, on financial protection, and on health outcomes.

The goals of universal health coverage (UHC) are to ensure that all people can access quality health services, to safeguard all people from public health risks, and to protect all people from impoverishment due to illness, whether from out-of-pocket payments for health care or loss of income when a household member falls sick. Countries as diverse as Brazil, France, Japan, Thailand, and Turkey have shown how UHC can serve as vital mechanisms for improving the health and welfare of their citizens, and lay the foundation for economic growth and competitiveness grounded in the principles of equity and sustainability. Ensuring universal access to affordable, quality health services will be an important contribution to ending extreme poverty by 2030 and boosting shared prosperity in low-income and middle-income countries (LMICs), where most of the world's poor live. The book synthesizes the experiences from 11 countries – Bangladesh, Brazil, France, Ethiopia, Ghana, Indonesia, Japan, Peru, Thailand, Turkey and Vietnam – in implementing policies and strategies to achieve and sustain UHC. These countries represent diverse geographic and economic conditions, but all have committed to UHC as a key national aspiration and are approaching it in different ways. The study examined the UHC policies for each country around three common themes: (i) the political economy and policy process for adopting, achieving, and sustaining UHC; (ii) health financing policies to enhance health coverage; and (iii) human resources for health policies for achieving UHC. The findings from these country studies are intended to provide lessons that can be used by countries aspiring to adopt, achieve, and sustain UHC. Although the path to UHC is specific to each country, countries can benefit from the experiences of others in learning about different approaches and avoiding potential risks.

Beyond Survival: Protecting Households from Health Shocks in Latin America 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 households to protect themselves, against this impoverishment. The authors use empirical evidence from six case studies commissioned for this report, on Argentina, Chile, Columbia, 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.