To Achieve the MDGs in Latin America and the Caribbean Equity Must Lead the Way

IntroductionIn the year 2000, the global community set forth a pledge to bring about a more equitable, peaceful and just world through the Millennium Development Goals (MDGs) that advocate for the needs of children, women and other vulnerable people groups. Many consider Latin America and the Caribbean (LAC) the most inequitable region of the world. In LAC, there are broad disparities in social and economic indicators that pervade all aspects of life including health. We want to put a spotlight on LAC’s maternal and child health in the context of the Millennium Development Goals (Figure 1) and highlight the disparities women and children face, especially the poorest, the rural dwellers, and the members of indigenous groups. The aim of this contribution is to show that it is through reaching the region’s most vulnerable and marginalized that true and sustainable achievement of these goals can be accomplished.

Latin America and the Caribbean is a vibrant, diverse region. It is comprised of 33 countries and approximately 300 million people. It has more than 50 million indigenous people and 120 million Afro-descendents, representing a substantial group that is considered marginalized compared to their counterparts of European descent (UNDP 2010). With the diversity of the region come health inequities, defined as differences in health care access that are “systematic, socially generated, and largely remediable”(UNICEF 2008). A United Nations Development Programme (2010) report identifies women, indigenous population and African-descendents as the groups hardest hit by inequality in the region. As a whole, LAC is making strides in achieving the Millennium Development Goals (MDGs). With the goal year of 2015 approaching, progress in LAC has been encouraging but at times insufficient and also uneven across the region’s countries and between the different people groups within each country.

Health and Health Inequities are not produced in a vacuum: The interrelatedness of the MDGsHealth inequities among women and children of the LAC reflect broader social determinants of health and include economic status (rich and poor), ethnicity (indigenous and non-indigenous), geographical location (rural and urban), and the level of the mothers’ education and gender (UNICEF 2008). The Millennium Development Goals provide a framework to connect the multiple linkages between economic (poverty) and non-economic determinants (education, gender, health, and environment) (United Nations ESCAP et al 2007).

The health-related MDGs (4, 5, and 6) are intimately interconnected to the non-health-related goals (1, 2, 3, 7, and 8) and they impact each other. To examine this in more depth, we can look at MDG 5, “improve maternal health”. The dynamics of maternal health are complex and can be thought of in terms of root causes, contributing factors, direct causes and downstream impacts (Figure 2) (United Nations ESCAP et al 2007). Root causes such as poverty and hunger (MDG 1) and gender inequality (MDG 3) lead to low levels of maternal education and health literacy (MDG 2). Lack of education can lead

to poor access to early contraception, barriers to access to health care and increased health risks (MDG 6 – higher rates of HIV and malaria for example). These in turn can lead to early, unintended pregnancies, unsafe abortions, increased risk of pregnancy and postpartum complication (e.g. bleeding) and lack of access to good water and sanitation (MDG 7). All these contribute to increased rates of maternal mortality (MDG 5) and morbidity. Poor maternal health and outcomes (MDG 5) lead to further poverty (MDG 1) and increased risk of infant death (MDG 4), child malnutrition (MDG 1) and child illiteracy (MDG 2). Upstream, global partnerships (MDG 8) that impact supply of medicines, vaccines and other essential medical technologies affect the quality of the available health services and goods that women and children can access.

As a concrete example, in the LAC, children of mothers with no education are 3.1 times as likely as children of mothers with secondary or higher education to die before 5 years of age (United Nations 2011). The concept of synergy among MDGs underscores how essential it is to give similar attention to each goal. They are not competing interests. Treating each simultaneously enables targeting of all social determinants of health and can help lead to better outcomes for the women and children of the region.

The current situation: LAC’s MDG progress and the continuing disparitiesAccording to the MDG Report 2011, the LAC met the target for hunger reduction (MDG 1c), for water supply (MDG 7c) and is making sufficient progress in child survival (MDG 4), tuberculosis control (MDG 6), Internet usage/improved communication technologies (MDG 8) and gender equality (MDG 3) targets. Progress has been insufficient in maternal health (MDG 5), HIV and Malaria (MDG 6), basic sanitation (MDG 7c), education (MDG 2), and poverty reduction (MDG 1a). Though progress has been made in maternal and child health and the social determinants of health of the region, a deeper examination of disaggregated data (by geographic region, ethnicity, and economic status) reveal the disparities between and within the LAC countries. To illustrate this, below is a closer look into malnutrition (MDG 1), child (MDG 4) and maternal (MDG 5) health, and water and sanitation (MDG 7).

Malnutrition (MDG 1) is introduced and exacerbated at different points in the life cycle of mothers and children. A mother’s nutritional status affects the growth and development of the baby in her womb as well as her risk of death at delivery. For the child, nutrition during the first few years of life is critical to future development, including height and school performance. In the LAC, chronic malnutrition affects 16% of children under five years of age with particularly serious effects seen in Central America and Andean countries (Martinez 2006). The LAC has reached the target of halving the proportion of undernourished children with a decline of 10 percent in 1990 to 4 percent in 2009 (United Nations 2011). Despite this heartening progress, there are clear disparities between and within countries. The highest underweight percentages among children under age 5 are found in Haiti (22%) and Guatemala (19%), which approach Africa’s regional average of 24%. In contrast, countries like Chile (1%) and Cuba (4%) have undernutrition percentages that are at the level of developed countries (UNICEF 2011). Furthermore, within countries there are striking differences in malnutrition rates (Figure 3) between indigenous and non-indigenous areas. An example is the higher

malnutrition rates among school-aged children in the indigenous (comarca indigena) of Panamá compared to the rest of the country.

Millennium Development Goal 4, improving child health, is measured by mortality rates of children under five years old (U5MR). In the LAC, the infant mortality rates (IMRs) comprise 80% of the U5MRs (ECLAC 2011a). It has been said that the infant mortality rate is a barometer of “society’s recognition and exercise of the most fundamental human right: the right to life and health (Jimenez 2007).” If the current trend of mortality rates U5MRs continues, the LAC will reach the MDG target of a two-thirds reduction by 2015 (52 deaths per 1,000 live births in 1990 to 23 in 2009) (United Nations 2011). Unfortunately, progress is uneven. If the current trends do not change, the sub-region of the Caribbean will not meet the MDG 4 target since it only had a 50% decrease in IMRs between 1990 and 2009 (ECLAC 2011a). In terms of geographic location, the LAC’s ratio of rural-to-urban U5MR of 1.7 is the worst among the regions of the world (United Nations 2011). In terms of socio-economic status, the poorest children in the LAC are nearly three times as likely to die than children from the richest households (United Nations 2011). This again is worst of all the regions of the world.

LAC countries with the highest IMRs are also those with lower incomes, lower literacy among women and less access to water and basic sanitation and lower public health expenditure (ECLAC 2011a). Disparities in child mortality are also seen in various territories between and within countries and indigenous groups (Figure 4). For example, the Quechua and Aymara peoples are located in both Bolivia and Chile. The IMRs of the Bolivian Aymara (69.1 deaths per 1,000 live births in 2000 vs 15.1 in Chile) and Quechua (80.6 deaths vs. 19.1) were much higher than their Chilean counterparts (ECLAC 2011a). Another example is the inequalities in IMRs in the Nicaragua 2005 census, which showed the worst rates among rural dwelling Afro-descendents (47.4 deaths per 1,000 live births) compared to rural dwelling indigenous groups (39.1 deaths) and rural dwelling non-ethnic peoples (33.9 deaths). All these rural rates were higher than all urban dwelling groups in Nicaragua (urban dwelling Afro-descendents 24.1 deaths, indigenous 24.4 deaths, and non-ethnic groups 18.8 deaths).

Millennium Development Goal 5, improving maternal health, is comprised of the goals to reduce the maternal mortality ratio (MMR) by three-quarters between 1990 and 2015 and achieve universal access to reproductive health. Besides MMR, other measures for this MDG include skilled birth attendance and access to family planning. There has been significant progress made since 1990 in both Latin America and the Caribbean although with the current trend the MDG targets will not be met. In the Caribbean, maternal mortality ratios improved from 320 maternal deaths per 100,000 live births in 1990 to 170 in 2009 while in Latin America, the maternal mortality ratio went from 130 maternal deaths in 1990 to 80 maternal deaths per 100,000 live births in 2009 (United Nations 2011). Maternal deaths reflect the state and quality of access to essential services like contraception, antenatal care, birth attendance, emergency obstetric services and postpartum care (ECLAC 2011b). Even worse, maternal deaths are merely the tip of the iceberg since it is estimated that for every woman who dies from a pregnancy-related cause, roughly 20 more experience morbidity in the form of injury, infection, disease or

disability (Paxton 2011). Moreover, there is a consensus that maternal mortality rates are uncertain and are likely underreported (United Nations 2011). For skilled birth attendance, a proxy for women’s access to health care (Paxton 2011), the LAC showed improvements from 69% of women attended 4 or more times by any provider during pregnancy to 84% in 2009 (United Nations 2011). For unmet family planning need, 1 in four women of childbearing age in the LAC (married or in a union) have an unmet need for contraception (United Nations 2011).

A special mention must be made about adolescent pregnancy and mortality. In LAC, the proportion of births that occur in adolescence is 18% compared to the global average of 13% (UN DESA 2010). In the LAC, indigenous girls are known to have more children than other teenage mothers (ECLAC 2011a). A cross-sectional study of Latin American adolescent pregnancies found that maternal death rates for adolescents under 16 years of age are 4 times greater than for women in their twenties (Conde-Agudelo 2005). Because of their place in society, adolescent girls are less likely to have access to health services and less able to exercise their reproductive rights as compared to their adult counterparts. Their children, in turn, are also often vulnerable to illnesses, undernutrition and mortality. Adolescent pregnancies therefore perpetuate disparities, economic-, health-related or otherwise, from generation to generation and need to be addressed if maternal mortality and child mortality are to be reduced. Reaching adolescents, therefore, is crucial to achieving MDG 5 and the other MDGs.

Some progress has been made in the LAC for Millennium Development Goal 6a to “halt and begin to reverse the spread of HIV/AIDS by 2015” but the burden of HIV is significant. The Caribbean sub-region has the second highest prevalence amongst regions of the world, 2nd only to Sub-Saharan Africa, at 0.9% (United Nations 2011). Of the 240,000 people living with HIV in the Caribbean in 2008, three quarters live in Haiti and the Dominican Republic (ECLAC 2011a). The LAC has made improvements on its provision of antiretroviral therapy to those with advanced HIV. In the Latin America, access improved from 39% in 2004 to 51% in 2009 while in the Caribbean access improved from 5% (2004) to 38% (2009) (United Nations 2011). In terms of measure of correct knowledge of HIV/AIDS among 15-24 year olds, there are wide variations from country to country e.g. (8-10% in Guatemala in 2002 and 83-89% in Argentina in 2005 (ECLAC 2011a)). In the LAC, this statistic is especially important because the vast majority of those who have HIV/AIDS are 15 to 49 years of age and are the economically active segment of the population (USAID 2011). Thus, their illness or death will lead to multiple economic, social, and health-related effects.

Access to clean drinking water and basic sanitation are needed conditions to promote good health. Millennium Development Goal 7c calls on countries to halve, by 2015, the proportion of people without sustainable access to drinking water and basic sanitation. As of its 2010 update, the Joint Monitoring Programme (JMP) for Water Supply and Sanitation, the United Nations official body monitoring the progress towards MDG 7c, the LAC, as a region, is on track to meet the MDG targets for water and sanitation. The region achieved the improved drinking water target nine years prior to the MDG target year of 2015. This encouraging progress is uneven. Urban residents, with 90% coverage

except in Haiti (70%), have greater access to improved drinking sources than their rural counterparts (WHO 2008). This is also seen in indigenous groups depending on their geographical location. For example in Costa Rica, there is a 1% difference in water supply coverage between indigenous and non-indigenous groups in urban areas while the difference is 36% in rural areas (WHO 2008). For improved sanitation coverage, urban coverage is 86% and rural coverage is only 52% (WHO 2008). Interestingly, it appears that in certain countries, the disparity of access between indigenous and non-indigenous populations is worse in urban areas. For example in Paraguay there is a 75% difference in sanitation coverage between indigenous and non-indigenous populations in urban areas while there is only a 7% difference in the rural areas (WHO 2008).

Future Directions: Seeking Equitable, Sustainable SolutionsWhere do we go from here? From years of work in the LAC, it is known that successful delivery of essential health services has been done through an integrated approach that has maximized community partnerships in the framework of the continuum of care (UNICEF 2008). The continuum of care approach espouses care for the mother and child from the time of pregnancy to delivery, the immediate postnatal period and early childhood (Tinker 2005). Many maternal and child deaths and disabilities can be averted by implementing proven cost-effective interventions in these pivotal periods. Since they are the most affected, the LAC’s most vulnerable and marginalized groups should be the targets of these interventions in an equity approach. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels (Victora 2003) and to truly achieve the health and non-health-related MDGs.

Since health and health inequities are produced in the backdrop of the social determinants of health, addressing these through all of the MDGs is the key to sustainable results. True comprehensive health care includes “treatment and social assistance in a systematic framework designed to achieve sustainable results while providing high quality care for each patient .” For sometime now, social assistance has been existence in many Latin American countries in the form of conditional cash transfers i.e. giving monetary incentives to promote use of preventive services. For example, a program evaluated in 70 municipalities in western Honduras showed that providing direct payments to poor Honduran families on the condition that they keep up to date with preventive health had a large impact in increasing antenatal and well-child visits (Morris 2004). Overall, conditional cash transfers in the LAC seem to be effective at increasing health utilization although their effectiveness decreases if infrastructure and health services and goods are not in place (Lagarde 2009). This further underscores the need to address the strengthening of health systems.

There is growing consensus in the world community that strengthening of health systems is part of the foundation for the achievement of the MDGs (ECLAC 2011). Four proposed areas of health systems improvement are service delivery, public policy, universal coverage, and leadership (ECLAC 2011). Service delivery has to be based on the needs of the consumers, quality, and accessible. For example, in the LAC, despite high coverage for skilled birth attendance, a proxy for health service delivery, the

maternal mortality ratios remain high. This reflects that other factors have to be reassessed and addressed to decrease the MMRs. Integrated public policy should address the social determinants of health and foster and help build alliances between health ministries, organizations such as pharmaceutical companies and religious groups and other key stakeholders including mothers and children (Farmer 2007) to develop sustainable, effective interventions. Universal coverage should be endeavored to equalize the access of all people to the services they need regardless of their financial ability to access them. Lastly, active leadership in the form of good governance and strong political will is needed to promote best practices and create an environment of collaboration and accountability to actual health and social outcomes.

Furthermore, to reach the LAC’s most marginalized – rural dwelling women from indigenous and afro-descendents – certain important steps should be taken.Often cultural barriers and sheer distance from health care facilities preclude these groups from accessing mainstream medical care. National and local governments should make strong efforts to link their public health services with established indigenous health systems. Development of campaigns and interventions should be done in collaboration with the indigenous communities and should be sensitive to their cultural beliefs and practices (UNICEF 2008). Infrastructure such as construction of health facilities in indigenous communities and establishment of better roads from these communities will lead to decreasing the inequities to access experienced by indigenous and afro-descendent groups.

ConclusionAchieving the MDGs is not just a matter of reaching the world’s objectives; it is a matter of social justice. Every effort must be made to ensure that the benefits of these ideal goals not exclude the LAC’s and rest of the world’s most vulnerable, women and children who are currently and traditionally bypassed by the world’s advancements. What we have looked at are not just numbers and facts but people, as Anthony Lake, UNICEF’s Executive Director reminds us “behind every statistic is the life of a child – each one precious, unique and endowed with the rights we are pledged to protect (UNICEF 2010).” May global health community endeavor to truly advocate for them and create a more just and equitable world.

One limitation of our analysis is the lack of information to measure MDG at local level, as most of the statistics are available at national level.

In economics and public health schools, it is normally assumed that there is a “trade-off” - that you have to choose between efficiency and equity. In fact, we are arguing here that this trade-off is not necessary. The hypothesis we are testing here is that, as the needs are greatest among the unreached, and at the same time, we have new, innovative, efficient strategies and tools to reach the poorest, the benefits of concentrating on them can outweigh the additional cost of reaching them. So even though it may cost more to reach hard to reach children. the additional benefits, in terms of lives saved and malnutrition prevented that we get out of there, is so much higher that it outweighs the extra costs, and that in the end, we get a higher cost effectiveness.

 Furthermore, we are arguing that it is not only cost effective. As the burden of child deaths and the burden of malnutrition is so concentrated in those harder to reach groups, reaching the poor is the best way to achieve the MDGs, if not the only way to achieve the MDGs in many of the countries. For example, if you are carrying out a vaccination programme in 2 communities, one with very high incidence of childhood diseases and another easier to reach community, but where children have less diseases, then even if it costs a little more to get into the first community, many more lives will be saved through the same vaccination programme. ( Narrowing the Gaps to meet the goals, UNICEF September, 2010

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Figures and Tables:

Figure 1: The 8 Millennium Development Goals

Source: United Nations Development Program (http://www.beta.undp.org/undp/en/home/mdgoverview.html)

Figure 2: Interrelatedness of the MDGs illustrated through MDG 5: Improve Maternal Mortality (indicator: decrease by ¾ the maternal mortality rates from 1990 to 2015)

Description: Showing the dynamic interplay between the MDGs that leads to health outcomes for mothers and children.Source: United Nations Economic and Social Commission for Asia and the Pacific (ESCAP) http://www.unescap.org/esid/hds/pubs/2450/2450MDGs.pdf

Figure 3: Chronic malnutrition percentages among school-aged children in Central America

Description: The darker regions in the map correspond to higher levels of chronic malnutrition. Of note, regions with highest malnutrition are located in the indigenous regions of the Panama (shown as yellow on the inset).Modified from: Institute of Nutrition of Central America and Panama. Special Report and from http://en.wikipedia.org/wiki/Provinces_of_Panama

Figure 4:

Description: The Quechua and Aymara peoples are located both in Bolivia and Chile. The IMRs of the Bolivian Aymara (69.1 deaths per 1,000 live births in 2000 vs 15.1 in Chile) and Quechua (80.6 deaths vs. 19.1) are much higher than their Chilean counterparts.

Source: UN Economic Commission for Latin America and the Caribbean (ECLAC)Achieving the Millennium Development Goals (MDGs) with equality in Latin America and the Caribbean. Progress and challenges, June 2011, p. 189.