All health systems in Latin America face the challenge of epidemiological transition and population aging, with the consequent increase in the burden of non-communicable diseases and chronic diseases. (1)Knaul FM, Frenk J, Shulman L, et al, for the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the cancer divides: a blueprint to expand access in low and middle income countries. Harvard Global Equity Initiative, Boston, MA, October 2011. http://ghsm.hms.harvard.Edu/uploads/pdf/ccd_report_111027.pdf (accessed Feb 13, 2013).
Non-communicable diseases, such as cardiovascular diseases, diabetes and cancer, represent more than 69% of deaths in the region. (2)PAHO. Non-communicable diseases (NCDs) in the Americas: quick facts and figures. Http://new.paho.org/hq/index. Php?Option=com_docman&task=doc_view&gid=14462&Itemid= (accessed Feb 13, 2013) In addition, the global financial crisis and national crises have repeatedly and negatively affected the region, limiting the development of its national health systems.
Each health system in a country is unique, and many have become fragmented or partial structures that provide minimal care and only for urgent needs, especially for the poor sector of the population and the unemployed sector. Many health systems in Latin America are not well financed by public or government spending, and require a high monetary outlay for health services. As a result, there is an imbalance in the allocation of resources, lack of investment in equipment and infrastructure, and inequalities in cancer care in certain population groups. (4)Frenk J, Gonzalez-Pier E, Gomez-Dantes O, Lezana MA, Knaul FM. Comprehensive reform to improve health system performance in Mexico. Lancet 2006; 368: 1524–34. The segmentation of health systems gives venue for independent institutions that provide all services related to health care, including administration and insurance, and the financing and delivery of health care to specific populations, while excluding others; social security institutions serving only salaried workers are one example. The national systems were developed as a set of subsystems (public entities, social security, and private providers with different levels of quality), each with different modalities of administration, financing, affiliation, and health care. (3)Londoño JL, Frenk J. Structured pluralism: towards an innovative model for health system reform in Latin America. Health Policy 1997; 41: 1–36. (5)World Health Organization. Health Systems. Http://www.who.int/topics/health_systems/en/ (accessed Oct 19, 2012). Fragmented health care systems are often ineffective in terms of financing and delivery of care, coupled with offering fewer services to the poor , thus promoting inequality. The adverse effects of fragmented systems on quality, cost, and health outcomes disproportionately affect the poor sector of the population. (6)Economist Intelligence Unit. Breakaway: the global burden of cancer— challenges and opportunities, 2009. http://www.livestrong.Org/pdfs/GlobalEconomicImpact (accessed Aug 14, 2012).
Health systems in Latin America are characterized by the lack of health coverage for populations excluded from social security or other mixed public financing mechanisms. Families are exposed to a high risk of excessive and impoverished medical expenses, and for the poorest families, preventive and health protection measures represent a cost that they cannot bear. Families who do not have access to public insurance can end up in poverty when they try to finance care, especially for chronic diseases, and they are forced to sacrifice other basic needs such as food, housing and education. (7)Knaul F, Wong R, Arreola-Ornelas H, et al. Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries. Salud Publica Mex 2011; 53 (suppl 2): 85–95. ( (Knaul FM, Wong R, Arreola-Ornelas H, eds. Financing health in Latin America: household spending and impoverishment (vol 1). Cambridge, MA, USA: Harvard Global Equity Initiative, Mexican Health Foundation, International Development Research Center, 2013 . In 2008, it was estimated that approximately a third of the population of Latin America was at high risk of impoverishment and of having to face excessive health expenses. (8)Economic Commission for Latin America and the Caribbean. Social panorama of Latin America, 2008. http://www.cepal.cl/publications/xml/3/34733/PSI2008-SintesisLanzamiento.pdf (accessed Oct 19, 2012).
An Alternative Model
An alternative model that has been developed in Latin America strives to achieve universal health care and provide equitable care to all citizens. (9)Rodin J, from Ferranti D. Universal health coverage: the third global
health transition? Lancet 2012; 380: 861–62. (10)United Nations. Global health and foreign policy. UN Secretary- General’s report, 2009. http://www.who.int/trade/events/UNGA_Background_Rep3_2.pdf (accessed Feb 13, 2013).
Achieving universal health care often implies the integration of existing Subsystems, and this process is being applied in several Latin American countries (Table 1). (11)Rodin J, from Ferranti D. Universal health coverage: the third global health transition? Lancet 2012; 380: 861–62. (12)General Health Council. Guide for conducting economic evaluation studies to update the basic table of supplies for the health sector in Mexico http://www.csg.salud.gob.mx/descargas/pdfs/cuadro_basico/GUxA_EVAL_ECON25082008_2_ech.pdf (accessed Sept 22, 2012).
A key example is Mexico, where health service reform is leading to universal health coverage through the integration of health insurance for uninsured poor populations, known as Seguro Popular. (13)Knaul FM, Gonzalez-Pier E, Gomez-Dantes O, et al. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet 2012; 380: 1259–79. They have also been carried out health care system reforms that share aspects of the Mexican Popular Insurance in Colombia, Peru, the Dominican Republic and Chile. (14)Knaul FM, Adami HO, Adebamowo C, et al. The global cancer divide: an equity imperative. In: Knaul FM, Gralow JR, Atun R, Bhadelia A, eds. Closing the cancer divide: an equity imperative. Cambridge, MA: Harvard Global Equity Initiative, 2012: 33–61.
Although the health systems of many countries have progressed, obstacles remain for the management of chronic and non-communicable diseases. Is particularly difficult to meet the variety of needs for cancer treatment, including primary prevention, secondary prevention, or screening early diagnosis, treatment, rehabilitation, long-term follow-up and survival, palliative and end-of-life care. (15)Knaul FM, Alleyne G, Piot P, et al. Health system strengthening and cancer: a diagonal response to the challenge of chronicity. In: Knaul FM, Gralow JR, Atun R, Bhadelia A, eds. Closing the cancer divide: an equity imperative. Cambridge, MA: Harvard Global Equity Initiative, 2012: 79–95.
Furthermore, fragmented health systems cause delays in diagnosis and initiation of treatment, which are associated with advanced-stage diseases and contribute to high mortality rates in the region. In Latin America, low detection rates, late referrals, and failure to seek medical help when symptoms appear contribute to the disease occurring late in breast, cervical, and gastric cancer. For lung cancer, the diagnostic study requires a multidisciplinary approach, including high-quality imaging systems and invasive biopsy; Most areas do not have the capacity for these evaluations, which constitutes an obstacle to adequate staging and subsequent treatment. In many areas, access to early cancer care is affected by inadequate health system infrastructure, especially in low-income, indigenous, and geographically isolated populations.
The full integration of vertical initiatives — that is, administration, financing, service provision, and resource generation — in the Pre-existing health systems have not yet been achieved and would greatly improve cancer care. A key obstacle in most Latin American countries is the lack of an integrated national plan for cancer care that includes the
comprehensive cancer treatment and prevention programs with complementary efforts to combat tobacco use and passive exposure to same. According to the Capacity Assessment of the National Cancer Control Program, carried out by WHO and the International Atomic Energy Agency (IAEA) in 2009, the Latin American countries that have national cancer plans are Bolivia ( in preparation), Brazil (state level), Colombia, Costa Rica, Cuba, Guatemala (in preparation), Honduras, Nicaragua, Panama (in preparation), Peru, El Salvador and Uruguay (in preparation). (16)WHO. World health statistics 2011. http://www.who.int/whosis/whostat/2011/en/index.html (accessed Jan 3, 2013).
National Cancer Plan
Several countries, such as Argentina and Chile, have cancer plans designed to treat certain malignancies, such as breast cancer, and Mexico is preparing a national cancer plan designed to address the control of all cancers. Most national cancer plans focus on breast cancer, cervical cancer, and pediatric cancers. In addition, most Latin American countries have included cancer prevention in their general national health plans, especially with measures against tobacco and obesity. Establishing national cancer plans is one way to integrate existing health systems and apply a cross-cutting strategy to meet the complexities of cancer prevention and care. Here, we provide examples from different health systems in Latin America that show the progress made to face the challenge of cancer as chronic diseases that involve a high cost. Although most countries continue to struggle with fragmentation and the lack of universal coverage of health care, these countries are taking a phased approach at the health system level in cancer prevention and treatment.