Inequalities in health system coverage and quality: a cross-sectional survey of four Latin American countries

Abstract

The premise of health as a human right in Latin America has been challenged by health system fragmentation, quality gaps, a growing burden of chronic disease, sociopolitical upheaval, and the COVID-19 pandemic. We characterised inequities in health system quality in Colombia, Mexico, Peru, and Uruguay. We did a cross-sectional telephone survey with up to 1250 adults in each country. We created binary outcomes in coverage, user experience, system competence, and confidence in the system and calculated the slope index of inequality by income and education. Although access to care was high, only a third of respondents reported having a high-quality source of care and 25% of those with mental health needs had those needs met. Two-thirds of adults were able to access relevant preventive care and 42% of older adults were screened for cardiovascular disease. Telehealth access, communication and autonomy in most recent visit, reasonable waiting times, and receiving preventive health checks showed inequalities favouring people with a high income. In Uruguay, inequality between government and social security services explained a substantial proportion of disparities in preventive health access. In other study countries, inequalities were also substantial within government and social security subsectors. Essential health system functions are unequal in these four Latin American countries.

Figure 1

Proportion of respondents who reported health system coverage, user experience, system competence, and confidence in the health system across four Latin American countries (A) Health system coverage indicators include quality source (respondent rates usual souce or most recent source of care as very good or excellent), telehealth consultation within the past 12 months, consultation in the past 12 months among those with chronic care needs, and mental health-related consultation in the past 12 months among those with mental health care needs. (B) User experience indicators were rated very good or excellent for the most recent visit in terms of respect, communication, and autonomy, as well as waiting time under 1 h and there was no report of discrimination in health care in the past 12 months. (C) System competence indicators include receiving a preventive check in the past 12 months, cardiovascular check in the past 12 months, continuity of care (rating of very good or excellent on provider knowledge of health history among chronic care visits), and safety (no medical mistakes in past 12 months). (D) Confidence in system indicators include quality care (somewhat confident or very confident in their ability to get high-quality care in case of serious illness), affordable care (somewhat confident or very confident in their ability to afford high-quality care in case of a serious illness), responsiveness (somewhat confident or very confident that public opinion is considered when making health policy), and resilience during the COVID-19 pandemic (rating of very good or excellent for government pandemic management).

Figure 2

Prevalence and income inequality in access to preventive checks by usual source of care in Colombia, Mexico, Peru, and Uruguay Solid points and lines provide the proportion accessing preventive checks in the past year within each sector by country and the 95% CI around this estimate. Dashed lines represent the slope index of inequality centred around the proportion accessing preventive checks to indicate the magnitude of within-sector income inequality; only statistically significant (ie, p<0·05) slope index of inequality is shown.