Latin American countries were hard hit by COVID-19 with rates of excess mortality above the OECD average. The pandemic brought additional stress to health systems already overstretched by a growing burden of chronic diseases, unequal access to health care services, overall under-investment in health and strong budgetary restrictions, and systemic inefficiencies. Doubling down on primary health care will be a cost-effective strategy to increase preparedness for future pandemics and address the structural challenges in the region. The report examines the experience of seven countries in Latin America – Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico and Peru – considering primary health care policies and actions taken to absorb the impact of the COVID-19 pandemic and recover from it. The findings and recommendations of this report provide guidance to public authorities in the region in their efforts to better prepare and increase the resilience of health systems through stronger primary health care.
Primary Health Care for Resilient Health Systems in Latin America
Abstract
Executive Summary
Latin American countries were hard-hit by COVID‑19, as shown by rates of excess mortality well above the OECD average. The pandemic has revealed weaknesses in health systems and brought additional stress to health systems in countries that already experienced important structural challenges. Doubling down on primary health care will help strengthen health systems, both to increase preparedness to future pandemics and to address the structural challenges in the region.
A framework for understanding the performance of primary health care system
High performing primary health care systems have a strong focus on prevention. When primary health care services are the main source of care, have appropriate information to assess patients’ medical history, and are able to co‑ordinate care effectively with other health services, they are well positioned to carry-out three core functions related to prevention:
1. primary prevention, especially providing health promotion and routine vaccination;
2. secondary prevention, including providing regular exams and screening to identify diseases; and
3. tertiary prevention, delivering routine care for underlying health conditions.
These three core functions are critical to preparedness and resilience during health crises. Many key linkages have been observed between core primary health care functions and the ability of countries to respond effectively to the COVID‑19 pandemic, through for example the COVID‑19 vaccination rollouts, the early detection of COVID‑19 and the use of outreach services to manage mild COVID‑19 in community and primary care settings.
Despite strong policy efforts, primary health care is not strong enough across LAC‑7 countries
During the last decades, some LAC‑7 countries have implemented policies to strengthen primary health care and place it at the centre of their health care strategy (such as Brazil, Chile and Costa Rica), but there is significant variation in their effective implementation.
Unlike most other OECD countries, patient registration and referral systems are not fully operationalised in LAC‑7 countries. Opportunities to provide proactive care are often being lost because primary health care does not act as the first point of care in most LAC‑7 countries and many patients directly seek care in outpatient specialised clinics and hospitals. Chile is the only country where registration with primary health care is mandatory, while in Argentina and Costa Rica patients have financial or quality incentives to do so.
In all LAC‑7 countries, significant gaps in performance remain across each of the three core functions:
On primary prevention, there is scope to strengthen health promotion and vaccination. Brazil, Mexico, Argentina and Peru have lower vaccination coverage rates for diphtheria, tetanus toxoid and pertussis (DTP3) and for measles than other OECD countries, and there are marked socio‑economic inequalities. In Brazil for example, vaccination coverage rates for measles and DTP3 is respectively 16% and 25% higher amongst high-income groups than low-income groups.
When it comes to secondary prevention, more could be done to improve the depth and scope of cancer screening strategies. Breast cancer screening in most LAC‑7 countries has not reached the targets set out in the countries’ screening programmes. In Peru and Brazil, the breast cancer screening coverage rate is less than half the OECD average.
Inappropriate management of chronic diseases suggests ineffective tertiary prevention. Hospitalisations for diabetes, avoidable through strong primary health care, are relatively higher in Mexico and Costa Rica than in other OECD countries. LAC‑7 countries also underperform compared to other OECD countries with lower cancer survival rates and higher volume of antibiotics consumption.
Primary health care helped to mitigate the impact of COVID‑19 on health in LAC‑7, but access to care worsened
Although there are significant primary health care performance gaps in LAC‑7 countries, several policies and actions have been implemented to absorb the impact of the COVID‑19 pandemic and recover from it:
Primary health care has contributed to the COVID‑19 emergency response. Examples include primary prevention activities, efforts to create awareness on COVID‑19 risks and tailor messages and information campaign on non-pharmaceutical interventions in Peru and Argentina. Successful COVID‑19 vaccination programmes were implemented at primary health care level in Chile, Argentina, Peru, Costa Rica and Brazil.
COVID‑19 testing has been systematically carried out in primary health care in some LAC‑7 countries. In Costa Rica, all EBAIS were responsible for the detection, notification and investigation of cases, and primary health care also implemented sampling campaigns in places with an epidemiological outbreak.
Despite initial delays to adapt to the health emergency, all LAC‑7 countries implemented comprehensive adaptations to primary health care to advise suspected or confirmed patients in home isolation or at primary health care units when more treatment was necessary. The Respiratory Care Modules (Módulos de Atención Respiratoria del Seguro Social, MARSS) in Mexico was responsible for treating suspected and confirmed cases of COVID‑19.
However, many LAC‑7 health systems faced challenges in maintaining routine care, showing how primary care systems were not resilient enough during the COVID‑19 pandemic. Coverage for DTP3 vaccines amongst children aged one fell by 8% in 2020 compared to the 2015‑19 average. For cancer screening, recent evidence shows worrying disruption of screening and early detection services. In Chile for example, cervical cancer screening coverage decreased by 20% in 2020 compared to 2015‑19. These care disruptions will come at persistently elevated human and financial costs in the years to come, as they risk exacerbating health conditions.
Increasing preparedness and resilience of LAC‑7 health systems to face future high impact shocks through stronger primary health care will be critical, if the well-being and health gains achieved during the last two decades are to be maintained. LAC‑7 countries should make primary health care the front door of the health system for everyone to deliver crucial health services. A stronger gatekeeping function for primary health care, with systematic patient registration and referral system, will help making individuals more resilient against COVID‑19 and potential future outbreaks of infectious diseases. But primary health care will need the right equipment, accountability mechanisms, guidelines and trainings to perform its core functions.
LAC‑7 countries will also need to invest in health workforce planning given the existing workforce shortage. This requires strengthening efforts to examine needs for human resources with greater cross-sectoral collaboration, and expanding the role of some health professionals including nurses and community health workers. Lastly, investing in stronger health information infrastructure, through a consolidated system of electronic health records, is most needed to provide a good understanding of the health status and health needs of the population.
