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1.

Progress in reducing inequalities in reproductive, maternal, newborn,' and child health in Latin America and the Caribbean: an unfinished agenda/ Avances en la reducción de las desigualdades en materia de salud reproductiva, materna, neonatal e infantil en América Latina y el Caribe: un programa inacabado

Restrepo-Méndez, María Clara; Barros, Aluísio J. D.; Requejo, Jennifer; Durán, Pablo; Serpa, Luis Andrés de Francisco; França, Giovanny V. A.; Wehrmeister, Fernando C.; Victora, Cesar G.
| Idioma(s): Inglés
OBJECTIVE: To expand the "Countdown to 2015" analyses of health inequalities beyond the 75 countries being monitored worldwide to include all countries in Latin America and the Caribbean (LAC) that have adequate data available. METHODS: Demographic and Health Surveys and Multiple Indicator Cluster Surveys were used to monitor progress in health intervention coverage and inequalities in 13 LAC countries, five of which are included in the Countdown (Bolivia, Brazil, Guatemala, Haiti, and Peru) and eight that are not (Belize, Colombia, Costa Rica, Dominican Republic, Guyana, Honduras, Nicaragua, and Suriname). The outcomes included neonatal and under-5 year mortality rates, child stunting prevalence, and the composite coverage index-a weighted average of eight indicators of coverage in reproductive, maternal, newborn, and child health. The slope index of inequality and concentration index were used to assess absolute and relative inequalities. RESULTS: The composite coverage index showed monotonic patterns over wealth quintiles, with lowest levels in the poorest quintile. Under-5 and neonatal mortality as well as stunting prevalence were highest among the poor. In most countries, intervention coverage increased, while under-5 mortality and stunting prevalence fell most rapidly among the poor, so that inequalities were reduced over time. However, Bolivia, Guatemala, Haiti, Nicaragua, and Peru still show marked inequalities. Brazil has practically eliminated inequalities in stunting. CONCLUSIONS: LAC countries presented substantial progress in terms of reducing inequalities in reproductive, maternal, newborn, and child health interventions, child mortality, and nutrition. However, the poorest 20% of the population in most countries is still lagging behind, and renewed actions are needed to improve equity. OBJETIVO: Extender los análisis de la "Cuenta Regresiva para 2015" de las desigualdades en materia de salud más allá de los 75 países sometidos a vigilancia en todo el mundo para incluir a todos los países de América Latina y el Caribe (ALC) que disponen de datos adecuados. MÉTODOS: Se utilizaron encuestas de demografía y salud y encuestas agrupadas de indicadores múltiples para vigilar el progreso de la cobertura de las intervenciones de salud y de las desigualdades en 13 países de ALC, 5 de ellos incluidos en la Cuenta Regresiva (Bolivia, Brasil, Guatemala, Haití y Perú) y 8 no incluidos (Belice, Colombia, Costa Rica, Guyana, Honduras, Nicaragua, República Dominicana y Suriname). Los resultados incluyeron las tasas de mortalidad neonatal y en menores de 5 años, la prevalencia del retraso del crecimiento en niños y el índice compuesto de cobertura (un promedio ponderado de 8 indicadores de cobertura en materia de salud reproductiva, materna, neonatal e infantil. Para evaluar las desigualdades absolutas y relativas, se emplearon el índice de desigualdad de la pendiente y el índice de concentración. RESULTADOS: El índice compuesto de cobertura mostró patrones monotónicos en función de los quintiles de riqueza, con los niveles más bajos en el quintil más pobre. La mortalidad neonatal y en menores de 5 años, así como la prevalencia del retraso del crecimiento, fueron más elevadas entre los pobres. En la mayor parte de los países aumentó la cobertura de las intervenciones, mientras que la mortalidad en menores de 5 años y la prevalencia del retraso del crecimiento disminuyeron más rápidamente entre los pobres, de manera que las desigualdades se redujeron con el transcurso del tiempo. Sin embargo, en Bolivia, Guatemala, Haití, Nicaragua y Perú aún se observan marcadas desigualdades. Brasil prácticamente ha eliminado las desigualdades en cuanto a retraso del crecimiento. CONCLUSIONES: Los países de ALC mostraron avances considerables en la reducción de las desigualdades con respecto a las intervenciones de salud reproductiva, materna, neonatal e infantil, y en materia de mortalidad y nutrición infantil. Sin embargo, el 20% más pobre de la población en la mayor parte de los países sigue quedándose a la zaga, y son necesarias iniciativas renovadas para mejorar la equidad.
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2.

Cruise ships and bush medicine: globalization on the Atlantic Coast of Nicaragua and effects on the health of Creole women.

Mitchell, Emma McKim; Steeves, Richard; Dillingham, Rebecca
| Idioma(s): Inglés
OBJECTIVES: Global health research into the relationship between health, economic inequalities, and globalization is necessary to address increasing health disparities in low income countries. Nicaragua has high levels of poverty and extreme poverty when compared with other Central and South American Countries. DESIGN AND SAMPLE: Photovoice and ethnographic research methods were used to explore health experiences of Creole women in Bluefields, Nicaragua and the intersections between culture, socioeconomic status, and gender. Twelve Creole women participants, ages 18-45. MEASURES: After initial focus groups, participants used disposable cameras to document health experiences. Follow-up interviews were conducted about the meaning of each photo. Participants then selected photos to be included in a city-wide photoshow. RESULTS: In initial focus groups, participants described great distress over changes they perceived in Creole culture and how these changes affect the health of the next generation. Participants related most of these changes to the economy and globalization. Photos taken were primarily of aspects of Creole culture, including household practices and traditional remedies from Creole culture. CONCLUSIONS: Findings on the relationships between culture, disease, and community-identified health risks in this minority population can help health care providers and public health policymakers develop and sustain culturally appropriate health interventions.
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3.

Sociopolitical determinants of international health policy.

De Vos, Pol; Van der Stuyft, Patrick
| Idioma(s): Inglés
For decades, two opposing logics have dominated the health policy debate: a comprehensive health care approach, with the 1978 Alma Ata Declaration as its cornerstone, and a private competition logic, emphasizing the role of the private sector. We present this debate and its influence on international health policies in the context of changing global economic and sociopolitical power relations in the second half of the last century. The neoliberal approach is illustrated with Chile's health sector reform in the 1980s and the Colombian reform since 1993. The comprehensive "public logic" is shown through the social insurance models in Costa Rica and in Brazil and through the national public health systems in Cuba since 1959 and in Nicaragua during the 1980s. These experiences emphasize that health care systems do not naturally gravitate toward greater fairness and efficiency, but require deliberate policy decisions.
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4.

Developing a common framework for integrated solid waste management advances in Managua, Nicaragua.

Olley, Jane E; IJgosse, Jeroen; Rudin, Victoria; Alabaster, Graham
| Idioma(s): Inglés
This article describes the municipal solid waste management system in Managua, Nicaragua. It updates an initial profile developed by the authors for the 2010 UN-HABITAT publication Solid Waste Management in the World's Cities and applies the methodology developed in that publication. In recent years, the municipality of Managua has been the beneficiary of a range of international cooperation projects aimed at improving municipal solid waste management in the city. The article describes how these technical assistance and infrastructure investments have changed the municipal solid waste management panorama in the city and analyses the sustainability of these changes. The article concludes that by working closely with the municipal government, the UN-HABITAT project Strengthening Capacities for Solid Waste Management in Managua was able to unite these separate efforts and situate them within a strategic framework to guide the evolution of the municipal solid waste management system in the forthcoming years. The creation of this multi-stakeholder platform allowed for the implementation of joint activities and ensured coherence in the products generated by the different projects. This approach could be replicated in other cities and in other sectors with similar effect. Developing a long term vision was essential for the advancement of municipal solid waste management in the city. Nevertheless, plan implementation may still be undermined by the pressures of the short term municipal administrative government, which emphasize operational over strategic investment.
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5.

Treatment and prevention of malnutrition in Latin America: focus on Chile and Bolivia.

Weisstaub, Gerardo; Aguilar, Ana Maria; Uauy, Ricardo
| Idioma(s): Inglés
Seven million children under 5 years of age died worldwide in 2011, and one-third had malnutrition. Latin America and Caribbean countries stand out for the notable improvement of their health and nutrition situation, particularly in pregnant women and young children. Nutrition-sensitive interventions such as promoting food security, women's empowerment, social safety nets, clean water, and sanitation, among others, are critical for success. In Bolivia, the program Desnutrición Cero (Malnutrition Zero) was able to reduce mortality from severe malnutrition after 5 years from 25% to less than 5%, based on widespread implementation of the World Health Organization 10-steps protocol for hospitalized care and the application of community management. The Economic Commission for Latin America estimated the cost of malnutrition for Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and the Dominican Republic as US $6,658 million. Approximately 1 million children have dropped out of school because of malnutrition, and as a result, malnourished children have 2 years less schooling, which brings social and economic losses not only to those affected but to society at large. National and international nutrition and food programs developed over the past 50 years have been implemented as integral components of broader strategies of primary healthcare and education, oriented toward preventing deaths and improving the quality of life of low-socioeconomic-status groups. Treating hundreds or thousands of affected children will not solve the global public health problem of malnutrition. Access to adequate amounts of quality foods represents a basic human right and is a necessary precondition for health. In turn, good nutrition and health are prerequisites for human, social, and economic development.
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6.

Determinantes sociales de la exclusión a los servicios de salud y a medicamentos en tres países de América Central./ [Social determinants of exclusion from health services and medicines in three Central American countries].

Acuña, Cecilia; Marina, Nelly; Mendoza, Adriana; Emmerick, Isabel Cristina Martins; Luiza, Vera Lucía; Azeredo, Thiago Botelho
| Idioma(s): Español
OBJECTIVE: Examine the social determinants that affect population behavior with regard to the search for and acquisition of medicines, and their relationship to exclusion from health services based on aggregate data from three Central American countries: Guatemala, Honduras, and Nicaragua. METHODS: A descriptive, observational cross-sectional study was conducted by administration of a household survey. The study sample was selected in accordance with the conglomerate method. Data was analyzed with the SPSS® V.17 program using descriptive statistics, bivariate, multivariate, and principal components analysis (PCA). RESULTS: Although the majority of the persons could access health care, health exclusion (odds ratio [OR] 4.10; 95% confidence interval [95% CI]) was the main determinant of lack of access to medicines. The characteristics of housing (OR 0.747, 95% CI), formal employment of head of the household (OR 0.707, 95% CI), and socioeconomic status of the household (OR 0.462, 95% CI) were also important determinants of lack of access to medicines. CONCLUSIONS: The phenomena of lack of access to health services and medicines are not independent from one another. It was corroborated that the health system, as an intermediate social determinant of health, is an important factor for improvement of access to medicines. Public policies that aim to achieve universal coverage should consider this relationship in order to be effective.
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7.

Determinantes sociales de la exclusión a los servicios de salud y a medicamentos en tres países de América Central/ Social determinants of exclusion from health services and medicines in three Central American countries

Acuña, Cecilia; Marina, Nelly; Mendoza, Adriana; Emmerick, Isabel Cristina Martins; Luiza, Vera Lucía; Azeredo, Thiago Botelho
| Idioma(s): Español
OBJETIVO: Examinar los determinantes sociales que afectan la conducta de la población en relación con la búsqueda y obtención de medicamentos, y su relación con la exclusión de los servicios de salud para datos agregados de tres países de América Central: Guatemala, Honduras y Nicaragua. MÉTODOS: Estudio observacional descriptivo de corte transversal, mediante la aplicación de una encuesta de hogares. La muestra del estudio se seleccionó de acuerdo al método de conglomerados. Los datos fueron analizados con el programa SPSS® V.17, utilizando estadística descriptiva y análisis bivariado, multivariado y por componentes principales (ACP). RESULTADOS: Aunque la mayoría de las personas pudo acceder a la atención en salud, la exclusión en salud (razón de probabilidades [RP] 4,10; intervalo de confianza de 95% [IC95%]) fue el principal determinante de la falta de acceso a los medicamentos. Las características de la vivienda (RP 0,747, IC95%), la formalidad del empleo del jefe(a) de hogar (RP 0,707, IC95%) y las condiciones socioeconómicas del hogar (RP 0,462, IC95%) fueron también importantes determinantes de la falta de acceso a los medicamentos. CONCLUSIONES: Los fenómenos de la falta de acceso a servicios de salud y a medicamentos no son independientes entre sí. Se corroboró que el sistema de salud, como determinante social intermediario de la salud, es un factor importante para la mejora del acceso a medicamentos. Las políticas públicas orientadas a alcanzar la cobertura universal deben contemplar esta relación para ser eficaces. OBJECTIVE: Examine the social determinants that affect population behavior with regard to the search for and acquisition of medicines, and their relationship to exclusion from health services based on aggregate data from three Central American countries: Guatemala, Honduras, and Nicaragua. METHODS: A descriptive, observational cross-sectional study was conducted by administration of a household survey. The study sample was selected in accordance with the conglomerate method. Data was analyzed with the SPSS® V.17 program using descriptive statistics, bivariate, multivariate, and principal components analysis (PCA). RESULTS: Although the majority of the persons could access health care, health exclusion (odds ratio [OR] 4.10; 95% confidence interval [95% CI]) was the main determinant of lack of access to medicines. The characteristics of housing (OR 0.747, 95% CI), formal employment of head of the household (OR 0.707, 95% CI), and socioeconomic status of the household (OR 0.462, 95% CI) were also important determinants of lack of access to medicines. CONCLUSIONS: The phenomena of lack of access to health services and medicines are not independent from one another. It was corroborated that the health system, as an intermediate social determinant of health, is an important factor for improvement of access to medicines. Public policies that aim to achieve universal coverage should consider this relationship in order to be effective.
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8.

Comparing progress toward the millennium development goal for under-five mortality in León and Cuatro Santos, Nicaragua, 1990-2008.

Pérez, Wilton; Eriksson, Leif; Blandón, Elmer Zelaya; Persson, Lars-Åke; Källestål, Carina; Peña, Rodolfo
| Idioma(s): Inglés
BACKGROUND: Social inequality in child survival hampers the achievement of Millennium Development Goal 4 (MDG4). Monitoring under-five mortality in different social strata may contribute to public health policies that strive to reduce social inequalities. This population-based study examines the trends, causes, and social inequality of mortality before the age of five years in rural and urban areas in Nicaragua. METHODS: The study was conducted in one rural (Cuatro Santos) and one urban/rural area (León) based on data from Health and Demographic Surveillance Systems. We analyzed live births from 1990 to 2005 in the urban/rural area and from 1990 to 2008 in the rural area. The annual average rate reduction (AARR) and social under-five mortality inequality were calculated using the education level of the mother as a proxy for socio-economic position. Causes of child death were based on systematic interviews (verbal autopsy). RESULTS: Under-five mortality in all areas is declining at a rate sufficient to achieve MDG4 by 2015. Urban León showed greater reduction (AARR = 8.5%) in mortality and inequality than rural León (AARR = 4.5%) or Cuatro Santos (AARR = 5.4%). Social inequality in mortality had increased in rural León and no improvement in survival was observed among mothers who had not completed primary school. However, the poor and remote rural area Cuatro Santos was on track to reach MDG4 with equitable child survival. Most of the deaths in both areas were due to neonatal conditions and infectious diseases. CONCLUSIONS: All rural and urban areas in Nicaragua included in this study were on track to reach MDG4, but social stratification in child survival showed different patterns; unfavorable patterns with increasing inequity in the peri-urban rural zone and a more equitable development in the urban as well as the poor and remote rural area. An equitable progress in child survival may also be accelerated in very poor settings.
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9.

Meeting targets or saving lives: maternal health policy and Millennium Development Goal 5 in Nicaragua.

Kvernflaten, Birgit
| Idioma(s): Inglés
In support of maternal health, disease-specific and target-oriented global policy initiatives, such as in Millennium Development Goal 5, have led to a prioritisation of narrow indicators at the expense of more comprehensive approaches. In line with global policy, Nicaragua has made skilled attendants and institutionalised delivery central to its efforts to achieving MDG5 on maternal health. Drawing on ethnographic fieldwork in Nicaragua, involving participant observation and interviews with hospital and community health workers, and women and their families, this paper critically discusses how target-oriented maternal health strategies were manifested in local realities. It shows that Nicaragua's brigadistas (community health workers) and parteras (traditional birth attendants) have been driven to narrowing their own roles to identifying pregnant women and advocating that they have an institutional delivery as one their most important tasks, making them agents of MDG 5 target achievement. This has engendered fear among brigadistas and parteras of being held individually responsible in the event of a maternal death, creating dissatisfaction with their role and reducing their motivation. While intended to improve maternal health, the pressure to reach targets has unintended negative implications for the relationship between women, the local volunteers and the formal health system, which needs to be addressed.
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10.

"Love isn't there in your stomach": a moral economy of medical citizenship among Nicaraguan community health workers.

Nading, Alex M
| Idioma(s): Inglés
Drawing on participant-observation in Nicaraguan dengue prevention campaigns and a series of semistructured interviews with Nicaraguan health ministry personnel, this article shows how community health workers (CHWs) balanced two kinds of "medical citizenship." In some situations, CHWs acted as professional monitors and models of hygienic behavior. At other times, CHWs acted as compassionate advocates for their poor neighbors. In 2008, Nicaragua's Sandinista government moved to end a long-standing policy of paying CHWs, recasting them as citizen-volunteers in a "popular struggle" against dengue. Although CHWs approved of the revival of grassroots advocacy, they were hostile to the elimination of compensation. Framing this ambivalence as part of CHWs' desire to serve as "brokers" between the poor and the state, I suggest that attention to medical citizenship provides insight into the sometimes contradictory ways in which CHWs engage the participatory health policies now taking hold in Latin America and elsewhere.
Resultados  1-10 de 2.799