The role of gender inequality and health expenditure on the coverage of demand for family planning satisfied by modern contraceptives: a multilevel analysis of cross-sectional studies in 14 LAC countries.

Background: Despite international efforts to improve reproductive health indicators, little attention is paid to the contributions of contextual factors to modern contraceptive coverage, especially in the Latin America and the Caribbean (LAC) region. This study aimed to identify the association between country-level Gender Inequality and Health Expenditure with demand for family planning satisfied by modern contraceptive methods (DFPSm) in Latin American sexually active women. Methods: Our analyses included data from the most recent (post-2010) Demographic and Health Survey or Multiple Indicator Cluster Survey from 14 LAC countries. Descriptive analyses and multilevel logistic regressions were performed. Six individual-level factors were included. The effect of the country-level factors Gender Inequality Index (GII) and Current Health Expenditure on DFPSm was investigated. Findings: DFPSm ranged from 41.8% (95% CI: 40.2-43.5) in Haiti to 85.6% (95% CI: 84.9-86.3) in Colombia, with an overall median coverage of 77.8%. A direct association between the odds of DFPSm and woman's education, wealth index, and the number of children was identified. Women from countries in the highest GII tertile were less likely (OR: 0.32, 95% CI: 0.13-0.76) to have DFPSm than those living in countries in the lowest tertile. Interpretation: Understanding the contribution of country-level factors to modern contraception may allow macro-level actions focused on the population's reproductive needs. In this sense, country-level gender inequalities play an important role, as well as individual factors such as wealth and education. Funding: Bill and Melinda Gates Foundation and Associação Brasileira de Saúde Coletiva (ABRASCO).

Mexico: Health System Review.

This analysis of the Mexican health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Mexican health system consists of three main components operating in parallel: 1) employment-based social insurance schemes, 2) public assistance services for the uninsured supported by a financial protection scheme, and 3) a private sector composed of service providers, insurers, and pharmaceutical and medical device manufacturers and distributors. The social insurance schemes are managed by highly centralized national institutions while coverage for the uninsured is operated by both state and federal authorities and providers. The largest social insurance institution - the Mexican Social Insurance Institute (IMSS) - is governed by a corporatist arrangement, which reflects the political realities of the 1940s rather than the needs of the 21st century. National health spending has grown in recent years but is lower than the Latin America and Caribbean average and considerably lower than the OECD average in 2015. Public spending accounts for 58% of total financing, with private contributions being mostly comprised of out-of-pocket spending. The private sector, while regulated by the government, mostly operates independently. Mexico's health system delivers a wide range of health care services; however, nearly 14% of the population lacks financial protection, while the insured are mostly enrolled in diverse public schemes which provide varying benefits packages. Private sector services are in high demand given insufficient resources among most public institutions and the lack of voice by the insured to ensure the fulfilment of entitlements. Furthermore, the system faces challenges with obesity, diabetes, violence, as well as with health inequity. Recognizing the inequities in access created by its segmented structure, both civil society and government are calling for greater integration of service delivery across public institutions, although no consensus yet exists as to how to bring this about.

Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries.

BACKGROUND: Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions. METHODS: We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15-49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12-23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression. FINDINGS: Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66-0·92), antenatal care (0·86, 0·75-0·94), and skilled birth attendants (0·75, 0·68-0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries. INTERPRETATION: The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level-such as vaccines-show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. FUNDING: The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.