Building a Data Platform for Cross-Country Urban Health Studies: the SALURBAL Study.

Studies examining urban health and the environment must ensure comparability of measures across cities and countries. We describe a data platform and process that integrates health outcomes together with physical and social environment data to examine multilevel aspects of health across cities in 11 Latin American countries. We used two complementary sources to identify cities with ≥ 100,000 inhabitants as of 2010 in Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Nicaragua, Panama, and Peru. We defined cities in three ways: administratively, quantitatively from satellite imagery, and based on country-defined metropolitan areas. In addition to "cities," we identified sub-city units and smaller neighborhoods within them using census hierarchies. Selected physical environment (e.g., urban form, air pollution and transport) and social environment (e.g., income, education, safety) data were compiled for cities, sub-city units, and neighborhoods whenever possible using a range of sources. Harmonized mortality and health survey data were linked to city and sub-city units. Finer georeferencing is underway. We identified 371 cities and 1436 sub-city units in the 11 countries. The median city population was 234,553 inhabitants (IQR 141,942; 500,398). The systematic organization of cities, the initial task of this platform, was accomplished and further ongoing developments include the harmonization of mortality and survey measures using available sources for between country comparisons. A range of physical and social environment indicators can be created using available data. The flexible multilevel data structure accommodates heterogeneity in the data available and allows for varied multilevel research questions related to the associations of physical and social environment variables with variability in health outcomes within and across cities. The creation of such data platforms holds great promise to support researching with greater granularity the field of urban health in Latin America as well as serving as a resource for the evaluation of policies oriented to improve the health and environmental sustainability of cities.

[Changes in gallbladder cancer mortality and hospital discharges due to preventive cholecystectomy in Chile]. / Mortalidad por cáncer de vesícula y egresos hospitalarios por patología biliar en Chile 2002-2014, en relación a la garantía GES colecistectomía preventiva.

BACKGROUND: Gallbladder cancer is a relevant public health problem in Chile. AIM: To analyze the mortality trend due to gallbladder cancer and hospital discharges due to biliary disease between 2002 and 2014. To analyze the effect on these parameters of the new health system called explicit guaranties in health whose acronym in Spanish is GES. MATERIAL AND METHODS: Mortality and hospital discharge databases available at the website of the Ministry of Health were analyzed. Changes in crude and adjusted rates were evaluated, analyzing data by geographical regions, sex and age. The standardization was carried out using the direct method and using as reference the Chilean population in 2002. The trends were evaluated through the Poisson regression method. RESULTS: There is a 4.5% trend towards a decreasing mortality at a national level, as compared with the figures before GES came into force. Mortality among people aged 35 to 49 decreased by 4% before GES, and by 8% after GES. The trend of hospital discharges varied from -1% before GES, to a 2% increase after GES. Discharges among people aged 35-49 years increased from 0.1% to 2.9%. CONCLUSIONS: The discharge rate increase after GES, does not yet show a break in the reduction of mortality at the national level, although it does benefit the group of 35 to 49 years.

Comparison of Health Examination Survey Methods in Brazil, Chile, Colombia, Mexico, England, Scotland, and the United States.

Comparability of population surveys across countries is key to appraising trends in population health. Achieving this requires deep understanding of the methods used in these surveys to examine the extent to which the measurements are comparable. In this study, we obtained detailed protocols of 8 nationally representative surveys from 2007-2013 from Brazil, Chile, Colombia, Mexico, the United Kingdom (England and Scotland), and the United States-countries that that differ in economic and inequity indicators. Data were collected on sampling frame, sample selection procedures, recruitment, data collection methods, content of interview and examination modules, and measurement protocols. We also assessed their adherence to the World Health Organization's "STEPwise Approach to Surveillance" framework for population health surveys. The surveys, which included half a million participants, were highly comparable on sampling methodology, survey questions, and anthropometric measurements. Heterogeneity was found for physical activity questionnaires and biological samples collection. The common age range included by the surveys was adults aged 18-64 years. The methods used in these surveys were similar enough to enable comparative analyses of the data across the 7 countries. This comparability is crucial in assessing and comparing national and subgroup population health, and to assisting the transfer of research and policy knowledge across countries.

Overcoming social segregation in health care in Latin America.

Latin America continues to segregate different social groups into separate health-system segments, including two separate public sector blocks: a well resourced social security for salaried workers and their families and a Ministry of Health serving poor and vulnerable people with low standards of quality and needing a frequently impoverishing payment at point of service. This segregation shows Latin America's longstanding economic and social inequality, cemented by an economic framework that predicted that economic growth would lead to rapid formalisation of the economy. Today, the institutional setup that organises the social segregation in health care is perceived, despite improved life expectancy and other advances, as a barrier to fulfilling the right to health, embodied in the legislation of many Latin American countries. This Series paper outlines four phases in the history of Latin American countries that explain the roots of segmentation in health care and describe three paths taken by countries seeking to overcome it: unification of the funds used to finance both social security and Ministry of Health services (one public payer); free choice of provider or insurer; and expansion of services to poor people and the non-salaried population by making explicit the health-care benefits to which all citizens are entitled.

Health-system reform and universal health coverage in Latin America.

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens--with defined and enlarged benefits packages--and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

Assessment of universal health coverage for adults aged 50 years or older with chronic illness in six middle-income countries.

OBJECTIVE: To assess universal health coverage for adults aged 50 years or older with chronic illness in China, Ghana, India, Mexico, the Russian Federation and South Africa. METHODS: We obtained data on 16,631 participants aged 50 years or older who had at least one diagnosed chronic condition from the World Health Organization Study on Global Ageing and Adult Health. Access to basic chronic care and financial hardship were assessed and the influence of health insurance and rural or urban residence was determined by logistic regression analysis. FINDINGS: The weighted proportion of participants with access to basic chronic care ranged from 20.6% in Mexico to 47.6% in South Africa. Access rates were unequally distributed and disadvantaged poor people, except in South Africa where primary health care is free to all. Rural residence did not affect access. The proportion with catastrophic out-of-pocket expenditure for the last outpatient visit ranged from 14.5% in China to 54.8% in Ghana. Financial hardship was more common among the poor in most countries but affected all income groups. Health insurance generally increased access to care but gave insufficient protection against financial hardship. CONCLUSION: No country provided access to basic chronic care for more than half of the participants with chronic illness. The poor were less likely to receive care and more likely to face financial hardship in most countries. However, inequity of access was not fully determined by the level of economic development or insurance coverage. Future health reforms should aim to improve service quality and increase democratic oversight of health care.

Integrating social determinants of health in the universal health coverage monitoring framework.

Underpinning the global commitment to universal health coverage (UHC) is the fundamental role of health for well-being and sustainable development. UHC is proposed as an umbrella health goal in the post-2015 sustainable development agenda because it implies universal and equitable effective delivery of comprehensive health services by a strong health system, aligned with multiple sectors around the shared goal of better health. In this paper, we argue that social determinants of health (SDH) are central to both the equitable pursuit of healthy lives and the provision of health services for all and, therefore, should be expressly incorporated into the framework for monitoring UHC. This can be done by: (a) disaggregating UHC indicators by different measures of socioeconomic position to reflect the social gradient and the complexity of social stratification; and (b) connecting health indicators, both outcomes and coverage, with SDH and policies within and outside of the health sector. Not locating UHC in the context of action on SDH increases the risk of going down a narrow route that limits the right to health to coverage of services and financial protection.

[Universal health coverage assessment based on national socioeconomic characterization surveys]. / Seguimiento de cobertura sanitaria universal con equidad en Chile entre 2000 y 2011 usando las Encuestas CASEN.

BACKGROUND: The Chilean health reform aimed to expand universal health coverage (UHC) with equity. AIM: To analyze progress in health system affiliation, attended health needs (health visit for a recent problem) and direct payment for services, between 2000 and 2011. MATERIAL AND METHODS: We evaluated these outcomes for adults aged 20 years or older, analyzing databases of five National Socioeconomic Characterization Surveys. Using logistic regression models for no affiliation and unattended needs, we estimated odds ratios (OR) and prevalences, adjusted for socio-demographic characteristics. RESULTS: The unaffiliated population decreased from 11.0% (95% confidence interval (CI) 10.6-11.4) in 2000 to 3.0% (95% CI 2.8-3.2) in 2011. According to the model, self-employed workers had a higher adjusted prevalence of no affiliation: 27.4% (95% CI 24.1-30.6) in 2000 and 7.8% (95% CI: 5.9-9.7) in 2011. The level of unmet needs decreased from 33.5% (95% CI 31.8-35.1) to 9.1% (95% CI 8.1-10.1) in this period. Not being affiliated to the health system was associated with higher unmet needs in the adjusted model. Indigent affiliates, entitled to free care in the public system, reported payments for general and specialist visits in a much lower proportion than other groups. However, direct payments for visits increased for this group during the decade. CONCLUSIONS: Concurrent with the introduction of new health and social policies, we observed significant progress in health system enrolment and attended health needs. However, the percentage of impoverished people who made direct payments for services increased.

Health Effects of Chronic Intermittent Hypoxia at a High Altitude among Chilean Miners: Rationale, Design, and Baseline Results of a Longitudinal Study.

OBJECTIVES: This study aims to assess the health effects on mining workers of exposure to chronic intermittent hypoxia (CIH) at high- and very high-altitude mining compared with similar work at lower altitudes in Chile, and it also aims to constitute the baseline of a 5-year follow-up study. METHODS: We designed a cross-sectional study to assess health conditions in 483 miners working at 2 levels of altitude exposure: 336 working at a very high or high altitude (HA; 247 above 3900-4400 m, and 89 at 3000-3900 m), and 147 below 2400 m. Subjects were randomly selected in two stages. First, a selection of mines from a census of mines in each altitude stratum was made. Secondly, workers with less than 2 years of employment at each of the selected mines were recruited. The main outcomes measured at the baseline were mountain sickness, sleep alterations, hypertension, body mass index, and neurocognitive functions. RESULTS: Prevalence of acute mountain sickness (AMS) was 28.4% in the very high-altitude stratum (P = 0.0001 compared with the low stratum), and 71.7% experienced sleep disturbance (P = 0.02). The adjusted odds ratio for AMS was 9.2 (95% confidence interval: 5.2-16.3) when compared with the very high- and low-altitude groups. Motor processing speed and spatial working memory score were lower for the high-altitude group. Hypertension was lower in the highest-altitude subjects, which may be attributed to preoccupational screening even though this was not statistically significant. CONCLUSIONS: Despite longer periods of acclimatization to CIH, subjects continue to present AMS and sleep disturbance. Compromise of executive functions was detected, including working memory at HA. Further rigorous research is warranted to understand long-term health impacts of high-altitude mining, and to provide evidence-based policy recommendations.

A Novel International Partnership for Actionable Evidence on Urban Health in Latin America: LAC-Urban Health and SALURBAL.

This article describes the origins and characteristics of an interdisciplinary multinational collaboration aimed at promoting and disseminating actionable evidence on the drivers of health in cities in Latin America and the Caribbean: The Network for Urban Health in Latin America and the Caribbean and the Wellcome Trust funded SALURBAL (Salud Urbana en América Latina, or Urban Health in Latin America) Project. Both initiatives have the goals of supporting urban policies that promote health and health equity in cities of the region while at the same time generating generalizable knowledge for urban areas across the globe. The processes, challenges, as well as the lessons learned to date in launching and implementing these collaborations, are described. By leveraging the unique features of the Latin American region (one of the most urbanized areas of the world with some of the most innovative urban policies), the aim is to produce generalizable knowledge about the links between urbanization, health, and environments and to identify effective ways to organize, design, and govern cities to improve health, reduce health inequalities, and maximize environmental sustainability in cities all over the world.

Educational Inequalities in Cardiovascular Risk Factor and Blood Pressure Control in the Elderly: Comparison of MESA Cohort and Chilean NHS Survey Outcome Measures.

BACKGROUND: Social determinants differ between countries, which is not always considered when adapting health policies and interventions to face inequalities in noncommunicable diseases and their risk factors. OBJECTIVES: The study sought to analyze educational inequalities in controlled blood pressure (CBP), obesity, and smoking in study populations from Chile and the United States in 2 periods, both countries with large social inequalities. METHODS: The study used data from the first and fifth waves of the MESA (Multiethnic Study of Atherosclerosis) cohort, and the 2003 and 2009 to 2010 Chilean National Health Survey (CNHS) survey outcome measures. The study compared cardiovascular risk factors prevalence as well as relative index of inequality (RII) and slope index of inequality (SII) between the 2 samples. RESULTS: In the CNHS 67.9% and 52.6% of participants had below primary education in 2003 and 2009 to 2010, respectively, compared with 12.3% and 8.1% in the first and fifth waves of the MESA study, respectively. Smoking prevalence was higher and increased in the CNHS compared with the MESA study, concentrated in better-educated women in both years (RII: 0.34; 95% confidence interval [CI]: 0.17 to 0.68; and RII: 0.55; 95% CI: 0.34 to 0.89, respectively). In contrast, smoking decreased over time in the MESA study in all socioeconomic strata, although relative inequalities increased in both sexes (for women, RII: 2.32; 95% CI 1.36 to 3.97; for men, RII: 3.34; 95% CI 2.04 to 5.47). CBP prevalence in both periods was higher in the first and fifth waves of the MESA study (69.7% and 80.2%) compared with the 2003 and 2009 to 2010 CNHS samples (34.2% and 52.3%), but only for the MESA study RII, favoring the better educated, was it significant in both periods and sexes. Obesity inequalities for Chilean women decreased slightly between 2003 and 2009 as prevalence grew in the most educated (RII: 2.21 to 1.68; SII: 0.29 to 0.22, respectively); conversely, they increased for both sexes in the MESA study. CONCLUSIONS: The study findings confirm that patterns and trends in prevalence, and absolute and relative inequalities vary by country, suggesting that context and cultural issues matters.

Applying the Innov8 approach for reviewing national health programmes to leave no one behind: lessons learnt from Indonesia.

The World Health Organization's Innov8 Approach for Reviewing National Health Programmes to Leave No One Behind is an eight-step process that supports the operationalization of the Sustainable Development Goals' commitment to 'leave no one behind'. In 2014-2015, Innov8 was adapted and applied in Indonesia to review how the national neonatal and maternal health action plans could become more equity-oriented, rights-based and gender-responsive, and better address critical social determinants of health. The process was led by the Indonesian Ministry of Health, with the support of WHO. It involved a wide range of actors and aligned with/fed into the drafting of the maternal newborn health action plan and the implementation planning of the newborn action plan. Key activities included a sensitization meeting, diagnostic checklist, review workshop and in-country work by the review teams. This 'methods forum' article describes this adaptation and application process, the outcomes and lessons learnt. In conjunction with other sources, Innov8 findings and recommendations informed national and sub-national maternal and neonatal action plans and programming to strengthen a 'leave no one behind' approach. As follow-up during 2015-2017, components of the Innov8 methodology were integrated into district-level planning processes for maternal and newborn health, and Innov8 helped generate demand for health inequality monitoring and its use in planning. In Indonesia, Innov8 enhanced national capacity for equity-oriented, rights-based and gender-responsive approaches and addressing critical social determinants of health. Adaptation for the national planning context (e.g. decentralized structure) and linking with health inequality monitoring capacity building were important lessons learnt. The pilot of Innov8 in Indonesia suggests that this approach can help operationalize the SDGs' commitment to leave no one behind, in particular in relation to influencing programming and monitoring and evaluation.

Mediation of the effect of childhood socioeconomic position by educational attainment on adult chronic disease in Chile.

OBJECTIVES: We estimated the roles of childhood socioeconomic position (ChSEP) and education attainment on chronic diseases in Chilean adults, mediated through structural determinants and health behaviors, to identify potential pro-equity interventions. METHODS: We analyzed Chile's longitudinal Social Protection Surveys, a national sample of 14,788 adults with follow-up to 2009. Controlled direct effects (CDE) and natural effects (NDE and NIE) of ChSEP and education on number of chronic diseases were estimated with negative binomial models. RESULTS: CDE of low ChSEP with education fixed at 12 years showed a 12% increase with 4% indirect effects. CDEs at favorable levels of BMI, smoking, alcohol use, and physical activity were similar. CDE estimates for education adjusted for ChSEP were larger with negligible mediation. CDEs for women were generally larger. CONCLUSIONS: Low ChSEP exerts a primarily direct effect on later chronic disease, modestly mediated by education. Education attainment showed larger direct effects with minimal mediation by behaviors. Strengthening current-early child development and education policies, particularly gender aspects, may reduce social inequalities and key pathways for reducing chronic disease inequalities in Chile.

Effective universal health coverage and improved 1-year survival after acute myocardial infarction: the Chilean experience.

UNLABELLED: In 2005, Chile implemented a universal system of health guarantees (AUGE) aimed at improving equitable access to quality medical care for priority health conditions, including acute myocardial infarction (MI). OBJECTIVE: To evaluate 1-year survival in MI patients before and after AUGE. METHODS: Retrospective cohorts of patients with MI (with and without ST segment elevation) discharged alive from six public hospitals between January 2001-June 2005 (pre-AUGE) and July 2008-March 2009 (post-AUGE). Chilean national mortality and MI Registry (hospital-based) databases were linked using a unique identification number (ICD-10 codes I00-I99 were used to identify cardiovascular deaths). One-year survival was assessed using Weibull multivariate regression. RESULTS: About 1867 patients were discharged alive pre-AUGE and 534 post-AUGE; 25% were women in both periods. When comparing pre-AUGE and post-AUGE, there was an increase in the use of primary and elective angioplasty (1.7 vs 23.6% and 7.3 vs 20.0%), beta-blockers (62 vs 71%) and statins (40 vs 90%); P < 0.001 all. One-year survival was 92% pre-AUGE (95% CI: 91-93%) and 96% post-AUGE (95% CI: 94-97%) (HR = 0.50, 95% CI: 0.31-0.82; P = 0.003). The post-AUGE improvement persisted after adjusting for variables associated with long-term case-fatality (HR = 0.44, 95% CI: 0.26-0.75). Percutaneous coronary intervention (HR = 0.31, 95% CI: 0.09-0.99) and statins use at discharge (HR = 0.45, 95% CI: 0.31-0.66) had the highest effects associated with lower case-fatality and both treatments increased in the post-AUGE period. CONCLUSIONS: The implementation of AUGE in Chile appears to have contributed to improved treatment of MI in public hospitals and increased 1-year survival, which is consistent with its aim to improve access to quality medical care and to reduce health inequities.

Mortalidad por cáncer de vesícula y egresos hospitalarios por patología biliar en Chile 2002-2014, en relación a la garantía GES colecistectomía preventiva / Changes in gallbladder cancer mortality and hospital discharges due to preventive cholecystectomy in Chile

Background: Gallbladder cancer is a relevant public health problem in Chile. Aim: To analyze the mortality trend due to gallbladder cancer and hospital discharges due to biliary disease between 2002 and 2014. To analyze the effect on these parameters of the new health system called explicit guaranties in health whose acronym in Spanish is GES. Material and Methods: Mortality and hospital discharge databases available at the website of the Ministry of Health were analyzed. Changes in crude and adjusted rates were evaluated, analyzing data by geographical regions, sex and age. The standardization was carried out using the direct method and using as reference the Chilean population in 2002. The trends were evaluated through the Poisson regression method. Results: There is a 4.5% trend towards a decreasing mortality at a national level, as compared with the figures before GES came into force. Mortality among people aged 35 to 49 decreased by 4% before GES, and by 8% after GES. The trend of hospital discharges varied from −1% before GES, to a 2% increase after GES. Discharges among people aged 35-49 years increased from 0.1% to 2.9%. Conclusions: The discharge rate increase after GES, does not yet show a break in the reduction of mortality at the national level, although it does benefit the group of 35 to 49 years.

Achieving effective universal health coverage with equity: evidence from Chile.

Chile's 'health guarantees' approach to providing universal and equitable coverage for quality healthcare in a dual public-private health system has generated global interest. The programme, called AUGE, defines legally enforceable rights to explicit healthcare benefits for priority health conditions, which incrementally covered 56 problems representing 75% of the disease burden between 2005 and 2009. It was accompanied by other health reform measures to increase public financing and public sector planning to secure the guarantees nationwide, as well as the state's stewardship role. We analysed data from household surveys conducted before and after the AUGE reform to estimate changes in levels of unmet health need, defined as the lack of a healthcare visit for a health problem occurring in the last 30 days, by age, sex, income, education, health insurance, residence and ethnicity; fitting logistic regression models and using predictive margins. The overall prevalence of unmet health need was much lower in 2009 (17.6%, 95% CI: 16.5%, 18.6%) than in 2000 (30.0%, 95% CI: 28.3%, 31.7%). Differences by income and education extremes and rural-urban residence disappeared. In 2009, people who had been in treatment for a condition covered by AUGE in the past year had a lower adjusted prevalence of unmet need for their recent problem (11.7%, 95% CI: 10.5%, 13.2%) than who had not (21.0%, 95% CI: 19.6%, 22.4%). Despite limitations including cross-sectional and self-reported data, our findings suggest that the Chilean health system has become more equitable and responsive to need. While these changes cannot be directly attributed to AUGE, they were coincident with the AUGE reforms. However, healthcare equity concerns are still present, relating to quality of care, health system barriers and differential access for health conditions that are not covered by AUGE.

[Health equity in the world's most unequal region: a challenge for public policy in Latin America]. / Equidad en salud en la región más desigual del mundo: un reto de políticas públicas en América Latina.

Re-democratization has transformed the social agenda and the role of the state in Latin America with a growing commitment to health equity and social justice, yet these aspirations are strained by the region´s profound socioeconomic inequalities. Efforts to provide universal coverage to the right to health have led to the development of a variety of public policies, whose scope depends on how the concepts of health and equity are understood. In general, policy action has centered on health system reforms and only recently on integrated intersectorial action to address wider social determinants of health, particularly structural determinants. Furthermore, if the goal is health equity the predominant minimum standards approach cannot be the final answer, but only a step on the road to equality. Finally, realizing universal coverage of the right to health through public policy requires the strengthening of governmental institutional capacities with an intersectorial and participatory lens.

[Application of a simple methodological approach to analyze health inequalities: the case of infant mortality in Chile]. / Aplicación de una aproximación metodológica simple para el análisis de las desigualdades: El caso de la mortalidad infantil en Chile.

BACKGROUND: the infant mortality gradient by maternal education is a good indicator of the health impact of the social inequalities that prevail in Chile. AIM: to propose a systematic method of analysis, using simple epidemiological measures, for the comparison of differential health risks between social groups that change over time. MATERIAL AND METHODS: data and statistics on births and infant deaths, obtained from the Ministry of Health, were used. Five strata of maternal schooling were defined and various measures were calculated to compare infant mortality, according to maternal education in the periods 1998-2001 and 2001-2003. RESULTS: of particular interest is the distinction between a measure of effect, Relative Risk (RR), which indicates the size of the gap between socioeconomic extremes and the etiological strength of low maternal schooling on infant mortality, and a measure of global impact, the Population Attributable Risk (PAR%), which takes into account the whole socioeconomic distribution and permits comparisons over time independently of the variability in the proportions of the different social strata. The comparison of these measures in the two periods studied, reveals an increase in the infant mortality gap between maternal educational extremes measured by the RR, but a stabilization in the population impact of low maternal schooling. CONCLUSIONS: these results can be explained by a decline in the proportion of mothers in the lowest educational level and an increase in the proportion in the highest group.