Dr. Roses, PAHO Director, presentation on Social Inequalities in health in the Region of the Americas. PAHO's Regional Health Observatory (RHO Pan American health Organization (PAHO)

1. The Americas: A Region of Extremes Social Inequalities: A Barrier to Exercising the Right to Health Dr. Mirta Roses Periago , PAHO Director [Bethesda, MD. 16 September 2010.]

3. Wide gaps among and within the Region of the Americas

4. Demographic Transition in the Americas

5. Demographic Transition in the Americas

6. The Aging Process in the Region Source: Regional Health Observatory, PAHO.

8. The reality check: Life Expectancy vs. Spending

9. The most unequal Region in the world Pan American Health Organization BO NI EC MX UY CR VE SV PA AR PY BR CO RD GT CL PE HN Latin America 0.40 0.45 0.50 0.55 0.60 0.65 0.40 0.45 0.50 0.55 0.60 0.65 2002 2008 Countries in which inequality decreased Countries in which inequality Increased

11. Source: ECLAC, Indigenous and Afro-descendent Peoples of Latin America and the Caribbean: Socio-demographic Data for Policies and Programs . Santiago, Chile, 2006 Inequalities in Life Expectancy at Birth Indigenous and non-indigenous populations, by sex, Panama, 2000 census Pan American Health Organization SEX ETHNIC ORIGIN Indigenous peoples Non-indigenous peoples Male 61.1 69.6 Female 63.6 75.1

12. Total fertility rate, indigenous and non-indigenous population Selected countries of the Americas, ~2000 Note: The countries are shown in descending order of the TFR in the indigenous population. Source : ECLAC. Indigenous and Afro-descendent Peoples of Latin America and the Caribbean: Socio-demographic Data for Policies and Programs . Santiago, Chile: 2006. Fertility Rate: Indigenous population and non-indigenous population Pan American Health Organization

13. Adolescent Birth Rate- Region of the Americas Nicaragua is 2.5 times higher compared with Cuba The difference between the extremes is 5 times Source: PAHO Basic Indicators Pan American Health Organization

14. International Aid for Population Activities by Components of ICPD* Latin American and Caribbean, 1997-2007 -En Millones de Dólares US -Los Datos de 2007 son Provisionales Family Planning Services - In US$ Million - 2007 provisional data Data Analysis and Collection Reproductive Health Services HIV/AIDS and STD *ICPD: International Conference on Population and Development

15. Proportion of deaths by age groups and cause of death in Country groups according to income Classification of countries according World Bank income criteria Source: PAHO Basic Indicators

16. Diabetes Mortality Rates * Age group (50 to 69) Selected countries of the Americas. (2004, 2005 and 2006 lad) Source: Mortality Database. PAHO/HSD/HA * per 100.000 pop 0 50 100 150 200 Venezuela Uruguay United States Puerto Rico Peru Paraguay Panama Mexico Ecuador Cuba Costa Rica Colombia Chile Canada Brazil Bolivia Argentina Mexico and Paraguay have a higher risk of death from Diabetes compared to others Mortality rates 50-69

17. Source: Mortality Database, PAHO/HSD/HA and World Bank Premature mortality due to Cerebrovascular Disease by Gross National Income in the Americas (Circa 2006) * Occurrence of death in age ≤ 64 years old

18. * Per 100.000 pop 0 20 40 60 80 Mortality Rate 50 - 69 Venezuela Uruguay United States Puerto Rico Peru Paraguay Panama Mexico Ecuador Cuba Costa Rica Colombia Chile Canada Brazil Bolivia Argentina Cervical Cancer Rates * Age group 50-69 Selected countries of the Americas (2004, 2005 and 2006 lad) Cervical Cancer still a problem in the Region. We have to look at the quality of the data Pan American Health Organization

19. The weight of social determinants

21. Social exclusion in health and environment Source: PAHO Basic Indicators Pan American Health Organization

22. Coefficient of linear correlation= - 0.63 More access to improved sanitation, less Infant Mortality Source: PAHO Basic Indicators

23. Women aged 30-49 years Source: ENDEMAIN, Ecuador-INEC 2004 ; DHS -2002 Guatemala Proportion of Women never screened for Cervical Cancer Ecuador and Guatemala Women aged 15-49 years Indigenous Other Mestizo White Indigenous Ladino

24. In Bolivia the highest 20% income is 36 times the lowest 20% More inequality is related to higher infant and maternal mortality rates Maternal Mortality Ratio Infant and Maternal Mortality Rates are higher in more unequal countries Infant Mortality Ratio Source: PAHO Basic Indicators

25. Some countries have progressed decreasing the IMR in low level social economic groups Latin America and Caribbean: Infant Mortality Rates Educational level of mothers. Circa 1990 and 2005. (Selected countries) Source : ECLAC, based on data from the database of Indicators for the Action Plan of the “ICPD”, www.cepal.org/celade and national reports on demographics and health for Bolivia (DHS 2008) and Brazil (PNDS 2006) ECLAC 2007.

26. Infant Mortality Rate: Indigenous, Afro and other Populations Selected Countries of the Americas. Census 2000 Source: PAHO/ECLAC/CELADE. Special census micro-data process. 2000. Indigenous Total Afro Other Countries IMR

27. Source: Wilkinson & Pickett, The Spirit Level (2009) The Prevalence of Mental Illness is Higher in More Unequal Rich Countries

28. National health expenditure on health in LAC: magnitude and trends Source: National Health Expenditure Data base. HSS/PAHO. Changes in the composition of the National Health Expenditure. Latin America and the Caribbean, 1980 – 2005 Central Government Out of pocket expenditure Local Government Public Insurance Private Insurance 1980 1995 1990 1995 1998-2000 2004-05 National health expenditure as percentage of the GDP

29. Public source health expenditure as % of GDP Canada, LAC and USA. Selected periods 1960-2006

30. PAHO’s Role to tackle health inequities

33. We have to think in: Similar situations among countries Specific situations in each country

34. Focus Priority Country Intermediate Country Highly Developed Country Framework for Technical Cooperation Each Country has a specific situation in the Framework Addressing the unfinished agenda Protecting achievements Facing new challenges

35. PAHO’s Commitment with the MDGs

37. Amazonia Altiplano El Chaco La Mosquitia Transnational Territories

38. Monitoring Regional Progress

42. Health and Vital Statistics: Regional Situation Source: Health and Vital Statistics Regional Evaluation

43. 32 countries studied 19 (59%) - good quality and coverage data 6 (19%) - medium data quality 7 (22%) - poor or very poor data quality Mortality Data

44. Mortality Data has improved Source: Regional Health Observatory / PAHO The proportion of unknown cause of death are decreasing

45. Without good data for monitoring the MDGs, different agencies or researchers are making estimates for the Region What is the problem with estimates? We need good information

46. Variability is observed more often in small populations MDG Infant Mortality Rate: Forecasting is difficult for countries with a small population Country 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Belize 21.2 17.9 14.3 18.4 19.6 17.2 Grenada 19.5 14.3 17.6 19.6 11.1 7.3 Cayman Islands 9.1 1.6 13.7 4.8 6.4 7.0 8.7 8.3 1.3 Turks and Caicos 9.7 8.2 7.3 0.0 14.5 4.3 1.8 Virigin Islands (RU) 10.8 9.5 9.2 31.3 11.2 28.3 7.2 22.7 25.1 22.4 Saint Kitts & Nevis 13.9 14.3 17.6 15.3 13.5 21.7 14.1 Saint Vincent and the Grenadines 17.2 24.2 15.7 19.2 18.1 17.8 15.7 26.2 Saint Lucia 15.0 12.0 16.7 13.5 16.2 15.0 Trinidad and Tobago 16.2 17.1 18.5 21.1 18.5 24.2 24.0 16.5

47. red: repetitions Forecasting is difficult for countries with limited data blue: too few observations Country 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Anguilla 35.5 5.2 0 0 Netherlands Antilles 12.6 12.3 Aruba 6.5 1.5 Bermuda 3.6 0 0 Jamaica 19.9 21.09 Bolivia 67 54 54 54 54 54 El Salvador 35 35 35 25 25 25 25 21.5 Guatemala 48 39 39 39 39 39 39 Haiti 80.3 80.3 80.3 80.3 80.3 57 57 Honduras 34 34 34 34 34 23 23 23 23 23 23 Montserrat 0 0 25.0 0 0 0 23.8 0 Nicaragua 45.2 31 31 31 31 31 33 Peru 33.3 33.3 33.3 33.3 33.4 33.4 33.4 21 21 21 21

50. National Basic Indicators pamphlets

51. Special Populations Key Countries PAHO Vision Equity Pan-Americanism Technical Priorities Consensus and coordination has increased Organization of Americas States (OAS) Foundations/ Private sector We Are Not Alone On Our Journey... NGO’s Bi/Multi-Laterals

52. Thank you