Your SlideShare is downloading. ×
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Health Systems in South America: challenges to the universality, integrality and equity
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Health Systems in South America: challenges to the universality, integrality and equity

6,578

Published on

O livro “Sistemas de Saúde na América do Sul: desafios para a universalidade, a integralidade e a equidade” foi apresentado em 6 de setembro de 2012, por ocasião da VII Reunião do Conselho de Saúde …

O livro “Sistemas de Saúde na América do Sul: desafios para a universalidade, a integralidade e a equidade” foi apresentado em 6 de setembro de 2012, por ocasião da VII Reunião do Conselho de Saúde Sul-americano, instância da Unasul que reúne os 12 Ministros de Saúde do bloco, ao qual o Isags é vinculado.

A publicação está organizada em uma Introdução do Diretor-Executivo do ISAGS, o ex-Ministro da Saúde do Brasil José Gomes Temporão, e 14 capítulos. No capítulo 1, é feita uma análise transversal dos Sistemas de Saúde dos países da América do Sul e dos desafios à universalização da cobertura sanitária na região. Os 12 capítulos seguintes, referentes a cada um dos países da Unasul, foram redigidos com base nas contribuições feitas pelos próprios governos a partir de um guia metodológico composto de 11 dimensões, elaborado colaborativamente pelos países. E, por fim, é feita uma análise a respeito da cooperação regional com vistas à universalização da cobertura em Saúde e das vantagens e debilidades da Unasul para esse processo.

Published in: Education, Travel, Art & Photos
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
6,578
On Slideshare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
86
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Health Systems in South America: Challenges to the universality, integrality and equity
  • 2. SOUTH AMERICAN INSTITUTE OF GOVERNMENT IN HEALTH Executive Director José Gomes Temporão Technical Coordinator Henri Jouval MINISTERS OF HEALTH IN SOUTH AMERICA IN MAY 2012 Juan Luis Manzur - Argentina Juan Carlos Calvimontes - Bolivia Alexandre Padilha - Brazil Jaime Mañalich - Chile Beatriz Londoño - Colombia Carina Vance - Ecuador Bheri Ramsaran - Guyana Esperanza Martínez - Paraguay Carlos Alberto Tejada - Peru Jorge Venegas - Uruguay Michel Blokland - Suriname Eugenia Sader - Venezuela ISAGS EDITORIAL COUNCIL Ernesto Báscolo Juan Eduardo Guerrero Juan Garay Laura Nervi Lígia Giovanella Luis Beingolea Paulo Buss
  • 3. May 2012 Health Systems in South America: Challenges to the universality, integrality and equity
  • 4. Copyright @ 2012 ISAGS Organized by: Ligia Giovanella Oscar Feo Mariana Faria Sebastián Tobar Text translation and review: Jorge Davidson Cover and Graphic Design: Carlota Rios Editing and images: Carlota Rios and Robson Lima Photographs: Radilson Carlos Gomes Support: Amaro Grassi, Flávia Bueno, Laura Santana, Luana Bermudez, Mariana Theophilo Cataloguing-in-Source 614 S622 2012 Support: Fundação para o Desenvolvimento Científico e Tecnológico em Saude (Fiotec), Fundação Oswaldo Cruz (Fiocruz), Ministerio da Saúde Brasil ISAGS Contacts Av. Nilo Peçanha, 38 – 5° andar – Centro 20020-100 – Rio de Janeiro – RJ Telephones: +5521 2215-1858 Fax: +5521 2215-6347 e-mail: isags@isags-unasur.org www.isags-unasur.org Health Systems in South America: Challenges to the universality, integrality and equity / South American Institute of Government in Health, Ligia Giovanella, Oscar Feo, Mariana Faria, Sebastián Tobar (orgs.). Rio de Janeiro: ISAGS, 2012 852 P. ISBN 978-85-87743-20-6 1. Public Health. 2. Health Systems. I. South American Institute of Government in Health. II. Giovanella, Ligia (org.). III. Feo, Oscar (org.). IV. Faria, Mariana (org.). V. Tobar, Sebastián (org.).
  • 5. Index Prologue 8 Presentation 9 Introduction: Universal Health Systems for a World in Transformation 13 I. Health Systems in South America 21 II. Health System in Argentina 70 III. Health System in Bolivia 159 IV. Health System in Brazil 223 V. Health System in Chile 290 VI. Health System in Colombia 340 VII. Health System in Ecuador 431 VIII. Health System in Guyana 504 IX. Health System in Paraguay 541 X. Health System in Peru 588 XI. Health System in Suriname 669 XII. Health System in Uruguay 711 XIII. Health System in Venezuela 760 XIV. International Cooperation in the Building of Universal Health Systems within UNASUR: Strengths and Weaknesses 795 ISAGS Guide to Direct the Critical Analysis of Health Systems in South America 827 Participants to the Opening Workshop of the South American Institute of Government in Health 833 Participants to the Meeting of the Executive Committee in ISAGS Opening Ceremony 834 National Coordinators of the South American Health Council 834
  • 6. Prologue In the process of enacting a mandate arising from the meeting of Heads of State of the Union of South American Nations (UNASUR), the Ministers of Health of the 12 Member States of the recently created organization met for the first time in April 2009 in the city of Santiago, Chile as the Health Council of UNASUR. At this memorable meeting the bases were set for what would become, the following year in Cuenca, the Quinquennial Plan (2010 – 2015) of the UNASUR Health Council. At this meeting in Santiago, Brazil launched for the first time the idea of creating a health institute to promote training, research and technical cooperation that would support each Member State and the Union of Nations as a whole to measure the quality of intersectoral governance in health. Health is one of the main social policies of any government and legitimacy of governments is always dependent upon the good performance in the social sector, particularly in terms of health. A good government in health contributes to broaden the governability of young democracies being implemented in South America. It was therefore critical that the Health Council of Unasur could serve as support to each and every government of the Member States in the dissemination and exchange of successful health governance experiences. To fully meet those general objectives it was critical to create the South American Institute of Government in Health (ISAGS). As institute of government in health for South America, it was important that it had as an objective the formation of leadership, technical support to health systems and also the management of existing knowledge, creating new knowledge when necessary and placing this information at the disposal of health authorities in South America. In this sense, one of the first initiatives was the study and subsequent workshop on health system governance in UNASUR nations that resulted in the publication of this book that you are now reading.
  • 7. 8 HEALTH SYSTEMS IN SOUTH AMERICA At a time when multilateralism is under challenge to prove its usefulness, as noted in the criticisms to the United Nations System that has recently celebrated 60 years, Unasur emerges to reassert the importance of organizations of this nature. Trends towards multipolarity in today’s world are gaining prominence, the centrality of hegemonic power is becoming void of significance, and regionalism is acquiring historical significance. A new political and economic scenario has been emerging over the last few years with the creation of Unasur, The Bolivarian Alternative for the Americas (ALBA) and, more recently, the Community of Latin American and Caribbean States (CELAC) that actually encompasses Unasur, the Caribbean Community (CARICOM) and the System of Central American Integration (SICA). Development, reduction of asymmetries, fight against poverty, trade in local currencies, alternative to the U.S. dollar, physical and energy integration, and sovereignty (dietary and nutritional, infrastructural, energetic, productive, scientific, cultural, military and also in health) became the key principles of the new and rising paradigm. Other essential key ideas are joint international action and good governance. The Health Ministers of Unasur have been acting as a bloc in international fora such as the WHO and PAHO and presenting common positions at events as the United Nations high-level meeting on non-communicable chronic diseases and the World Conference on Social Determinants of Health, both held in 2011; and the Rio + 20 Conference in 2012. Isags, on the other hand, has supported the organization of workshops on governance as the one that gave rise to this book and, more recently, Workshops on Health Surveillance Governance, Health and the Environment in Sustainable Development and on Global Health and Health Diplomacy. These brief comments on the origin and development of Unasur Health and Isags ensure the dynamic progress of these initiatives. The demands generated at the Workshop on Health Systems have posed new challenges for their rating and would have to be addressed by the Council of Ministers and Isags. All these endeavors must be approached to ensure continuous improvement of governance in the social and health sectors, in particular, as an expression of the renewed democracy of the region. Rio de Janeiro, May 2012 Paulo M. Buss Director of the Center for International Relations of FIOCRUZ
  • 8. Presentation This book discloses a broad overview of health systems in the 12 nations that are part of the South American Health Council of Unasur. It describes the findings of the Opening Workshop of the South American Institute of Government in Health (Isags), “Health Systems in South America: challenges to the universality, integrality and equity” organized in Rio de Janeiro from July 26th to 29th , 2011. It originated in a proposal drafted by the Technical Group on Universal Health Systems of the Unasur Health Council that formulated the need of sharing a space for exchanging information related to the characteristics of health systems of the region that would also serve to unify criteria and discuss the challenges to providing health as a universal right, a concept that our countries consider as the main goal to guarantee the right to health. Isags took the responsibility to organize this workshop as its very first activity during the days following its formal opening on July 25th , 2011. The main purpose of the workshop was to foster the exchange of knowledge and a systematic and critical analysis of health systems in South America in the light of the challenges of universality, integrality and equity; identifying strengths and weaknesses that will make the process of defining cooperation lines and joint work easier. The preparation of the workshop started by developing a methodological guide which consisted of 11 dimensions to standardize the information that every country should deliver. This guide, developed by a group of experts, was discussed and validated in web conferences with the active and valuable participation of all the countries involved. Afterwards, the guide was sent to each country for data collection and preparation of the presentation to be delivered at the workshop; assessment was provided to the countries to help with the completion of the guide.
  • 9. 10 HEALTH SYSTEMS IN SOUTH AMERICA During the workshop, countries' representatives made a presentation on their health system with the aim of standardizing the information exchanged and providing full access to this information. It was decided that every country would prepare a broader explanatory document following the guide dimensions for publication. These documents make up the core of this publication which consists of 14 chapters and an Introduction based on the Opening Lecture of the workshop that underscores the challenges of universal health systems in the contemporary world. Chapter 1 provides a transversal analysis of health systems in South America and the challenges to structure universal health systems in the region. It is organized in two sections. In the first section relevant characteristics of health systems are summarized, analyzed and compared based on the dimensions selected from the facilitation guide such as the importance of health matters in the National Constitution, the structure of health systems, social protection, funding and health coverage arrangements in South American countries. In the second section, challenges to the universality, integrality and equity, including actions to be taken on social determinants of health, are examined. This analysis underlines the strengths common to all the countries and identifies weaknesses that require improvement in the region to accomplish universality with integrality and equity. The middle part of the book includes twelve chapters that analyze health systems of South American countries and documents developed by the Health Ministry of each country on the basis of the above mentioned guide composed of 11 dimensions, presented at the end of this book: 1. Social rights and health (legal bases and social participation) 2. Structure and organization of the health system (health system components, healthcare model, provision of healthcare services) 3. Current scenario in terms of universality, integrality and equity (models for population coverage, coverage of healthcare services, equity gaps) 4. Health system funding (sources of funding, public and private health expenditure) 5. Macromanagement (stewardship, policy formulation, powers of spheres of government and interinstitutional coordination, services and networks management models, healthcare services, and regulation of private health insurance and services) 6. Healthsurveillance(epidemiological,sanitaryandenvironmentalsurveillance) 7. Health workforce (gaps between the system demands and personnel supply, innovationsincontinuoustrainingandeducation,personnelmanagementmodels in healthcare, training and professional regulations, health workforce migration) 8. Action on social determinants of health (consistency between policies and action onsocialdeterminantsofhealth,intersectoralcoordinationstrategies,experiences developed, achievement of the Millenium Development Goals (MDGs)
  • 10. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 11 9. Strategic inputs to healthcare (policies on patents, investigation and innovation, price regulation, strategies for improving access to medication, national manufacturing capacities, dependence on foreign imports, evaluation for the incorporation and rational use of technology, use of Communication and Information Technology and telemedicine) 10. Research and innovation in health (national policies on health research, national institutes of health, gaps between research and system requirements) 11. Cooperation in health (strengths and weaknesses, technical support requirements, demand and potentialities) Chapter 14 summarizes the guidelines for cooperation in the building of universal health systems in the region on the basis of conclusions drawn at the workshop and proposals submitted by each country. Likewise, it seeks to identify cooperation needs and potential expertise in the areas mentioned by the countries in their national documents. We wish to express our gratitude and appreciation to all who contributed to the publicationofthiswork:theBrazilianMinistryofHealth,FiocruzInstituteandFiotec for providing funding, the Isags team for their effort in organizing the publication and in particular to all those who provided their support in the preparation of the country documents and made this publication possible. Congratulations to all the Ministers and Ministries that supported this significant initiative. Isags is proud to present this publication as a contribution to collective discussion, and to the construction and strengthening of our public health systems that are still facing significant challenges to universality, integrality and equity to guarantee the right to health of our people. This publication is the result of working together, sharing what we do and think, it is a tangible achievement: let’s use it to have a deeper understanding of each other, to find out what we are lacking and to grow stronger. Isags Board
  • 11. José Gomes Temporão1 The first point I wish to make when we think about health systems in South American countries is that these systems were historically created taking into account the disease rather than health as the core political category. Under the present historical conditions our countries are going through (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Surinam, Uruguay and Venezuela) the main focus when discussing the conception of health policies are social determinants of health. Why? Because all our systems were conceived on the basis of a biological model to control endemic diseases, through efforts that were, to a greater or lesser degree, fragmented. They were structured and based on medical knowledge centered on diseases as the reference parameter. At present, we all share the vision and the understanding that health is a socially determined political issue and that the development of the ideal health system that we all dream about should be based upon a deep and core discussion about social determinants of health. About how power and wealth are distributed in our societies, about the problem of inequities, about the need to radically develop democracy and about acting on the roots of production processes, about suffering and dying: the social determinants of health. The second point that should be underscored is that health systems are dynamic and hypercomplex structures. We can no longer think about health in our countries without considering the deep conjunctural and structural transformations our societies are experiencing in a variety of fields and dimensions reflected on their health systems. For didactic reasons we can call these transformations as the transition phenomenon in the field of public health. 1 Opening Conference of the workshop Sistemas de Salud de América del Sur: desafíos para la universalidad, integralidad y equidad, July 26th, 2011 – Inauguration of the South American Institute of Government in Health (ISAGS) Universal Health Systems for a World in Transformation
  • 12. 14 HEALTH SYSTEMS IN SOUTH AMERICA The first transition is demographic. The population in our continent is still predominantly young but we are experiencing a fast, continuous and sustained aging process. For example, it took France a whole century to reach the point that Brazil has reached in half of that time: fertility rate is dropping dramatically, life expectancy is lengthening, child mortality is diminishing, and the population is aging. These changes will cause a profound impact on our health systems because they are organized on structures designed to care for emergencies and acute conditions. Systems are not prepared to address the prevalence of chronic diseases, patients with multiple pathologies, metabolic syndrome; elderly patients who require different care, not necessarily medical, they rather need support, caretakers, nursing care. But the challenge of demographic transition is twofold: we will have to take better care of our future citizens, starting by planning the number of children and their development during childhood and follow them until old age. The second transition that is also linked to the demographic issue is the change in the epidemiological profile. We are following up the changes in the burden of diseases, morbidity and mortality profiles. Our continent has an additional aggravating factor because, apart from the increasing prevalence of chronic-degenerative diseases, there is still a significant burden of infectious- communicable diseases (double burden). The second aggravating factor and a significant one, is urban violence, homicide, interpersonal violence, a high traffic and occupational accident rates that complicate the epidemiological profile even further, a triple burden of disease in our countries. EstimatesoftheWorldHealthOrganization(WHO)revealthatinanearfuture one of the leading causes of morbidity will be senile dementia, neuropsychiatric disorders, depression and bipolar disorders. Our health systems are not prepared to address this new challenge. Even in Brazil, with a stronger health system, there is no adequate structure to provide care in these areas such as: family doctors, gerontologists, psychiatrists and psychologists. In spite of the fact that Brazil made a dramatic psychiatric reform it has yet not achieved an adequate structure to deal with this reality. Psychosocial care services are still insufficient. We have deinstitutionalized the mentally ill but have not achieved prevention. Our health systems must be prepared to deal with this new reality. The third fundamental transition that South American countries are going through is related to eating patterns. Strictly speaking, in Brazil we can no longer speak about famine or malnutrition but we cannot overlook the rise in juvenile obesity, a severe health problem. Changes in eating habits resulting from modifications in the family organization and structure in South American countries such as the rising number of women in the job market closely tied to
  • 13. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 15 profound changes in the industrialization of food production and the availability of ready or almost ready to eat meals will lead to the disruption of the traditional role of the person preparing food at home resulting in people increasingly eating out, consuming more industrialized food with high sodium, sugar and fat content. This is a new field within health regulation that also encompasses the advertising of food, beverages, fast food, etc. Recent data of the Brazilian Ministry of Health (Vigitel, 2011) reveal that 50% of the population in the country is considered to be overweight and 15% is obese. The forecasts of Type 2 Diabetes and hypertension epidemics in Brazil for the next decade depict a dramatic situation. The next dimension that requires consideration is the fourth transition, technology.Theincorporationoftechnologyinthemedicineofthefuture:biological drugs, robotics, nanodevices, therapeutic vaccines, and more personalized therapies. Genomics aims at the medicine of the future that will be predictive, personalized and preventive. Lately, adult human skin cells have been reprogrammed in induced pluripotent stem cells. But all of these possibilities are for the future. Reality is at present more dramatic. We live in a world divided into casts of citizens that either have access or not to modern technology. This scene appears once and again in every single one of our countries. The pharmaceutical industry is facing the dilemma of either having to launch new products and the actual chances of launching new molecules. The very few novelties launched to the market are protected by patents leading to unbearable costs that health systems all over the world cannot afford and that will cause a huge financial collapse in all the health systems of Unasur countries, threatening the sustainability of our health systems. The fifth transition our countries are experiencing is cultural, extremely complexandparadoxicalthatactuallyunfoldsintoseveralaspects.Somearepositive aspects when we see the tremendous dissemination of health information in the media that, in principle, should improve the level of information of our people about health promotion and prevention. But at the same time this wide access to health information brings about negative effects because many spaces in the media are actually supported by economic interests and strategies of the medical- industrial complex, the food industry, cosmetics, beverages, health insurance plans characteristic of a cultural process that conveys a negative dimension of health policy awareness.
  • 14. 16 HEALTH SYSTEMS IN SOUTH AMERICA Also, in relation to the cultural aspect, Internet appears as a new factor that complicates things further. Dr. Google is the most famous family doctor. When patients go to see their doctor they bring many printed pages on the disease they suspect they are suffering from. They sit in front of their doctor and say, “Doctor, this is the disease I am suffering from, what are you going to do to solve my problem?” They come with the diagnosis they have found over the web. Karl Marx used to say that production does not only produce an object for a subject, it also produces a subject for that object; that is to say, that production needs are internalized in individuals as if they were individual needs. That is how consumption, self-medication, medicalization standards are built. This is a complex process with positive and negative sides. But what I wanted to do is to simply point out at the fact that our health systems have to be able to properly deal with the communication and information dimensions. Our systems should learn how to use information and communication to build up a critical and political awareness in our citizens so that they will no longer be at the mercy of whatever is published or broadcast in the media by economic interests, corporations and industrial sectors. Education and adequate information are required to build up the new political awareness. This is not a matter for specialists only, it is for society as a whole. Thisculturaldimensionofpublichealthisintimatelyrelatedtoamedicalization process that is expressed in the expansion of the normative frame of medicine where healthy childhood, adolescence, adult life, tourists, the elderly, sexuality have become spaces for the intervention of medical knowledge. Within this dimension we also face the problem of judicialization of health, a phenomenon that is present in every one of our countries. The population is stimulated to resort to legal actions to demand their rights or what they consider their rights are, mainly in the area of pharmaceutical assistance programs. However, at this point it is necessary to make an epistemological differentiation between right, need and desire. If health is included in National Constitutions as a right and we have a health system structured to address the needs of the whole population, on the other hand, there are mechanisms that create desires and such desires are many times non defendable from the points of view of science, ethics and equity. But individuals resort to the law in search of defending the guarantee of this desire that it is not necessarily a right or a need.
  • 15. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 17 The sixth important transition that South American health systems are going through is organizational: it is not just a matter of managing health units, policlinics or hospitals; it is rather related to organizing networks, institutions, in an integrated and articulated manner. Meanwhile, this setting up of networks not only demands knowledge in the field of planning, management and information, etc., but it also requires sophisticated connection technologies using defined methodologies. This is because networks are formed by people who establish links or bonds. It is a slower process that demands what we could call the structuring of a health related complex. Present at this space of intervention are the co-responsibility, the participative management, the expanded clinic. This matter of managing knowledge, of placing knowledge at the disposal of health professionals and organizations is a key aspect. If we think positively about the future of our countries, the issue of innovation should be the core of our concerns. Health systems with a greater capacity for innovation will yield better outcomes. At present, health systems can be considered as outdated to face all these new complexities expressed by all the above transitions, the new life styles of this new society, of this new family. To innovate we also need to think again, revitalize our democracy. It is critical to pay attention to what is happening in the East and in Spain, and in countries where the younger population are strongly criticizing the economic decisions that have led to structural unemployment. These young people are demonstrating in the streets, holding permanent assemblies, struggling for democracy. We have to deepen the democracies of our countries, qualify and renovate them to be able to also renew our health systems. What are the key parameters for the innovation of health systems? If we understand that organizations and institutions are the product of human effort we have to immediately think about healthcare professionals. The greatest innovation capacity will also depend on the capacity that health professionals have of translating the needs of the population and incorporating them in developing and perfecting institutions. But this conquest is directly related to the quality of the education and training of these health professionals. At present, in a health system where physicians are being taught to pay more attention to machines than to patients, where healthcare professionals are forgetting to examine and touch patients; where physicians reduce the listening time to a minimum, the treatment effect of the “first drug” administered to every patient is avoided: the therapist himself. Medicine is not only evidence-based but also narrative-based! Under these conditions, the ability of young physicians and other professionals to innovate and have a critical vision of health systems is losing quality; it is becoming poorer and poorer. Systems with greater capacity for innovation will
  • 16. 18 HEALTH SYSTEMS IN SOUTH AMERICA therefore be the ones that build up new possibilities in the training of health professionals and those that protect direct democracy and participation of the population in the formulation of policies, in the control and monitoring of health services quality; that is to say, that democratization of society and social participation in institutional spaces of the health system are essential. But it is worth pointing out that when social participation is institutionalized as is now happening in the Health Councils (national, state and municipal) of Brazil the capacity to be critical, innovative and bold is partially lost. This is practically inevitable: the State apparatus is penetrated and autonomy is lost. We actually have to rethink how to organize large democratic spaces to renew health systems, which will also have a greater capacity for self-innovation the farther away they turn from disease and the closer they approach health, the more they dialogue with other sciences, other knowledge and policies. Working with other sectors and cross-sectioning are essential categories to be able to approach health from a broader and more integrated perspective. How can we think about health today without thinking about education, scientific and technological development or without thinking about other social and economic policies that directly and indirectly have an impact on health? The greater the openness of the Ministries in charge of health to this debate with other areas and other dimensions, the stronger their innovation capacity will be. The seventh transition could be called economic, scientific and of innovation. Lately, in Brazil, we have been building something new in the way we think about the relationship between health and development. We have to understand that health has an intrinsic dualism that differs from any other public policy: it is, at the same time, a fundamental policy to improve living conditions but it is also an economic and extremely important dimension that generates jobs, development and innovation. The available international estimates presented at the Global Forum for Health Research in 2006 indicate that health accounts for 20% of the world’s public and private expenditure where research and technological development account for an updated 135 billion dollars, clearly one of the most dynamic areas of research and development in the world. Health, therefore, has two dimensions that jointly offer new opportunities for the development of our countries. Health is part of the social policy and of the system of social protection and, at the same time, a source of wealth creation. The right to health articulates with a highly dynamic set of economic activities that can virtuously relate to a standard of development seeking economic growth and equality as complementary objectives.
  • 17. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 19 From this perspective, understanding the actions oriented towards health promotion, prevention and care as a burden on public budgets is limited. It is necessary to consider health as part of the development strategy and as a moving front towards a new standard of development committed to social well-being and sustainability. Health contributes as much to the rights of citizens as it does to the creation of investment, innovation, income, employment and tax collection for the State. In economic terms, the healthcare supply chain encompassing industrial activities and services accounts for over 9% of my country’s GDP, an important source of tax income. Its direct jobs, with formal qualified work positions, account for 10% of the jobs in our country and it is the area where public investment in research and development is more expressive. According to the estimates of the Brazilian Institute of Geography and Statistics (IBGE) in terms of direct and indirect employment in the whole production chain, the set of activities related to healthcare represents about 10 million workers predominantly dedicated to knowledge-intensive activities. The great challenge ahead is whether we will or will not have a structured policy to develop this economic-industrial health complex; if we are only going to remain at the mercy of the interests of large corporations or if we are going to build a proactive policy to place this industrial dynamics at the disposal of development and public health. We have to build a strategic vision for the industrial complex, we must discuss from within how we are going to access new technologies and knowledge. How we are going to access new, appropriate and profitable technologies that will have a direct impact on our health problems; by thinking about it within the dimension of innovation, research and development. Last year (2010) the sectoral trade balance, the difference between everything Brazil imported and exported in all the health-related industries was negative by 10 billion dollars. If we made the same calculation in the trade balance for the 12 countries the deficit would be even more meaningful. If the economic dimension is serious, it actually discloses something that is even more serious, knowledge deficiency; our inability to internally develop technology to face our main health problems. Therefore, it is necessary to develop industrial, science and technology and health policies conceived in an integral manner so that they generate investments, to deploy within each of our countries the technologies we need, defined by clinical guidelines based on our own realities, our populations, our health requirements, our actual patients. Finally and coming to the end of this conference, when we ponder on the challenges ahead to consolidate universal health systems, we must necessarily contemplate the following issue: it is a political process of building and maintaining hegemonic power. How can we build into the society a political awareness of the
  • 18. 20 HEALTH SYSTEMS IN SOUTH AMERICA value of health as a right and not as something you buy or you have access to depending on your social class or economic status? In Brazil, during the Military dictatorship in the 70’s, within what was called the Movement for the Brazilian Health Reform, the health sector managed to include practically all the reformist agenda in the National Constitution. But at this point in time we are amidst a political- ideological struggle to defend the maintenance and sustainability of this universal public health system because there are sectors in the Brazilian society that attempt to transform their vision on the health system, very close to the American model, the market model, completely opposite to what we believe is necessary to assure the universal right to health into the hegemonic model. We are amidst this struggle to defend the Brazilian universal health system. A good example is the 30 million Brazilians who recently migrated from social classes D and E to class C, as a result of the increase in minimum wage and the income transfer programs, they are now being instructed by the media (in multiple dimensions) that private health is more sophisticated and that buying a prepaid health insurance plan is part of the process of social advance. This situation weakens the public health policy as a right. Reversing this vision is our greatest challenge. Health systems are hypercomplex organizations under continuous change. Understanding them in the light of the transitions that the public health system is experiencing is essential to establish policies that will bring together the health sector dynamics to the interests of the population. It is essential to participate in its operations by enabling society to have a stronger role in monitoring its performance. Establishing cross-sectoral, transversal policies to interact with other fields of knowledge will strengthen our ability to reduce inequities. Thank you.
  • 19. I. Health Systems in South America Ligia Giovanella, Gabriela Ruiz, Oscar Feo, Sebastián Tobar, Mariana Faria INTRODUCTION The Health system is the sum of all the organizations, institutions and resources whose primary purpose is to improve health (WHO, 2000). In broader terms, health systems are the set of political, economic and institutional relations responsible for leading health-related processes expressed in organizations, standards and services with the purpose of reaching results consistent with the conception of prevalent health in society (Lobato and Giovanella, 2008). It is generally assumed that the health system is a set of actions, standards and persons whose activities are directly or indirectly related to individual and collective healthcare. It is important to highlight that a fundamental component of health policies is the organization and funding of health systems and that this concept reaches far beyond health services or healthcare. Another important concept is the historical and temporal character of health systems as a concrete response that a nation or community constructs to meet health needs and demands of its population. This response is undoubtedly related to the conception that health prevails in that society. From this perspective, there are two confronting and polarized positions in the world and in the South American region as well: on the one hand health is understood as a fundamental human and social right, stemming from the right to life, that must be assured by the State; and on the other hand health is understood as a market service or good ruled by the supply and demand laws where the State should only intervene to provide healthcare for the poorest, the excluded from the social dynamics. The latter is the understanding that dominated the sectoral agendas derived from the Washington Consensus that prevailed in the 90’s and was promoted by multilateral financial organizations. Reforms implemented under this vision favoured healthcare privatization and deepened inequalities in Latin America (Laurel, 2010; Feo 2003; Almeida, 2002).
  • 20. 22 HEALTH SYSTEMS IN SOUTH AMERICA We could say that there are four main components in a health system: i) health policies and norms framed within the larger social and economic development policies defined by the State and society; ii) health professionals, technicians and the people who make up the system; iii) the network of services and their models of care and management; and iv) the inputs and supplies required to meet the objectives. The dynamics and interrelationship of these components is given by the way services are funded, managed, regulated and provided. Additionally, when we speak about health systems it is essential to not only think about policies, institutions, resources, funding, standards or formal structures but about the participation processes, the leading role of the community, users, key actors involved in the production of their own health and in everything else that in their perception and understanding is part of health, including traditional medicine of nations. That is why a health system should be understood as a historical and social construction and as the concrete responses generated by a society to meet health needs of its people with the main purpose of promoting and maintaining health. Organization and Typology of Health Systems Approach to health has been variable throughout history, it was conceived by the aboriginal cultures as an unbreakable part of life but later on it was associated to a vision that reduced the idea of health to disease and cure, hospices and charity institutions basically to look after the poorer. From the institutional point of view, in Latin America, health systems emerged in the first half of the 20th  century with policies mainly focused on controlling epidemics related to the growing trading of merchandise that decimated populations and hindered economic interests (Rovere, 2007; Cueto, 2007). The first Ministry of Health (MoH) of the Latin American region was opened in Cuba dating back to 1902, the year of the creation of the Pan American Health Organization as the “International Sanitary Office”, later on the Pan American Sanitary Office (1923). The first MoH in South America was created in Chile (1932) followedbyPeru(1935),VenezuelaandParaguay(1936);thelastministry wascreated in Ecuador (1967). Simultaneously and under the influence of Bismark thinking, social security systems were created to look after people on wages under formal work relations and sometimes after their families. At the end of the 19th  century, Germany was facing the boom of industrialization and the struggle of workers in search of better working conditions. There were claims coming from political and academic sectors and therefore it became critical to implement measures that would guarantee the stability of the system. This situation led the German Chancellor Bismarck to propose a set of laws that to this date are the basis of many
  • 21. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 23 social security systems. That is how the compulsory and paid security systems were created only restricted to the working class. The systems covered disease, accidents, disability and old age and were funded by the State, employers and workers. Later on this system was extended to cover workers’ families and to other areas such as education and housing, not only in Germany, it extended to other countries as well. Years later, Beveridge in England took social security a step further and provided it with a more universal and integral character. His report in 1942 proposed extending the benefits of social security to all the population as a social right based on solidarity that would force society and the State to provide a minimum welfare regardless of the payments made by each individual to fund the services. Under this approach health must be mainly covered by the State with fiscal resources. This is the prevailing model of national health services in the United Kingdom and several other European countries. In the 80’s, Terris (1980) used to characterize the world health systems as: i) public healthcare, generally (under)funded with public funds; ii) insurance targeted to specific sectors of the population (workers) and financed by the contributions of insurance holders and/or their employers; iii) universal health systems that guarantee the total populational and service coverage with State funding. In Latin America what predominates is fragmented and segmented systems that coexist with the Bismark like social security systems that are difficult to place in context within a reality where informal and precarious work prevails (Sojo, 2011; Levcovitz, 2005). Health System that Served as the Basis for the Guide Isags developed a specific guide for the presentation and analytic description of health systems in South America –introduced at the end of the Book– based on an encompassing concept of health systems understood as the set of organized social responses to address health needs, promote, restore and maintain health of the population in every country at any specific historical time. The guide is also grounded on the view that health is a human right, essential for the development and that must be assured to all, being the main responsibility and duty of the State together with citizenship participation. In this regard, many of the countries in Unasur have also been fostering processes to expand rights and to build up citizenship in all their people. The health system apart from taking actions aimed at people in health services, involves actions directed to all the communities in every dimension of health surveillance, and is influenced by factors external to health services such as the industry of health supplies, biomedical equipment and drugs, the institutions that
  • 22. 24 HEALTH SYSTEMS IN SOUTH AMERICA generate knowledge and technology, and institutions in charge of training human resources (Viacava et al., 2004; Lobato and Giovanella, 2008). Several dimensions of health systems were taken into account in the development of the guide because it is assumed that government intervention in health is composed by several dimensions: a social protection dimension, an economic-industrial dimension and a political dimension (Moran, 1995). The social protection dimension is related to the role of the State in regulating and guaranteeing access of all citizens to health services as a social right of citizenship; that is to say, the access to health services in the construction of social citizenship as part of the Welfare State (Moran, 1995). The economic/industrial dimension involves all the companies, facilities and industries related to the production of supplies and the provision of healthcare services, the so called “health production complex.” Health is an important sector of the economy in South America as well, with a total expenditure that ranges between 4% and 9% of the GDP. Government intervention in the economic field of health is under continuous strain. On the one hand, the Government is in the midst of a trend towards rising production costs of health service production due to the increase of the demand attributed to changes in the demographic and epidemiological structure and to the excessive incorporation of technology without an adequate evaluation, while trying to reduce spending and reform the funding models in view of the need to contain expenditure in the public sector seeking for higher efficiency. On the other hand, it is interested in the economic growth, and the industrial and technological development of the country. Therefore, the State is simultaneously under the pressure of the industry to increase the demand in this sector (Moran, 1995; Viana and Baptista, 2008). The political dimension involves a significant constellation of actors, disputes for the allocation of resources in the health sector and access to the information. This point refers to the conflict arising among users, providers, insurers, funding agencies and regulators of health services (Moran, 1995; Viana and Baptista, 2008). A characteristic of the health system is the number and variety of actors and roles that add up to determine its complexity. In order to include all these dimensions the guide developed by Isags contemplated the analysis of social protection, social participation, innovation, research and strategic inputs for health. It is also understood that the national health policy should create the conditions to assure a good health for all citizens where every sector of society should be involved but the leading responsibility remaining in the hands of the State (Navarro, 2007). It is necessary to act on the more general social determinants of health/disease processes through coordinated efforts of all the social sectors and segments because the right to health depends on the model of economic
  • 23. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 25 and social development of each country (Raphael and Bryant, 2006) and on the intensity of social inequalities. In order to assure good health a national health policy should include interventions on: political, social and economic determinants, life style determinants, and socialization and empowerment determinants, to allow people to participate and demonstrate for the sake of a good health, states Navarro (2007). That is why the Isags guide included interventions on social determinants apart from the social participation strategies mentioned. Oriented by these conceptions about health policies and systems, the guide developed to facilitate the analytic description of health systems by the Ministries of Health of the twelve countries in the region consists of eleven dimensions: 1. Social rights and health: legal basis and social participation. 2. Health system structure and organization: health system components, healthcare model, provision of healthcare services. 3. Currentstatusintermsofuniversality,integralityandequity:socialprotection, model of the population coverage, coverage of services, equity gaps. 4. Health system funding: funding model, sources of funding, public and private expenditure in health. 5. Macromanagement: stewardship, policy formulation, powers of spheres of government and interinstitutional coordination, services and networks management models, healthcare services and private health insurance regulation. 6. Health surveillance: epidemiological, sanitary and environmental surveillance, implementation of the International Sanitary Regulations (ISR). 7. Health workforce: gaps between the system demands and personnel supply, innovations in continuous training and education, personnel management models in healthcare, training and professional regulations, health workforce migration. 8. Action on social determinants of health (SDH): consistency between policies and action on social determinants of health, intersectoral coordination strategies, experiences developed, reaching the Millenium Development Goals (MDGs). 9. Strategic inputs to healthcare: policies on patents, investigation and innovation, price regulation, strategies for improving access to medication, national manufacturing capacities, dependence on foreign imports, evaluation for the incorporation and rational use of technology, use of Communication and Information Technology and telemedicine. 10. Research and innovation in health: national policies on health research, national institutes of health, gaps between research and system requirements. 11. Cooperation in health: strengths and weaknesses, technical support requirements, demand and potentialities.
  • 24. 26 HEALTH SYSTEMS IN SOUTH AMERICA ThischapterprovidesatransversalanalysisofhealthsystemsinSouthAmerica that highlights the relevant characteristics of health systems in South American countries and the challenges to build universal health systems. It summarizes the dimensions selected and developed in the Isags Guide: the place health occupies in the National Constitution, the building of health systems, funding models, social protection and coverage in health, strategic inputs and actions on social determinants of health. This analysis underlines the strengths common to all the countries and identifies the weaknesses that require improvement in the region to accomplish universality of health with integrality and equity. CHARACTERISTICS OF HEALTH SYSTEMS IN SOUTH AMERICA Constitutional Framework of Health The national constitutions of South America conceive the right to health from different approaches. Half of the South American national constitutions consider health as a universal right. Such is the case of Bolivia, Brazil, Ecuador, Paraguay, Surinam and Venezuela. Other countries refer to this right in general terms, others relate it to the social determinants of health, and others include an voiced concern about the right to health also as a guarantee of access to health services. The Brazilian National Constitution of 1988 mentions health as the right of everybody and as the duty of the State, that must be assured by social and economic policies aimed at reducing the risk of disease. It recognizes the social determination of health and the State’s responsibility in assuring universal and equitable access to health actions and services, promotion, protection and recovery. Countries that have recently had their constitutions reformed as Venezuela (1999), Bolivia (2009) and Ecuador (2008) have been particularly diligent in including health as a right of all citizens and a responsibility of the State coming to the point of promoting reforms to the existing health sector in the attempt to guarantee this right. In other countries of the region health is not mentioned as a constitutional right but the Constitution guarantees health protection through ensuring universal access or else, the adherence to international instruments that consider health as such. Uruguay does not include the right to health in its Constitution (1997) but it is stated as a right in the Law passed to create the Integrated National Health System (SNIS) in 2007. Finally, some countries still maintain their National Constitution without any statement about health as a right or a responsibility of the State. The identification of principles and values that should guide the organization of the health system seems to be a recently adopted element. Countries with recent constitutional reforms clearly mention what values and principles will guide the organization of their health system. Among the principles and values mentioned,
  • 25. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 27 Argentina National Constitution in force: 1994 The right to health is not mentioned in the Constitution as such but the constitution states that it adheres to the Universal Declaration of Human Rights (Article 25) and the International Covenant on Economic, Social and Cultural Rights ratified by Argentina in 1986. Thus health appears as a right through the adherence to international instruments ratified by the country. Bolivia National Constitution in force: 2009 – New Political Constitution of the Plurinational State of Bolivia Article 18: Every person has the right to health. The State guarantees inclusion and access to health to all people without any discrimination whatsoever. The Unified Health System will be universal, free of charge, equitable, intracultural, intercultural, participative, with quality, warmth and social control. The system is guided by the principles of solidarity, efficiency and co-responsibility and is developed through public policies at every government level. Article 35: The State, at all levels, will protect the right to health by promoting public policies oriented towards improving the quality of life, collective wellbeing and free access of the population to healthcare services. The health system is unified and includes traditional medicine of the aboriginal nations and country people. Article 36: The State will guarantee access to the Universal Health Insurance. The State will be in charge of controlling the performance of the public and the private services and regulate them through the law. Principles and values: The New Political Constitution of the State defines the following as supreme values: human dignity, fairness, equality, freedom and political pluralism. The ethical- moral principles of a plural society are: ama ghilla, ama llulla, ama suwa (don’t be lazy, don’t be a liar, don’t be a thief) suma gamaña (live well) ñandereke (live in harmony), teko kavi (good life) inimaraei (earth without evil) and ghapaj ñan (noble path or life). Brazil National Constitution in force: 1988 Article 196: Health is the right of everybody and the duty of the State, guaranteed by social and economic policies aimed at reducing the risk of disease and other damages and providing universal and equitable access to health actions and services for health promotion, protection and recovery. Article 198: Health actions and public services are integrated into a regional network divided into hierarchies forming a unified system organized in accordance with the following guidelines: decentralization, with a single authority in every sphere of government; integral care, priority given to preventive actions, without working against healthcare services; community participation. The Unified Health System (SUS) has the following guidelines: the universal right to integral, preventive and curative care at every level of complexity of the system, social participation and decentralization. some are recurrent in all the countries, like universality, equity, integrality and social participation. The identification of interculturality as the guiding principle in the organization of the health system in countries like Ecuador, Paraguay, Bolivia and Venezuela deserves a special mention. Chart 1 below provides information about the approach to health in the national constitution, detailed by country, and the guiding values and principles of the health system. Chart 1 – Health in the National Constitutions in force in South American countries Constitutional framework of health Principles and values of the mentioned health system Country
  • 26. 28 HEALTH SYSTEMS IN SOUTH AMERICA Chile National Constitution in force: 1980 Article 19 § 9: The right to health protection. The State protects the free and egalitarian access to actions of health promotion, protection and recovery as well as rehabilitation of the individual. The State will likewise be in charge of coordinating and controlling actions related to health. It is the preferential duty of the State to guarantee that health actions be taken whether in the public or private sector in the form and conditions determined by the law that may establish payroll taxes. Every person will have the right to choose the health system they wish to use, whether public or private.” Colombia National Constitution in force: 1991 Article 48 defines social security as a public, obligatory service and as an unredeemable right of all inhabitants that will be provided under the direction, coordination and control of the State subject to the principles of efficiency, universality and solidarity under the terms established by the Law. Article 49: Healthcare and environmental sanitation are public services in charge of the State. Everyone is guaranteed access to health promotion, protection and recovery. It will be the State’s duty to organize, direct and regulate the provision of healthcare services to all the inhabitants and to look after environmental sanitation in compliance with the principles of efficiency, universality and solidarity. Also, under the terms set out by the Law, to establish policies for the provision of healthcare services by private organizations in charge of its surveillance and control. The State will also be responsible of setting the competences of the Nation, the territories and individuals and will determine the funding under its responsibility and in compliance with the terms and conditions set out by the law. The health services will be organized in a decentralized manner according to the level of care and with participation of the community. The law will determine the terms under which basic care for all inhabitants will be obligatory and provided free of charge. Every person has the right to obtain integral care of their own health and their community’s. Ecuador National Constitution in force: 2008 Article 32: Health is a right guaranteed by the State that is linked to other rights; among them is the right to water, food, education, physical culture, work, social security, healthy environments and others required to sustain well-being. The State will guarantee this right through economic, social, cultural, educational and environmental policies; continuous, timely access without exclusion to programs and services related to health promotion and integral care, sexual and reproductive health. Article 362: Public health services provided by the state will be universal and free of charge at every level of care and will include diagnosis, treatment, medication and rehabilitation as necessary. Principles: equity, universality, solidarity, interculturality, efficiency, efficacy, precaution and bioethics with a gender and generational approach. Guyana National Constitution in force: 1980, Constitution of The Co-Operative Republic of Guyana Article 24: Every citizen has the right to have access to free medical care and to social services at an elderly age or when affected by disability. Article 25: “Every citizen has the duty to participate in actions aimed at improving the environment and protecting the health of the Nation. Principles and values: health as a fundamental right, co-responsibility of the government and of citizens, equity, priority for health promotion, fast provision of effective and efficacious services, transparency. Chart 1 – Health in the National Constitutions in force in South American countries (cont.) Constitutional framework of health Principles and values of the mentioned health system Country
  • 27. UNIVERSAL HEALTH SYSTEMS FOR A WORLD IN TRANSFORMATION 29 Paraguay National Constitution in force: 1992 Articles 6, 7, 68, 69 and 70 of the Constitution refer to the Right to health: The State will protect and promote health as a fundamental right of people and for the interest of the community. Nobody will be deprived of public healthcare to prevent or treat diseases, pests or plagues or of receiving aid in situations of catastrophes or accidents. Every person is obliged to be subjected to the sanitary measures established by the law provided they are imparted with respect to human dignity” (Art. 68). Another article refers to quality of life. It recognizes conditioning factors such as extreme poverty and proposes investigating population factors and their links to economic and social development, environmental preservation and quality of life of the inhabitants (Art. 6). The right to a healthy environment is included in Art. 7. Art. 69: refers to the National Health System as the executor of integrated sanitary actions that sets up, coordinates and complements programs and resources of both the public and private sector. As of 2008 the process of reorienting the National Health System is founded on the guiding principles of: universality, equity, interculturalism, integral care with social participation. Peru National Constitution in force: 1993 Article 7: The right to health and the protection of the disabled: Everyone has the right to the protection of their health, their family´s and their community´s, as well as the duty to contribute to its promotion and defense. People unable to look after themselves due to physical or mental conditions have the right to dignity respect and to a legal protection, care, re-adaptation and security scheme. Suriname National Constitution in force: 1987 Article 36: Everyone has the right to good health. It is the State responsibility to promote general healthcare through continuous improvement of living and work conditions and to report measures of health protection. Uruguay National Constitution in force: 1997 Article 44: Every inhabitant has the right to look after his or her own health as well as to seek care in case of illness. The State will provide all the means for prevention and care free of charge only to those who are poor or lacking sufficient resources. Competence of the State to define the health policy. Law 18211 of 2007 creates the Integrated National Health System and defined health as a right of all people residing in the country – universalization of coverage. Venezuela National Constitution in force: 1999 Article 83: Health is a fundamental social right; it is the State obligation to guarantee it as part of the right to life. The State will promote and develop policies aimed at improving the quality of life, collective well-being and access to health services. Everyone has the right to protect their own health as well as the duty to actively participate in its promotion and defense and of complying with the health and sanitation measures set out by the law. Article 84: In order to guarantee the right to health, the State will create, exert stewardship and manage a public national health system that will be intersectoral, decentralized, participative, integrated with the social security system, ruled by the principle of being free of charge, universality, integrality, equity, social integration and solidarity. Principles and values: Solidarity, universality, integrity, unification, citizenship participation, co-responsibility, free of charge, equity, and multiethnic, pluricultural and multilingual sense of belonging in the design and execution of health policies, plans, services and programs. Chart 1 – Health in the National Constitutions in force in South American countries (cont.) Source: Drafted from the information of chapters 2 to 13 of this textbook and the review of National Constitutions in force. Constitutional framework of health Principles and values of the mentioned health system Country
  • 28. 30 HEALTH SYSTEMS IN SOUTH AMERICA Government Spheres and Health System Structure All the countries in the region have democratic governments with different types of territorial, political and health system organizations and different degrees of decentralization. Three countries have a federal organization (Argentina, Brazil and Venezuela). The remaining nine countries have a unitary-type of organization that, in general, is decentralized. Bolivia and Ecuador, as of the enforcement of the new national constitutions (2009 and 2008), define themselves as Plurinational States and Guyana defines itself as a Cooperative Republic. Some countries base their health system organization on a federal structure under which the State is organized. Such is the case of Argentina where health is not delegated by the Provinces to the National State and the provinces have a high degree of autonomy. However, the National State exerts a significant role as steward, coordinator and regulator with a normative function and there are formal instances such as the Federal Health Council (COFESA) created in 1981 as the forum to meet and articulate the inter-jurisdictional powers of the country. Brazil, which is also a federally organized country, has three federal agencies bearing the responsibility on health. Each government sphere has a single authority but seeks to act in concert with the other spheres through Inter-management Committees; it is tripartite at National level (involving the Union, the states and municipalities) and bipartite at state level (state and municipalities). Bolivia, one of the countries that recently reformed its health sector has four spheres of government involved in the administra