Has Latin America achieved universal health coverage yet? Lessons from four countries.

BACKGROUND: Seven years after the commitment to United Nations' call for Universal Health Coverage, healthcare services in Argentina, Brazil, Colombia, Mexico are generally accessible and affordable; but they still struggle to meet population health demands and address the rising health care costs. We aim to describe measures taken by these four countries to commit by Universal Health Coverage, addressing their barriers and challenges. METHODS: Scoping literature review, supplemented with targeted stakeholders survey. RESULTS: The four countries analysed achieved an overall index of essential coverage of 76-77%, and households out of pocket health expenditures fall below 25%. Services coverage was improved by expanding access to primary healthcare systems and coverage for non-communicable diseases, while provided community outreach by the increase in the number of skilled healthcare workers. New pharmaceutical support programs provided access to treatments for chronic conditions at zero cost, while high-costs drugs and cancer treatments were partially guaranteed. However, the countries lack with effective financial protection mechanisms, that continue to increase out of pocket expenditure as noted by lowest financial protection scores, and lack of effective financial mechanisms besides cash transfers. CONCLUSIONS: Argentina, Brazil, Colombia, and Mexico have made progress towards UHC. Although, better financial protection is urgently required.

Interchangeability between Pneumococcal Conjugate Vaccines: A Systematic Review and Meta-Analysis.

OBJECTIVES: To assess the efficacy, cost-effectiveness, immunogenicity, and safety related to the interchangeability between pneumococcal conjugate vaccines (PCVs) and vaccination schedules in pediatric population. METHODS: Systematic searches were conducted in December 2010 and April 2015 for economic evaluations in MEDLINE, EMBASE, LILACS, and Cochrane Central Register of Controlled Trials. Web sites and databases from medical societies, experts, and associations related to the topic, proceedings or congressional annals, and doctoral theses were also searched. No language or temporal restriction was applied. We included randomized controlled trials, economic evaluations, and systematic reviews evaluating antibody response, cost-effectiveness, and effectiveness of PCVs' interchangeability. A Strengthening the Reporting of Observational Studies in Epidemiology-based checklist was used to assess the risk of bias in observational studies and a Cochrane approach for experimental/quasi-experimental studies. Pairs of reviewers independently selected (through the Web-based Early Reviewer Organizer Software), assessed the quality, and extracted the data of the studies. Discrepancies were resolved by consensus. We planned to perform meta-analysis whenever appropriate. RESULTS: Forty-six of 202 studies were included. There was no direct information available on the interchangeability between PCVs. The immunogenicity and safety between the 10-valent PCV (PCV10) and the 7-valent PCV were similar when both vaccines were coadministered with other routine pediatric vaccines. PCV10 and 13-valent PCV (PCV13) were consistently more cost-effective than 7-valent PCV. CONCLUSIONS: There was no direct comparative information available on the interchangeability among PCVs, but they have pretty similar immunogenicity and safety. PCV10 versus PCV13 cost-effectiveness varied according to price, indirect effects, and indirect costs. PCV10 gains more quality-adjusted life-years because of the prevention of more frequent yet less severe events such as otitis media, and PCV13 prevents less frequent but more costly events such as invasive diseases.

Cost effectiveness evaluation of a rotavirus vaccination program in Argentina.

BACKGROUND: Rotavirus diarrhea is one of the most important vaccine-preventable causes of severe diarrhea in children worldwide. There are two live-attenuated virus vaccines licensed, Rotarix (RV1) a monovalent vaccine by GlaxoSmithKline and a pentavalent vaccine, RotaTeq(RV5), by Merck & Co., with similar results. This study aim was to evaluate the cost-effectiveness of the utilization of RV1 compared with RV5 in Argentina. METHODS: A deterministic Markov model based on the lifetime follow up of a static cohort was used. Quality Adjusted Life Years (QALYs) as a measure of results, the perspective of the health care system and a 5% discount rate for health benefits and costs has been used. A review of the literature to obtain epidemiologic and resources utilization of rotavirus diarrhea was performed. The sources used to estimate epidemiologic parameters were the National Health Surveillance System, the national mortality statistics and national database of hospital discharges records. Costs were obtained from different health subsectors and are expressed in local currency. RESULTS: Both vaccination alternatives were less costly and more effective than the strategy without vaccination (total costs $ 69,700,645 and 2575 total QALYs lost). When comparing RV1 vs. RV5, RV1 was less expensive ($ 60,174,508 vs. $ 67,545,991 total costs) and more effective (1105 vs. 1213 total QALYs lost) than RV5, RV1 being therefore a dominating strategy. Probabilistic sensitivity analysis showed results to be robust with a 100% probability of being cost-effective at a WTP threshold of 1 GDP per capita when comparing the RV1 vs. no vaccination. CONCLUSION: Both RV1 and RV5 schedules dominate the no vaccination strategy and RV5 was dominated by RV1. This information is a valuable input regarding the incorporation of this kind of vaccines into the national vaccination programs.

Epidemiology of Malaria in Latin America and the Caribbean from 1990 to 2009: Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this study was to evaluate the burden of malaria in Latin America and the Caribbean countries through a systematic review and meta-analysis of published literature, gray literature, and information from countries' public health authorities for the period 1990 to 2009. METHODS: The random-effects meta-analysis of the prospective studies, carried out in very highly endemic areas, showed an annual incidence rate of 409.0 malaria episodes/1000 person-years (95% confidence interval [CI] 263.1-554.9), considering all ages, which was 40-fold the one estimated from areas with passive surveillance only. RESULTS: Overall, the most prevalent species was Plasmodium vivax (77.5%; 95% CI 75.6-79.4) followed by Plasmodium falciparum (20.8%; 95% CI 19.0-22.6) and Plasmodium malariae (0.08%; 95% CI 0.07-0.010). Data from regional ministries of health yielded an estimated pooled crude annual mortality rate of 6 deaths/100,000 people, mainly associated with P. falciparum. CONCLUSION: This study represents the first systematic review of the burden of malaria in Latin America and the Caribbean, with data from 21 countries.

Preconception care: it's never too early.

The preconception window has been recognized as one of the earliest sensitive windows of human development, and interventions that focus on this period have the potential to affect not only pregnancy but long term outcomes as well. The journal Reproductive Health has published a supplement entitled 'Preconception Interventions' which includes a series of systematic reviews regarding the impact of public health interventions during the preconception period on maternal and child health. These articles describe the role that poor preconception health plays in creating health disparities across the globe. The reviews highlight our current understanding (or lack thereof) regarding how both maternal and paternal preconception health and knowledge shapes the long-term health of not only children, but of families, communities, and nations. Researchers and healthcare workers should take particular note of these interventions, as the preconception time period may be as important as the pregnancy and post-pregnancy periods, and is critical in terms of bridging the gap in the continuum of care, particularly for adolescents.

How can we improve the use of essential evidence-based interventions?

Between 250,000-280,000 women die worldwide during pregnancy and childbirth each year and children in low- and middle-income countries are 56 times more likely to die before the age of 5 than children in high-income countries. This Editorial discusses the publishing of a supplement within Reproductive Health titled Essential interventions for maternal, newborn and child health which aims to provide a scientific basis to the recommended interventions along with implementation strategies and proposed packages of care.

Avoidable hospitalizations for ambulatory care sensitive conditions as an indicator of primary health care effectiveness in Argentina.

Avoidable hospitalizations for ambulatory care sensitive conditions (AH-ACSCs) identify health problems that could be avoided by improving primary health care (PHC). On the basis of hospital discharges from Argentine public sector facilities, an expert panel convened to define a list of AH-ACSCs for children and adults. AH-ACSCs represented less than 30% of hospitalizations. Compared with country averages, poorer districts showed large differences in trends for adults but not for children. Despite that AH-ACSCs have demonstrated empirical validity to evaluate health system performance, its implementation to assess PHC in countries like Argentina, with pluralistic and fragmented health care systems, remains a big challenge.