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FISCAL SPACE for HEALTH in LATIN AMERICA and the CARIBBEAN B I Executive Summary A UNIVERSAL HEALTH SERIES FISCAL SPACE FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN B i FISCAL SPACE FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN Washington, D.C. 2020 ii Fiscal Space for Health in Latin America and the Caribbean © Pan American Health Organization, 2020 ISBN: 978-92-75-12000-2 eISBN: 978-92-75-22000-9 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO license (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). Under the terms of this license, this work may be copied, redistributed, and adapted for non- commercial purposes, provided the new work is issued using the same or equivalent Creative Commons license and it is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that the Pan American Health Organization (PAHO) endorses any specific organization, product, or service. Use of the PAHO logo is not permitted. Adaptations: If this work is adapted, the following disclaimer should be added along with the suggested citation: “This is an adaptation of an original work by the Pan American Health Organization (PAHO). Views and opinions expressed in the adaptation are the sole responsibility of the author(s) of the adaptation and are not endorsed by PAHO.” Translation: If this work is translated, the following disclaimer should be added along with the suggested citation: “This translation was not created by the Pan American Health Organization (PAHO). PAHO is not responsible for the content or accuracy of this translation.” Suggested citation. Fiscal Space for Health in Latin America and the Caribbean. Washington, D.C.: Pan American Health Organization; 2020. License: CC BY-NC-SA 3.0 IGO. 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PAHO/HSS/HS-2020 iii INDEX PREFACE .................................................................................................................................v ACKNOWLEDGMENTS ............................................................................................................vii EXECUTIVE SUMMARY............................................................................................................ix Rationale ..............................................................................................................................................ix Concepts ................................................................................................................................................x Methodology .........................................................................................................................................x Results ..................................................................................................................................................xi Conclusions ........................................................................................................................................xiv INTRODUCTION ....................................................................................................................... 1 CHAPTER 1: THEORETICAL FRAMEWORK .................................................................................5 1.1. Definition of fiscal space for health ........................................................................................... 5 1.2. Properties of fiscal space ........................................................................................................... 8 1.3. Analytical framework: components of a study on fiscal space ............................................... 9 1.4. Study typology .......................................................................................................................... 16 CHAPTER 2: ECONOMIC CONTEXT AND HEALTH SYSTEMS .....................................................19 2.1. Macroeconomic analysis ..........................................................................................................20 2.2. Public finance and health expenditure ...................................................................................26 2.3. Organization of health systems ................................................................................................31 CHAPTER 3: SOURCES OF FISCAL SPACE ...............................................................................39 3.1. Source I: Resources derived from economic growth .............................................................39 3.2. Source II: Reprioritization of the health sector .....................................................................50 3.3. Source III: Increase in the tax yield ........................................................................................ 57 3.4. Source IV: External sources of financing................................................................................. 78 3.5. Source V: Increase in the efficiency of the health expenditure ............................................83 CHAPTER 4: POLITICAL AND SOCIAL ANALYSIS ....................................................................91 4.1. Application of the regional analytical framework.................................................................. 91 4.2. Documentary analysis in Peru .................................................................................................92 4.3. Interviews of agents in Bolivia ................................................................................................93 4.4. Documentary and online surveys in Honduras ......................................................................94 CONCLUSIONS ......................................................................................................................97 REFERENCES .......................................................................................................................101 iv Executive Summary v PREFACE The Strategy for Universal Access to Health and Universal Health Coverage, approved in October 2014 by the 53rd Directing Council of the Pan American Health Organization (PAHO), represents a summary of best practices in the construction and strengthening of health systems throughout the world. This initiative is a milestone that builds on the principles of the Constitution of the World Health Organization (WHO) of 1948, which declares health a fundamental human right, and the Declaration of Alma-Ata of 1978 and its call to achieve health for all. However, given the limited capacity of health systems in the Americas to meet the health needs of their populations, universal access to health and universal coverage are a goal that has yet to be achieved. In recent decades, the Region’s governments have redoubled efforts to expand health coverage through policies to achieve universal coverage. The Strategy establishes the following four interdependent strategic lines that must be addressed holistically when attempting to strengthen or transform the health systems of the Region: 1. Expanding equitable access to comprehensive, quality, people- and community-centered health services. 2. Strengthening stewardship and governance. 3. Increasing and improving financing, with equity and efficiency, and advancing toward the elimination of direct payments that constitutes a barrier to access at the point of service. 4. Strengthening intersectoral coordination to address social determinants of health. Universal access to health and universal health coverage (Universal Health) means that all people and communities can make use of comprehensive, quality health services when they need to, throughout the life course. Meeting these two objectives requires the design and implementation of policies and activities
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