Health Equity Report 2016 Analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking SUMMARY REPORT © United Nations Children’s Fund Health Equity Report 2016: Analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking. Summary Report July 2016 Panama City, Panama Cover photo: © UNICEF / UNI100388 / LeMoyne United Nations Children’s Fund, UNICEF Latin America and Caribbean Regional Office Alberto Tejada street, Building 102, City of Knowledge Panama, Republic of Panama P.O. Box 0843-03045 Phone: (507) 301-7400 www.unicef.org/lac Twitter: https://twitter.com/uniceflac Facebook: https://www.facebook.com/UnicefLac ISBN: 978-92806-4846-1 This joint report reflects the activities of individual agencies around an issue of common concern. The principles and policies of each agency are governed by the relevant decisions of its governing body. Each agency implements the interventions described in this document in accordance with these principles and policies and within the scope of its mandate. This publication may be reproduced for use in research, advocacy and education only, provided the source is acknowledged (UNICEF). This publication may not be reproduced for other purposes without the prior written permission of UNICEF. Permissions will be requested to Communication Unit, [email protected]. Contents Introduction 1 What is health equity? 3 Health inequity in Latin America and the 3 Caribbean: an intergenerational cycle The relevance of health equity for the 4 achievement of universal health care, the human right to health and the Sustainable Development Goals What we don’t know: where more research is 4 needed Equity in reproductive health 6 Contraception use 7 Figure 1. Association between household wealth, place of 7 residence and women’s education and unmet needs for contraception in Latin America and the Caribbean Sexually transmitted infections 8 Cancer prevention and treatment 8 Equity in maternal survival 9 Maternal mortality and morbidity 9 Figure 2. Maternal mortality in the Latin American and 9 Caribbean region Box 1. Income inequality between countries: maternal 10 mortality Direct and indirect causes of maternal death and the 11 quality of health care Stillbirth 12 Equity in maternal health 12 Antenatal care 12 ii Contents Figure 3. Inequalities in utilization of at least four antenatal 12 care visits in Latin America and the Caribbean Skilled birth attendance 13 Figure 4. Antenatal care and skilled attendance at birth go 13 hand in hand Figure 5. Inequalities in skilled birth attendance across 14 Latin America and the Caribbean Figure 6. Across Latin America, indigenous and Afro- 14 descendant women have lower rates of utilization of antenatal care, skilled birth attendance and follow-up care Figure 7. Progress in maternal health coverage for 14 indigenous women in Mexico and Peru Caesarean sections 15 HIV and syphilis during pregnancy 15 Equity in neonatal survival 15 Box 2. Inequality by national income: neonatal mortality 16 Equity in neonatal health 17 Low birth weight 17 Postnatal care for mothers and newborns 17 Figure 8. Inequalities in postnatal care for newborns in 18 Panama across ethnic groups Birth registration and the right to an identity 18 Figure 9. Inequalities in birth registration in Latin America 18 and the Caribbean Equity in child survival 18 Infant and child mortality 19 Figure 10. Infant and under‐five mortality rates in Latin 19 American and Caribbean countries, 2015 Box 3. Inequality by national income: under-five mortality 20 Equity in child health 21 Immunization 21 Pneumonia 21 Contents iii Figure 11. Inequalities in seeking care for pneumonia 22 symptoms Asthma 22 Diarrhoeal diseases 22 Figure 12. Percentage of the population with access to 23 improved water facilities by urban and rural residence in Latin American and Caribbean countries, 2015 Figure 13. Percentage of the population with access to 24 improved sanitation facilities by urban and rural residence in Latin American and Caribbean countries, 2015 Communicable and vector-transmitted diseases 24 Equity in nutrition 25 Breastfeeding 25 Child growth and malnutrition 25 Figure 14. Guatemala, Bolivia, Honduras, and Haiti bear the 26 brunt of malnutrition in Latin America and the Caribbean Figure 15. Poverty, rural residence and low level of 27 education are associated with a higher prevalence of stunting in Latin American and Caribbean countries Overweight and obesity 27 Micronutrient deficiencies and anaemia 28 Equity in adolescent health 28 Early marriage and sexual initiation 28 Sexual and reproductive health services for adolescents 28 Adolescent pregnancy 29 Vulnerability, agency and lifestyle 30 Substance use: alcohol, tobacco and illicit drugs 30 Overweight and overnutrition in adolescence 30 Vulnerability and HIV among youth 30 Gender and the HIV epidemic 31 Transition from childhood to adolescence for youth with HIV 31 LGBT adolescents and discrimination 31 iv Contents Equity in violence and health 32 Violence against children with disabilities 32 Sexual abuse 32 Intimate partner violence during pregnancy 32 Discrimination and mistreatment in health facilities 32 Urban violence 32 A Promise Renewed for the Americas: A Call to 33 Action Annex. Key indicators included in the health 38 equity analyses References 39 Contents v Introduction Introduction Over the last decade, Latin America and the Caribbean Governments, international development agencies, civil has experienced rising incomes and countries in the region society representatives, academic institutions, the private have substantially improved health-care coverage for people sector, professional institutions and non-governmental who live in poverty as well as health outcomes for most of organizations to catalyse and support country-led efforts to their populations.1 Nineteen of thirty-three Latin American decrease gaps in access to quality health care. As a regional and Caribbean countries are now classified by the World movement, APR-LAC works in coordination with the global Bank as upper-middle income countries.2 Yet progress has A Promise Renewed initiative. APR-LAC is convened by the been uneven, and regional and national averages for income Inter-American Development Bank (IDB), the Pan American and social indicators reveal wide inequalities between and Health Organization/World Health Organization (PAHO/WHO), within countries. This is extremely apparent in the areas of the United Nations Children’s Fund (UNICEF), the United reproductive, maternal, neonatal, child and adolescent health. States Agency for International Development (USAID) and the World Bank. For many countries in Latin America and the Caribbean, efforts towards achieving universal health coverage and access As countries consider how to implement the 2030 Agenda to health care began as early as the 1990s. Over the past two for Sustainable Development to achieve the Sustainable decades, a few countries have implemented health system Development Goals, it is vital that national priorities and reforms that have fostered inclusion, citizen participation development goals for the next 15 years address the current and equitable access to health care. Despite this progress, health inequities in Latin America and the Caribbean, reflect however, most countries in the region still experience major the needs of the most vulnerable populations and be based inequities in health status and coverage of health interventions, on current evidence. As a contribution to this effort, UNICEF with major differences in health outcomes occurring based partnered with the Tulane University Collaborative Group for on people’s wealth, education, geographic location, gender, Health Equity in Latin America to review the available evidence ethnicity and/or age. on health inequity in the region. The resulting report, Health Equity Report 2016: Analysis of Reproductive, Maternal, We have the knowledge base to reduce and even eliminate Newborn, Child and Adolescent Health Inequities in Latin these inequities. Pro-poor health sector interventions have America and the Caribbean to Inform Policymaking,4 draws on been shown to improve health equity and overall progress over 700 sources, including a review of published research by narrowing existing gaps in access to health services findings and household surveys (Demographic and Health and health status. But strengthening health systems and Surveys, Multiple Indicator Cluster Surveys, Reproductive improving coverage are not enough to improve the health and Health Surveys and other national surveys) undertaken social well-being of populations. As stated in the 2030 Agenda from 2008 to 2014, to generate evidence of current health for Sustainable Development, “sustainable development inequities and underscore the need for better data, particularly recognizes that eradicating poverty in all its forms and within countries at the subnational level. dimensions, combating inequality within and among countries, preserving the planet, creating sustained, inclusive and This summary report draws on the findings of theHealth sustainable economic growth and fostering social inclusion Equity Report 2016 5 to illustrate the health inequities are linked to each other and are interdependent”. 3 affecting children, women and adolescents in Latin America and the Caribbean, to provide government policymakers, A Promise Renewed for the Americas