Building Resilient Health Systems in Latin America and the Caribbean Lessons Learned from the COVID-19 Pandemic © 2022 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Report No: AUS0003188 Some rights reserved. This work is a product of the staff of The World Bank with external contributions. The findings, interpreta- tions, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be construed or considered to be a limitation upon or waiver of the priv- ileges and immunities of The World Bank, all of which are specifically reserved. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution—Please cite the work as follows: Herrera, Cristian A., Jeremy Veillard, Nicole Feune de Colombi, Sven Neelsen, Geoff Anderson, and Katherine Ward. Building Resilient Health Systems in Latin American and the Caribbean: Lessons Learned from the COVID-19 Pandemic. 2022. Washington DC: World Bank. License: Creative Commons Attribution CC BY 4.0. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publi- cations, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover photos: Left: Jamie Martin / World Bank (CC BY-NC-ND 2.0); Center: Fernweh Impressionen, “Kakabila” (CC BY-NC-ND 2.0); Right: Scott Wallace / World Bank (CC BY-NC-ND 2.0) All photos used with permission, and any reuse requires permission of the copyright holder. Publication design: Danielle Willis Building Resilient Health Systems in Latin America and the Caribbean Lessons Learned from the COVID-19 Pandemic December 2022 Cristian A. Herrera Jeremy Veillard Nicole Feune de Colombi Sven Neelsen Geoff Anderson Katherine Ward iv Acknowledgments This work was made possible through the collaborative effort of several colleagues. Hortensia Reyes and Clara Juarez (National Institute of Public Health of Mexico) who led the qualitative component that was the basis for chapter 3 and the work in Mexico; Paula Bedregal (P. Universidad Católica de Chile) who led both quantitative and qualitative data collection in Chile and Peru; Task Team Leaders and World Bank colleagues from countries: Daniela Romero (Uruguay and Paraguay), Vanina Camporeale and Maria Eugenia Barbieri (Argentina), Gabriel Aguirre (Peru), Edson Araujo (Brazil), Juan Pablo Toro (Colombia), Victoria Haldane (costs review), and Mikhael Iglesias (climate change); and data experts: Maura Alvarez, Alexandru Titeu, Kiara Bardales, Fanor Balderrama, John Sina Moin, Pedro Pairazaman and Matias Muñoz. Authors would like to acknowledge Niek Klazinga (OECD and University of Amsterdam) as external advisor and peer reviewer, and Sulzhan Bali (World Bank) and Marcelo Bortman (World Bank) as peer reviewers. Finally, we are thankful for the support and guidance of Michele Gragnolati, Practice Manager of the LAC Health, Nutrition and Population Global Practice and Luis Benveniste, LAC Regional Director of Human Development. The authors would like to gratefully acknowledge and thank graphic designer Danielle Willis and translator Antonio Posada. 1 Executive Summary More than two years into the pandemic, the evidence is clear: COVID-19 has unleashed an unprece- dented socioeconomic and health crisis, and devastated communities across Latin America and the Caribbean (LAC). Fundamental changes must be initiated to strengthen health systems to regain lost ground and avoid similar losses in the future. A better recovery is imperative, but it will be challenging and will require innovation to better prepare for future crises, implementing effective universal health coverage and improving human capital outcomes. This report summarizes key findings about the pandemic’s impacts on health across the region. Drawing from a range of sources including World-Bank conducted research and phone surveys as well as research by partner organizations, governments, and academic experts, the first three chapters investigate three areas of impact: impacts on societies, impacts on people, and impacts on health systems. It then builds on those insights in a final chapter that maps out a five-pillar action plan and smart investments for decision-makers to consider in charting a way forward to build resiliency in health systems and improve health outcomes for all. With an eye to usability for busy policy makers and practitioners, each chapter begins with a one-page graphics-based overview that summarizes key findings and action points—providing users with a visually rich snapshot to guide both consideration of the details presented in this report and also subsequent discussions to determine best courses of action for a given country. The balance of this Photo credit: World Bank / Dominic Chavez (CC BY-NC-ND 2.0) executive summary section brings together much of the content of those one-pagers, looking first at the impacts of the pandemic and then turning to the way forward for health systems to enhance recovery and resilience. 2 Summary of Impacts Lack of preparedness prompted a government response to COVID-19 that worsened economic performance in LAC. GDP LAC GDP contraction in 2020 hit 7 percent—the largest in the last 100 years and the worst worldwide. On People By mid-2020, Argentina, Chile, Costa Rica, and Mexico registered 20 On Societies On Health percent drops in employment; by 2021, almost 20 million people had left disrupted access Systems the labor force. unleashed an to essential health preyed on pre- care services and The pandemic triggered a profound shock to the education sector which is unprecedented existing structural critical to both quality of life and national long-term economic productivity socioeconomic increased existing weaknesses and and development. and health crisis, inequities in uncovered new devastated access, threatening challenges, but also Students risk losing an amount equal to 14 percent of today’s global communities future health and catalyzed promising $ GDP due to school closures. productivity innovations Unprecedented negative impacts on children’s safety, health, and well- being (feeding programs, mental health, violence). COVID-19 Excess Mortality Rate per 100,000 (2020–2021) and GDP Growth 2019–2021 (observed vs. projected) On Societies Most impacted Underinvestment in public health before the pandemic left systems in LAC severely underprepared and oriented towards curative care. 13% of While home to only 8.5 percent of the world’s population, the region world’s accounted for 13 percent of all cases (July 2022). cases Highest excess mortality in Peru, Mexico, Ecuador, and Bolivia, with a steepening curve in Bolivia. Least impacted Adaptations to meet high COVID-19 demands have caused setbacks in health outcomes. Sources: COVID-19 Excess Mortality Collaborators 2022; IMF 2019; IMF 2022. Note: GDP = gross domestic product. 3 On People On Health Systems Declines in people accessing health services (evidence from phone Negative impacts: already known structural weaknesses exacerbated by surveys in 14 LAC countries) the pandemic. The main reason people did not seek care was healthcare system supply constraints such as the lack of staff, appointments or supplies, and facility closures. System fragmentation $ Financial constraints Limitations in human Shortcomings in governance resources and and trust infrastructure Inequities exacerbated and financial protection in health worsened (evidence from Peru) Negative impacts: newly exposed weaknesses, including significant service delivery disruptions. 14% At the end of 2021, healthcare use was 14 percent below pre-pandemic levels for the richest quintile and 32 percent lower for the poorest quintile. Countries with the greater pre-existing shortfalls in health system management had greater difficulties in coping with COVID-19. Service disruptions across the life course with longer-term health effects for children and youth, adults, and older people. Delayed care and lack of control in treatment adherence and filling prescriptions were the most frequent consequences. Decreases in vaccine coverage, childhood Children nutrition programs, and primary care services Beneficial innovations: notable effective, innovative measures that mitigated constraints and merit consideration to improve health system Decreases in key services and care (e.g., resilience and efficiency going forward. Adults diabetes and cardiovascular diseases) Decreases in key services and care (e.g., cancer Substantial expansions A B Use of data in Integrated use of Older People screening) of telemedicine and decision-making public and private telehealth services facilities Formal Healthcare Use Among Population with Illness Symptoms in the Past Month Telemedicine Services Authorized in Colombia 2012–2022 COVID-19 pandemic begins 48% drop for richest 62% drop for poorest Source: Ministerio de Salud y Protección Social, Registro Especial de Prestadores de Servicios de Source: Perú Instituto Nacional de Estadística e Informática n.d.b. Salud (March 31, 2022). 4 Five Key Investments Investments and Policy Considerations • Implement high-performing, people-centered primary health care (PHC) for all Resilient Health • Reform service delivery to ensure quality of care Systems: Quality • Invest in a fit-for-purpose workforce for the health sector Universal Health Coverage Health Emergency • Expand digital transformation and create a digital ecosystem to Ready improve access to and quality of services A Strategic • Engage the private sector with appropriate regulations to bridge Framework for gaps in service delivery and foster innovation Climate-Resilient, Health Systems Climate-Smart Strengthening $ Health Systems Resilient Health and Resilience Financing Health Emergency Ready Life Course Approach to Human INVEST in better public health emergency prevention, preparedness, Capital Investments and response, and ensure effective collaboration in face of public health threats • Invest in smart surveillance systems and coordination networks • Build a multisectoral prevention and response system • Invest in surge capacities including public health professionals Resilient Health Systems: Quality • Leverage PHC for better surveillance and response Universal Health Coverage Investments and Policy Considerations IMPROVE effective access to health care especially for the most vulnerable and deliver quality universal health coverage based in • Invest in affordable surveillance systems for timely warning and high-performing primary health care and resilient health systems response • Invest in the frontline • Scale up key multisectoral interventions • Invest in better prevention and health promotion • Strengthen infection prevention and control in all healthcare settings to mitigate the disproportionate burden of epidemic-prone • Empower health workers to deliver quality care and hospital-acquired diseases • Leverage data and digital ecosystems for quality UHC • Develop infrastructure and technical capabilities for development, manufacturing, and better procurement of drugs and vaccines • Leverage PHC capacities for better pandemic preparedness and response • Strengthen governance and international coordination for action in emergency situations 5 Investments and Policy Considerations $ Resilient Health Financing • Implement effective interventions targeting the first 1,000 days of life to strengthen early childhood development IMPLEMENT health financing reforms driving better population health and financial protection, reducing waste and inefficiencies, • Enact vaccination strategies tailored at national and subnational levels including for adults and ensuring the financial sustainability of health systems • Strengthen multi-pronged strategies to reduce teenage pregnancy • Adequate financing for health sector resiliency including • Leverage multi/inter-sectoral strategies to reduce behavioral risks • Boost investments in Pandemic Prevention, Preparedness • Extend proactive community-based education and health and Response and break the cycle of panic and neglect promotion contingency financing • Establish and expand healthy longevity strategies • Boost health taxes • Smart financing for efficiency and better population health Investments and Policy Considerations • Improve domestic resource mobilization through smarter Climate-Resilient, Climate-Smart taxation to boost government revenue Health Systems • Increase fiscal space for health and enhance pooling of health funds to reduce health system fragmentation STRENGTHEN adaptation of health systems to climate change to • Expand financial protection while achieving efficiencies and protect health and well-being in the medium and long term reduce waste • Implement strategic purchasing mechanisms to incentivize the • Integrate public health, population health, and climate change provision of high-value service ecosystems to improve access to surveillance systems and quality of services • Invest in adaptation efforts to provide essential services • Establish emergency funds that can be quickly accessed during • Invest in efforts to reduce the health sector’s carbon footprint emergencies to accommodate fast-changing needs Investments and Policy Considerations Life Course Approach to Human Capital • Integrate public health, population health, and climate change Investments surveillance systems • Invest in adaptation efforts to provide essential services despite IMPLEMENT highly effective human development interventions climate-related hazards and risks over the life course, especially in early childhood • Invest in efforts to reduce the carbon footprint of the health sector over the mid- to long-term • Commit to health and nutrition in the first 1,000 days of life • Re-commit to vaccination for all, including adults • Invest to reduce teen pregnancy and tackle risky behaviors • Invest in key multisectoral interventions promoting healthy longevity This report is part of series of knowledge products developed by the World Bank Group in response to the COVID-19 pandemic in Latin America and the Caribbean. Other knowledge products are available at: www.worldbank.org/en/ region/lac/brief/knowledge-covid-19-response worldbank.org