Scientific Papers

Human resources for health and maternal mortality in Latin America and the Caribbean over the last three decades: a systemic-perspective reflections | International Journal for Equity in Health

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Interest in the analysis of HRH and its relationship with the field of sexual and reproductive health, including maternal death in LAC, is still scarce. The classic studies by Annand and Barnighausen (2004) that related these two aspects to other regions of the [26] were not replicated in LAC. This omission is even more remarkable if we consider that there are now open-access information bases that would allow this type of analysis. This paper offers a first example of how these analyses could be performed and suggests that high staffing densities could be related to more significant reductions in maternal mortality in the region. However, it is necessary to consider the role of other resources that health systems contain that could positively reduce maternal mortality.

To function, health systems require a variety of resources, including human, financial, technological, drugs and infrastructure. HRH enables systems to achieve population care goals. The post-2015 agenda for sustainable development calls for a drastic reduction of the maternal mortality [11] and recognizes the strategic role of HRH in organizing and managing all other resources and achieving system goals such as coverage, equity, efficiency [27], and quality of care [28].

The data presented shows the enormous heterogeneity of the response of the regional health systems to the challenge posed by maternal mortality in the region. Although most countries articulated specific programs to achieve the reduction committed by all countries through the MDGs, not all had the same capacity to reduce it, and practically none met the target [29]. Initially, cases in the antipodes can be highlighted, such as Venezuela [30], which had the lowest increase in health personnel in the entire region and a significant increase in maternal mortality. On the other hand, Bolivia stood out with the most significant increase in health personnel and a substantial reduction in MMR. Furthermore, we found the entire block of English Caribbean countries with significant increases in the number of health personnel that do not explain the increases in the MMR during the period.

Following the systemic perspective, it is important to note the potential role played by the availability of other resources for health in the MMR levels. According to OECD data, by 2019 [31], among the countries with the lowest per capita expenditure on health, below 1,000 USD PPP annually, in the region were Haiti, Venezuela, Honduras, Belize, Nicaragua, Guatemala, Jamaica, St. Vincent & Grenada, Bolivia, Guyana, Dominica, St. Lucia, Peru, and El Salvador. According to the data analyzed, among the countries that achieved the greatest MMR reductions, we found Bolivia, El Salvador, Honduras, and Peru, which suggests that their low relative investment could have been used efficiently to reduce MMR. On the other hand, the English Caribbean countries Bahamas, Trinidad & Tobago, Suriname, Saint Kitt and Nevis, Barbados, and Antigua & Barbuda, which had per capita expenditure above 1,000 USD PPP, did not achieve significant reductions in MMR.

Another relevant resource is the availability of hospital beds. OECD data concerning this indicator show that Caribbean countries such as Barbados, Antigua & Barbuda, Grenada, Suriname, Trinidad & Tobago, and the Bahamas, had above 3 beds per 1,000 inhab. in 2014, while continental countries in the region, such as Colombia, Peru, Ecuador, El Salvador, Bolivia, and Mexico showed a ratio of less than 2 beds per 1 K inhab. Even Costa Rica was in this group of countries. There is likely no relationship between the availability of hospital beds and MMR if delivery care in these countries does not preferably take place in hospitals, although it is important to consider that countries such as Mexico, Peru, and Colombia do have a preference for hospital care in childbirth [32].

A third, more specific indicator is that care delivery in most countries occurs in health institutions rather than at home or in other settings. The region shows an average of 90% of delivery care performed in health institutions with some variations. Caribbean countries such as Guyana, Suriname and Belize show the lowest proportions (between 92 and 95%) of delivery care in health institutions while Cuba, Argentina, Colombia, and Costa Rica reached levels close to 100%.

As in HRH’s case, there is no direct relationship between the exemplified resources and MMR. However, it is important to note that only some countries (particularly Costa Rica) have managed to reduce MMR to a minimum without increasing the number of available resources. The answer can be found in the primary healthcare model historically prevalent in that country [33]. Other countries such as Honduras, El Salvador and Peru, whose health systems are not based on a primary health care model, depend on short-term programs to achieve temporary success [34]. In the case of the Caribbean countries we have already highlighted, the growth of maternal mortality may be related to the fall in financial and human resources. Moreover, according to UNFPA, in this region the increase in obesity, diabetes, high prevalence of HIV and adolescent pregnancy are primary determinants of high maternal mortality [35]. As the WHO points out in its 2016 report, the issue with health resources, including HRH, does not imply that we will have better health outcomes from their greater availability since various aspects play a role, including the type of training, the type of functions they perform, the level of care at which they operate, productivity and quality in the execution of tasks [11].

Focusing back on HRH, the data on the relationship between HRH availability and MMR is an example of what we might be projecting regarding health problems using encompassing views. It is important to identify the areas in which HRH planning, training, and distribution/availability decisions impact on a substantive level and the approaches that underlie their training and performance. Beyond the relationships between variables, we also need to consider the characteristics of the model of obstetric care. The current model, which is widely prevalent in LAC, intervenes massively in women’s bodies, creating a series of risks for both mothers and children [36]. For this reason, in recent years the WHO has recommended promoting low-intervention models of obstetric care, with the participation of a diversity of qualified service providers, which focus on the natural process and the emotional needs of women [37]. The change of model could help to reduce maternal mortality in all settings, particularly in those with scarce financial resources and low availability of human resources. Thus, we believe it may be possible to model, deconstruct, and reconstruct obstetric care to incorporate perspectives of rights, cultural inclusion, and care for the environment, among others [38,39,40]. The fragmentation of the approach to health and the excessive emphasis on disease by the HRH impacts the health system, the educational system, and the labor market. Finally, the area of construction of process and outcome indicators is identified, which, in line with the above, are modeled by the way health is conceptualized and the way health providers put in practice their skills. The previous areas, as effects of the process of planning, training, and distribution/availability of HRH, have a direct relationship with how equity and quality of health care are constructed from the conceptual, but above all from the operational level [41].

The results presented in this commentary should be interpreted while considering several limitations, mainly related to using the GBD data, as previously documented field [41,42,43,44], and the ecological descriptive analysis performed. First, there is an ecological fallacy in interpreting results due to the use of aggregate data from the GBD study, which are subject to statistical modeling and do not reflect individual-level data. In this sense, the relationships evidenced only suggest the existence of statistical associations and not causal relationships. Second, the GBD estimates depend on the quality of the data provided by the countries, which could be of great concern in countries with limited availability of data of acceptable quality. Third, although conceptual arguments justify the existence of the relationships explored [26], it is important to recognize the omission of relevant variables in the analysis performed, such as, for example, the level of investment of specific resources for maternal health care.

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