conditions and sanitation X X budget Constraints

(human resources, technology, infrastructure) Deficit health of the health resources X X X X X X Low supply in rural areas and peri-urban X X X X X Inefficiency in the health care services X X Insufficient standardization, monitoring, evaluation and reorientation of the services X X the Absence of a National integrated health System X Deficit and low commitment of health personnel X X Poor prioritization of health problems X Lack of sufficient training of staff in health X health Weak referral system and contrarreferencias of patients X Logical different between private sector and Public health X X Management focused on the institution X Gap between epidemiological situation and model of care X X Lack of channels of participation with health beneficiaries X health Policies and programs in Latin America. Problems and proposals 22 Cont. Table 5 Topics Argentina Brazil Bolivia Chile Colombia Costa Rica Cuba Ecuador El Salvador Guatemala Honduras Nicaragua Panama health

Paraguay Peru R. Dominica na Uruguay Venezuela demographic Conditions geographic Inaccessibility, and scarcity of means of transport and communications X X X X X population Growth X X X Changes in the epidemiological profile X X X Populations, multilingual and multi-ethnic, migrant X X Multi-causality of diseases X X cultural Barriers Lack of an intercultural approach X X Illiteracy X X Bad sanitary habits, lack of prevention in health X X lack of awareness of health citizens ‘ rights in health X undervaluation of women X discrimination in health services source: authored on the basis of country responses to the ECLAC survey on national health programmes, 2005. ECLAC – Social Policies series No 114 23 D. the differentiated impact of health care problems health care problems do not affect different sectors of the population in health

• the same way. The authorities of almost all the countries surveyed agree that these do not affect the non-poor strata, which have greater capacity to pay and wider access to specialized services both public and private (plans, health insurance, Social Security membership, etc.). Only in the case of Uruguay was health it highlighted that the increasing unemployment affecting non-poor segments does not allow them access to either the public system,
• because they are not at the level of indigence, or the private system, because of lack of resources. However, inequality in the impact of health care problems is determined not only by issues of socio-cultural and geographical accessibility, or both, but mainly by income disparities, health which generate inadequate living conditions to prevent and meet the population’s health needs. In general, the health

urban poor have greater access

to health services than those living in rural areas, where poverty is most extreme. However, this trend shows particular nuances. In Argentina, following the political, institutional and socio-economic crisis of the last months of 2001 and the first half of 2002, 17 of the 24 provinces had poverty incidence rates higher than the national average. Since there is a direct relationship between these circumstances and the health of the health population, the threat to the health heritage of Argentines, in general, is overwhelming. In Bolivia, despite the fact that the urban poor are less distant from Health Services, problems of costs and cultural differences persist. In Brazil, the urban poor have lower health

• access to health care in large cities, mainly in the poorest regions. In Colombia, for example, accessibility problems mainly affect the poor, but geographical and economic barriers have a greater negative impact on the rural population and cultural barriers on the ethnic population (El Salvador, Guatemala).
• In Ecuador, the urban poor face cost problems, but to a higher degree, and like ethnic groups, the rural poor have access difficulties. In some countries, it is noted that poor basic services and overcrowding account for the greatest problems with the urban poor(El Salvador, Guatemala). health In Honduras, both urban and rural poor and ethnic groups have the same problems because they share the

conditions of poverty health and extreme poverty

, according to the Human Development Index. In Nicaragua, the high cost of medicines affects the urban poor, as well as natural disasters that damage the rural poor and ethnic minorities alike. In addition, the rural poor have lower access to health services and programmes because there are health generally fewer services in these geographical areas (Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, Peru, Uruguay). In this regard, in Peru it is noted that, apart from the limited supply, the services

• delivered are of low quality. In Bolivia, the deficit in installed capacity and human resources for health care is added to the above. Ethnic groups present specific health-care problems because of monolingualism, high illiteracy rates, different manifestations of ethnic and racial discrimination that they health must overcome, and difficulties in their political participation and representation as ethnic and racial minorities within countries. In Latin America,
• as in other parts of the world, race and ethnicity have been consolidated, through a long and complex historical process, as determining aspects of the lack of equity and social, economic and cultural inequality. Along with gender and class discrimination, discrimination health policies and programs in America health