Executive summary
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- Bu səhifədəki naviqasiya:
- Immunization
- Malnutrition
- Illnesses and Injuries
- General Health: Incidence of Illnesses and Access to Health Care Services
Health2.23Panama’s public health spending is significantly greater than most countries in the Latin America and Caribbean region with similar per capita income levels. During 1990-2003, the upper middle-income countries in LAC devoted an average of 3.1 percent of GDP to health spending, while Panama spent almost twice as much. Only Costa Rica comes close to Panama in terms of health spending, while Chile spends less than one-half as much. 2.24Despite spending more on than any other LAC country, with the exception of Argentina, Panama performs worse than other middle income countries in the region in terms of infant, child and maternal mortality (Figure 2.6). Infant and child mortality have declined steadily since 1990, but this decline has not been as dramatic as in other middle-income countries. And if relative to the LAC average this may be explained by better initial indicators, relative to middle-income countries in LAC, Panama started off with worse rates. Moreover maternal mortality has risen substantially, from 55 in 1990 to 16017 in 2000. 2.25The problems in the health system are compounded, from an equity perspective, by the negative changes in the health status of the poor. The household survey data provide insights on the distribution of the effects of public spending on health. In the following sub-sections, we first look at data for children under six years of age, focusing on key indicators of vaccination, nutrition, and sickness (as reported by an adult caretaker). We then look more generally at the use of the health care system.
Immunization2.26While immunization rates are quite high in Panama, they are still far from universal, especially among the poor and the extreme poor (Table 2.4). Moreover, this disparity is getting worst. Between 1997 and 2003, only the non-poor have experienced positive changes in immunization (Figure 2.7). For the extremely poor, except for BCG, all other immunization rates for children have declined substantially. This is particularly disturbing given the fact that immunization rates among children of non-poor families have improved substantially. This result points to the marked inequalities in access to basic health services still present in Panama. Table 2.4: Vaccination Rates by Poverty, 2003 - (Ages 0 to 5)
Source: ENV-2003, Calculations by authors. Note: Refers to children who have received at least one dosage of the vaccine.
Malnutrition2.27Indicators of malnutrition provide a somewhat mixed picture of what has happened between 1997 and 2003 in Panama. The overall levels of malnutrition have remained high during the period. But chronic malnutrition seems to have increased by levels that suggest the occurrence of a natural disaster. In 2003, chronic malnutrition as measure by height for age z-scores was estimated to affect one-fifth of all children under five. However, in 1997 the estimated incidence of chronic malnutrition was only 14 percent (see Table 2.5). This finding has been questioned by observers in Panama and abroad because poverty has not increased accordingly, and other malnutrition indicators have remained unchanged. Moreover, chronic malnutrition appears to have increased equally across the consumption distribution, which is very counterintuitive.18 2.28It turns out that there are some discrepancies between different data sources. The best comparable source is the Censo de Talla (School Height Census). It tabulates the age and height of all children six years old up to ten years of age in primary school.19 The results from the last three school censuses are shown in Table 2.6. For 2000, the overall rate of chronic malnutrition is very similar to that of the 2003 ENV. However, the trend in chronic malnutrition shown in the Censo de Talla and the ENVs does not match. The ENV shows a rising rate while the Censo de Talla shows a slightly falling rate. Table 2.5: Changes in Malnutrition Rates in Children 0-5
Source: ENV 1997 and 2003. Authors’ calculations. Note: Q1 is the poorest consumption quintile while Q5 is the richest. ** Significant at .01 level * Significant at l05 level Table 2.6: Chronic Malnutrition among Children Aged 6-11
2.29One hypothesis offered to explain this discrepancy is that the 1997 indicator might have been badly constructed due to measurement errors in the field. Annex 2.1, examines this hypothesis carefully by looking at the malnutrition rates among children who were aged six to eleven at the time of the ENV-2003, i.e. children who are in the cohort that was in the 0 to 5 years of age range at the time of the ENV-1997. As discussed in the annex, at the national level the differences in chronic malnutrition in the age cohort are very small between the two points in time. However, when we look at the differences within specific subgroups (by geographic area) the differences are striking20. Thus, assuming that the 2003 data is more reliable, we conclude that chronic malnutrition has remained high and stable in Panama, hurting especially the extreme poor. In fact, more than one-third of all children in the first consumption quintile suffer from chronic malnutrition, compared to less than six percent in the top quintile. In the indigenous Comarcas, where extreme poverty reached 90 percent in 2003, more than half of all children under five suffered from chronic malnutrition, and one-fifth are underweight. Again, a concerted effort is needed to address poverty and malnutrition in indigenous areas, perhaps via targeted conditional cash transfers which seem to have succeeded in reducing malnutrition in Mexico and Nicaragua. Illnesses and Injuries2.30While the incidence of respiratory illnesses has increased among poor and the non poor children under five, the increase has been substantially higher for the poor and extremely poor (see Table 2.7 and Figure 2.8). On the other hand, the incidence of diarrhea has decreased substantially for the non-poor, and has increased significantly for the extreme poor. While the 1997 and 2003 surveys were not carried during the same period of the year (the 2003 survey was fielded a bit further into the rainy season), the differences are unlikely to be caused by seasonality. Table 2.7: Incidence of Illness among 0 to 5 Year Olds, 2003
Source: ENV 2003. Authors’ calculations
General Health: Incidence of Illnesses and Access to Health Care Services2.31As indicated in Table 2.8, there has been almost no change in the incidence of self-reported illnesses and injuries among the population older than six between 1997 an 2003. Moreover, while counterintuitive, the lower incidence among the poor and the extreme poor is typical to self-reported data, since the poor are less likely to visit health centers and be diagnosed. Interestingly, however, the change in the incidence of illnesses and injuries between the two surveys suggests a substantial improvement in health status of the whole population in Panama. On average, the incidence of illnesses and injuries fell by 13 percent overall, with the highest drop observed for the poor. Table 2.8: Self-reported Illness and Injury in 2003 and Percent Change from 1997
Source: ENV 2003. Authors’ calculations ** Significant at the .01 level. 2.32Among those who reported being ill or injured in the four weeks prior to the field interview and did not seek care cited high costs as the primary reason for not doing so. As expected, high costs are particularly constraining for the poor and the extreme poor (Table 2.9). For the poor, while considerations of health care quality were not important in 1997, in 2003 they have become considerably more critical of the services offered. For the non-poor, distance has become a more important reason for not seeking health cares in the last six years. For the poor, however, distance has become less important. Table 2.9: Reasons for Not Seeking Health Care when Needed, 1997-2003
Source: ENV-97 and 2003, authors’ calculations. ** significant at the .01 level * significant at the .05 level
Table 2.10: Time to Health Facility and Waiting in Health Facility, 2003
Source: ENV 2003 2.34Between 1997 and 2003 we observe a large shift on the sources of health care utilized by the population. As it can be seen in Figure 2.9, there has been a relative large increase in clinic and hospital use for all poverty groups. Even more puzzling is the fact that concurrently to this shift, there has been a substantial increase in the number of new primary health facilities available in the country (see Figure 2.9a).
2.35Figure 2.9b shows the distribution of public health facilities in the country in 2004. Each corregimiento is classified as (i) having no public health facility22, (ii) having only primary level public health facilities (dispensaries, health posts, health sub-centers) and (iii) having higher levels of public health care (from health centers up to hospitals). As can be seen, very few areas have no services at all, and the higher levels of care are fairly well distributed throughout the country.
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