Health systems, pandemic response and social participation: lessons from Latin America

Latin America has been hard hit by the COVID-19 pandemic, following years of privatization and fragmentation of health systems, and low public investment in health

February 05, 2022 by Leonardo Mattos, José Selig, Morena Murillo
Patients from riverside communities along the Rio Negro receiving care from Manaus' floating basic health unit. Photo: Gustavo Basso, Wikimedia Commons

Latin America has been one of the hardest hit regions during the pandemic. The arrival of COVID-19 has made the structural social inequality, present in all countries in the region, even more evident than before. The weakness of the heavily privatized, segmented, and fragmented health systems was evident in the low effectiveness, responsiveness and coordination of interventions. The legacy of international financial policies aimed at restricting public investment in health had an impact on the most marginalized population groups. The colonial strategies of “multilateral” institutions and rich countries in particular have intensified, restricting access to healthcare supplies, resources, and technologies and undermining the authority and role of WHO.

To analyze the lessons learned from the response of Latin American institutions, governments, health systems and peoples to the pandemic from a critical perspective, the Latin American Association of Social Medicine and Collective Health (ALAMES) and the Latin American circles of the People’s Health Movement (PHM) presented their reflections during the webinar “Health Systems and response to the pandemic: lessons from Latin America” on January 19, 2022.

Social Participation and Official Responses to the Pandemic in Latin America

ALAMES’ presentation explained that the management of the pandemic by Latin American governments remains focused on achieving control of the situation through epidemiological containment alone, without addressing the social situations that hinder its implementation. In this approach, the health system is perceived in a very limited way as a system of care, especially hospital care. This, of course, has been additionally worsened by bad decision-making and cases of corruption in many places. Within this framework of centralized, vertical and biomedical management, uncoordinated and ineffective, the conception of social participation is also restricted to a passive view of the population as supporters or collaborators of government decisions. Within this framework, the concern of most governments is the threats to the social reproduction of capital valorization strategies.

This can be observed through several stages. The first stage was characterized by measures to prevent the entry or limit the circulation of COVID-19 through restrictions on social and economic activity. At this point, the people’s participation was reduced to asking the general population to abide by government decisions, without consideration of inequalities in living conditions, which made it impossible for many people to abide by those rules.

In the second stage, the emphasis was on reactivating the economy under the slogan of returning to normality. By then, governments insisted that the transmission of the virus was mainly due to the behavior of the individuals. The pressure from the business sector (very participative), plus the fatigue caused by the restrictions and the decrease in the frequency of COVID-19 cases, led to the efforts to control the virus to be reduced to a minimum. The only thing that remained from the previous phase was the obligation to wear masks and adhere to social distancing, without their compliance being monitored, especially in the workplace.

In the third stage, efforts were focused on vaccination plans, and people’s participation became equated to adherence to vaccines, while individual physical measures became even more relaxed. Shortly after in the fourth stage, vaccination began to stagnate and a return to normalcy was delayed. At this moment, disinformation about vaccines and the pandemic had gained ground and, in spite of attempts to get it back on track, the pandemic strategy seems to be derailed with the emergence of the omicron variant.

Following this, restrictive measures have been further relaxed and vaccination campaigns lost strength. Almost all countries in the region show a significant rise in COVID-19 cases and a new and final stage in the management of the pandemic is launched. Although this is not officially admitted, countries are aiming to achieve so-called herd immunity while avoiding a further rise in the number of deaths. And in this case, participation is called upon. The mandate is: get sick.

Experiences of community and autonomous responses to the pandemic in Latin America

In the face of the failures of government interventions and as a counterpoint to the centralized management of the pandemic, PHM Latin America presented community and self-organized experiences of response in the region, with much broader conceptions of social participation from below.

In Guatemala, the Association of Community Health Services (ASECSA) together with health promoters, midwives, and traditional therapists have been at the forefront of prevention, care and rehabilitation actions since the beginning of the pandemic. In El Salvador, in contrast to the mandatory quarantines and the repression used to enforce them, communities organized in the National Health Forum decided to establish autonomous distancing and collective protection measures, effectively controlling the transmission of the virus.

In Argentina, the housing crisis, a consequence of the neoliberal policies of the previous government and aggravated by the pandemic, has left thousands of people unable to pay rent without a home. The situation has spurred movements to occupy unoccupied public land for housing – the so-called “land takeovers”. During the pandemic, the residents of the 14 de febrero neighborhood planned a self-organized response. With the participation of the community and the support of the Propuesta Tatu initiative, which brings together health professionals who develop health solidarity actions, the health brigades achieved success in epidemiological control and case tracking, which the government was doing in a limited and insufficient manner. In addition, the residents were guaranteed health care and basic necessities through solidarity actions.

In Brazil, the SUS – the public health system – has suffered from cuts in public resources due to neoliberal economic policies. During the pandemic, as in other countries, primary health care took a backseat to hospital-centered care, an approach worsened by President Bolsonaro’s denialism. In Pará, a state heavily affected by deforestation and environmental destruction, the pandemic response depended a lot on activists, who remained in more than twenty-two Indigenous communities to help with tests, vaccinations, and the implementation of health measures and care.

In Colombia, a study conducted by researchers associated with ALAMES and PHM found that institutional pandemic decisions are seen as mostly regulatory by the communities, and do not take into account their reality and needs. Among the barriers to participation, the main factors identified were the limited presence of the health system outside urban areas, the absence of mechanisms for consultation and agreement on pandemic actions with the public, and the rejection of autonomous community actions by the government. Still, communities managed to build their self-organized solutions to the pandemic situation, together with health committees and health promotion workers, and focused on strategies such as assemblies, creation of community action boards, creation of road access control posts, implementation of biosecurity measures, and adoption of traditional medicines to prevent and face COVID-19.

What is the path to alternative governance in health?

The experiences presented during the webinar show that the pandemic measures in Latin America, whether in a new regulatory framework or integrated into an existing one, must take into account that, first, they will be resisted by social groups that may understand that their rights and interests are at risk and, second, the possibilities of compliance with these measures may not be achieved for the same reasons.

To avoid this, and bring into place an effective pandemic response, a new social actor is required: the population represented through its organizations, without mediators or delegations of any kind. This is why it is necessary for the countries to generate spaces and opportunities for social participation, not only for oversight or accountability, but as an actor indecision-making throughout the entire policy cycle.

Leonardo Mattos is from the People’s Health Movement global secretariat, Universidade Federal do Rio de Janeiro, Brazil.

José Selig is from the Latin American Social Medicine and Collective Health Association (ALAMES), Universidad Autónoma de Santo Domingo, Dominican Republic.

Morena Murillo is from the People’s Health Movement Latin America coordination, Foro Nacional de Salud El Salvador, El Salvador.

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