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An innovative

public-private partnership

to reduce

health equity gaps in Mesoamerica



In Mesoamerica, inequality measures six centimeters. That is the average difference in height between five-yearold children in the poorest 20 percent of the population and those in the wealthiest fifth.

Between birth and age five, each additional centimeter of height is associated with higher cognitive skills, stronger performance in school and, eventually, a better chance to earn decent wages. Amplified over the span of a lifetime, those six centimeters can become an abyss separating the poor from the wealthy. The height difference is due to malnutrition, but it is also caused by the absence or poor quality of basic health services. Most governments in Mesoamerica have made important progress in providing these services to their people. Indicators such as life expectancy and infant mortality have improved dramatically in recent years. But these gains have yet to reach the most marginalized populations, with parts of Mesoamerica lagging behind their peers in other regions.

Salud MesoamĂŠrica 2015, a five-year initiative, has been launched to close the health equity gap in Central America and the southern states of Mexico.

Who are we?

Who are we? The Salud MesoamĂŠrica 2015 (SM2015) Initiative is an innovative public-private partnership between the Bill & Melinda Gates Foundation, the Carlos Slim Health Institute (ICSS), the Government of Spain, and the Inter-American Development Bank (IDB) to reduce health equity gaps affecting the extreme poor according to priorities established by the countries in the region. This is a five-year Initiative scheduled for completion in 2015. The Bill & Melinda Gates Foundation, the Carlos Slim Health Institute, and the Government of Spain are each contributing US$50 million for the implementation of life-changing health solutions aimed mainly at poor children and women in the region. The US$150 million will finance projects in the areas of reproductive health, maternal and neonatal 4

health, maternal and child nutrition, immunization, and malaria and dengue.

The Initiative supports the efforts of the governments of this region to achieve the health Millennium Development Goals through investment in interventions of proven efficacy for the 20 percent poorest of the population

The IDB is the executing agency responsible for designing projects jointly with ministries of health which, in turn, allocate counterpart resources.

Objectives What are the objectives of the Salud Mesoamérica 2015 Initiative? The work of the Initiative will focus on reducing the equity gap in coverage and quality of basic health services for millions of people living in poverty in the Mesoamerican region, particularly women and children under five years of age. The Initiative supports regional government efforts to meet the health Millennium Development Goals through investment in proven efficacy interventions for the poorest 20 percent of the population. Moreover, the Initiative offers a unique opportunity to promote and place the health equity issue on the regional and national agenda. The Initiative envisages supporting enhancement of information systems and strengthening of human resources among health systems.

The Initiative has these specific objectives:

• Increase the availability and use of evidence to design and implement pro-poor health policy.

• Build long-term political and financial commitment to closing the health equity gap.

• Increase the supply, quality, and use of basic health services in poor communities.

• Contribute to the elimination of malaria and to the control of dengue.

The Initiative will support information systems and human resources strengthening within health systems. The Initiative works in close coordination with the Mesoamerican Public Health System (SMSP) and is a catalytic tool to achieve regional health goals established by the SMSP and the Council of Central American Health Ministers (COMISCA). A regional vision and alignment with country health agendas is critical to the Initiative’s success and its impact in vulnerable communities.


Why was the Salud MesoamĂŠrica

2015 Initiative established?

Why was the Salud MesoamĂŠrica 2015 Initiative established? The Mesoamerican region consists of the Central American countries (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama) and the nine southern states of Mexico, and is among the most unequal regions in the world. In spite of the progress made in health over the past decade, the extreme poor continue to fare substantially worse than their better-off peers These socioeconomic inequalities are reflected in rates of illness, injury, and health behaviors. Maternal mortality rates in the Mesoamerican region are among the highest in the American continent;


chronic malnutrition and anemia are very frequent; timely immunization of children under two remains a challenge; and infectious diseases like malaria and dengue still affect the poor disproportionately. Distribution of public expenditure in health for the poorest does not commensurate with health needs. These inequalities are unacceptable, yet mostly preventable. The factors driving health equity gaps can be changed, provided that they are addressed in an efficient and integrated manner.

Data on health inequalities

in Mesoamerica

Maternal and neonatal health

maternal mortality

• Maternal mortality ratios in the Mesoamerican region are among the highest on the American continent, and are related to poor women’s limited access to safe childbirth, pre- and postnatal care, emergency obstetric care, and family planning services. • Only 48 out of 100 poor women receive care during pregnancy, compared to 99 out of 100 women in the 20 percent wealthiest segment of the population, and 77 out of 100 women in the average population. 1


• Only 50 out of 100 poor women receive qualified medical attention during childbirth, compared to 92 out of 100 women in the 20 percent wealthiest segment of the population, and 67 out of 100 women in the average population. • Eighty percent of all cases of infant mortality 1 occur during the first 28 days of life for the newborn. Neonatal mortality is related to low access to qualified medical attention during childbirth and first days of life.

According to a 2006 study by the World Health Organization based on data from 2000.

Only 50 out of 100 poor women receive qualified medical attention during childbirth



• In Mesoamerica, poor children under the age of five have a mortality rate of 63.6 per 1,000 live births, compared to 33.3 on average at the regional level. In other words, double the number of children under five years of age in the poorest 20 percent of the population die, compared to the regional average.


Nutrition • Approximately 2.5 million children under five years of age are affected by chronic malnutrition in Mesoamerica. • A poor child between the ages of four and five is six centimeters shorter on average than a child the same age from the wealthiest 20 percent of the population. In other words, a poor child is on average 99 centimeters tall while a child of the same age in the wealthiest quintile measures 105 centimeters. These inequalities are a direct cause and consequence of the vicious circle of poverty in the region. Each additional centimeter of height is associated with higher cognitive skills and school performance, and, later, higher income in the labor market. • In the region2, 32 out of every 100 poor children under the age of five suffer delays in growth, compared to 4 out of every 100 children in the 20 percent wealthiest segment.

Aproximately 2.5 millon children under five years of age are affected by chronic malnutrition in Mesoamerica 2


Regional data of this indicator do not include Guatemala.


Malaria • Since 1990, malaria incidence in Mesoamerica has decreased 82 percent, and, due to significant increases in investment by governments and donors, the illness is currently restricted to a few geographic areas. Despite this progress, its concentration in rural and remote areas results in a high level of transmission among children under five years of age and pregnant women in the poorest 20 percent of the population. • Ninety-five percent of malaria cases in the region are related to Plasmodium vivax, the malaria parasite species predominant in Mesoamerica. P. Vivax rarely causes death, but a person living in an area with moderate endemicity might suffer up to 30 symptomatic episodes of malaria in his or her life. Moreover, there is a strong correlation between the occurrence of malaria and the socioeconomic characteristics of households and communities in Mesoamerica.


• Only 57 percent of children are vaccinated in a timely manner in Mesoamerica. • Complete and timely immunization of children between 12 and 24 months old in the poorest 20 percent of the population ranges between 85 percent in Belize and Honduras and 54 percent in El Salvador and Guatemala.

• Dengue is an increasing public health problem in Latin America. Residents of poor neighborhoods with no access to running water or sewage have a high risk of contagion of dengue fever. • In 2008, in Central America and Mexico, there were about 157,933 reported cases of dengue, of which 9,347 were hemorrhagic dengue, the most severe form, with 39 deaths due to the virus. The high season for transmission of dengue coincides with the rainy season, which starts in May and continues until October or November.



What makes us


What are the expected results?

• A significant decrease in the mortality rate of children under five years of age.

• Reduction of chronic malnutrition and micronutrient deficiency in children under 24 months old and among pregnant women.

• Increase in coverage and quality of childhood vaccination in poor communities.

• Increase in coverage and quality of pre- and postnatal care and improved access to family planning.

• Use of evidence to design health policies and programs geared toward the extreme poor.

• Use of performance measures and evaluation of all operations financed by the Initiative.

• Elimination of malaria transmission in low-risk communities; and considerable reduction in transmission in communities facing high risk.

• Reduction of dengue vectors in the region; and, also, more timely and effective diagnosis, care, and notification of dengue outbreaks.

What makes us different? Salud Mesoamérica 2015 is built on an operational model that acts on both the supply and demand sides of basic health services. Specific program components include: using an innovative results-based financing model, implementing evidence-based health policies, and creating incentives to increase the use of quality health services by the poorest in the population. • The Initiative has an integrated approach; by improving coverage and quality of health services, promoting the use of health services and adoption of healthier behaviors by poor households.

• R  esults-Based Finance: funds from the Initiative, allocated by country, will be supplemented with national resources to develop operations. If countries achieve agreed results in policy, coverage and quality of health services, the Initiative will reimburse half of government contributions. To verify results achieved, rigorous, independent evaluations will be conducted during project implementation. • T  he Initiative promotes national and regional policy dialogue aimed at improving access, coverage, and quality of health services, such as allocation and targeting of public resources to guarantee health services to the poorest in the region.

The resources are assigned by country based on poverty and inequality status • Unlike other international programs, countries participating in the Initiative do not compete for resources because amounts are allocated per country over a five-year period based on each country’s poverty and inequality status. Moreover, governments themselves determine priorities and projects that will be financed within the areas identified.




Carlos Slim Health Institute

Spanish Cooperation (Government of Spain)

The Carlos Slim Health Institute (ICSS) was created in 2007 by the initiative of Mr. Carlos Slim HelĂş for the development and funding of programs aimed at contributing to solving the principal health problems in Latin America and the Caribbean under an innovative and human spirit and with a clear concern for the neediest populations.

Spanish Cooperation aims to contribute substantial progress toward sustainable human development, eradication of poverty, and a full enjoyment of rights. The Principles of Paris Declaration and Accra Agenda for Action provide a framework for its work that uses different instruments, including a more active and efficient multilateralism.

The goal of the Institute is to create and apply best solutions, focusing on all aspects of health: from pregnancy and childbirth to geriatric care; from improvement in household environment to caring for nature; from the physical and emotional well-being of people to social factors; from the recognition of individual efforts related to health to the recognition of contributions by organizations and communities; from personal self-care to large problems in the Latin American region; from the dissemination of traditional knowledge useful for health care to the development of and introduction of the most advanced technological solutions. The Carlos Slim Institute works to generate health solutions with a clear and promising goal: help people live longer and better.


The horizontal priorities of Spanish Cooperation are social inclusion and the fight against poverty, promotion of human rights and democratic governance, integration of gender in development, improvement of environmental sustainability, and respect for cultural diversity. Health is one of the main priority sectors of Spanish Cooperation development policy. Health is considered a fundamental right and necessary condition to achieve the enjoyment of all other rights. Without an adequate health policy, it is impossible to reach a well-balanced and long-lasting development that allows women and men to achieve their individual goals. Health is a public good and, as such, its management is a key component of public responsibility. The Salud MesoamĂŠrica 2015 program involves participation of the Ministry of Economy and Finance, the Ministry of Foreign Affairs and Cooperation, and the Spanish Agency for International Development Cooperation.

Inter-American Development Bank

Bill & Melinda Gates Foundation

The Inter-American Development Bank (IDB) is the main source of multilateral financing and expertise for economic, social, and institutional development in Latin America and the Caribbean, with a mandate to achieve measurable results, increased integrity, transparency, and accountability.

Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift themselves out of hunger and extreme poverty.

The IDB partners with countries to combat poverty and promote social equity through programs tailored to local conditions. Working with governments as well as with the private sector, the Bank seeks to achieve sustainable economic growth, increase competitiveness, modernize public institutions, and foster free trade and regional integration.

In the United States, it seeks to ensure that all people—especially those with the fewest resources—have access to the opportunities they need to succeed in school and life. Based in Seattle, Washington, the foundation is led by CEO Jeff Raikes and Co-chair William H. Gates Sr., under the direction of Bill and Melinda Gates and Warren Buffett.

Established in 1959, the IDB has fifty years of experience in the region. Since then, the Bank consolidated as a group creating the Inter-American Investment Corporation (IIC) and the Multilateral Investment Fund (MIF).

Salud Mesoamérica 2015 [ENG]