Improving the performance of hospitals and the health system in Latin America and the Caribbean
Authors: Gabriel Bastías, Fernando Poblete
Journal: The Lancet Global Health (2021)

Lack of available human resources has been recognised as one of the major challenges faced by health systems in the past several years.1WHOThe world health report 2006: working together for health. World Health Organization, Geneva2006Google Scholar This is associated with different negative outcomes, such as greater mortality,2Anand S Bärnighausen T Human resources and health outcomes: cross-country econometric study.Lancet. 2004; 364: 1603-1609Summary Full Text Full Text PDF PubMed Scopus (390) Google Scholar particularly in middle-income and lower-income countries. The COVID-19 pandemic has provided an unprecedented example of the difficulties experienced by these countries, with catastrophic consequences partly due to the constraints of limited and insufficiently qualified health-care workers.3Bourgeault I Maier C Dieleman M et al.The COVID-19 pandemic presents an opportunity to develop more sustainable health workforces.Hum Resour Health. 2020; (published online Oct 31.)https://doi.org/10.1186/s12960-020-00529-0Crossref Scopus (26) Google Scholar In The Lancet Global Health, Linda H Aiken and colleagues4Aiken LH Simonetti M Sloane DM et al.Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study.Lancet Glob Health. 2021; 9: e1145-e1153Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar present their study that elaborates on this issue, focusing on the availability of nurses in hospital systems. This study should be highlighted as one of the first works done in Latin America and the Caribbean (LAC) associating the quantity of nurses, the work environment, and the relationship between them with clinical results and productivity (inpatient 30-day mortality, 30-day readmission, length of stay (LOS), and patient experience). The authors did a multilevel cross-sectional study to measure staffing and work environments in public and private Chilean adult high-complexity hospitals. For this, they used data from surveys of 1652 hospital nurses from 40 hospitals (34 public and six private) that were linked with satisfaction surveys of 2013 patients and discharge data for 761 948 inpatients. They included adult patients on medical and surgical units who had been hospitalised for more than 48 h. Aiken and colleagues found that, after adjusting for patient characteristics, each patient added to nurses' workloads increased mortality (odds ratio 1·04, 95% CI 1·01–1·07, p<0·01), readmissions (1·02, 1·01–1·03, p<0·01), and LOS (incident rate ratio 1·04, 95% CI 1·01–1·06, p<0·05). The authors estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1·2 million and $5·4 million if the additional nurses resulted in average workloads of between 12 or ten patients per nurse, respectively. Although the limitations mentioned by Aiken and colleagues are a challenge in this type of study, there are important lessons and aspects that now, more than ever, should be addressed in the region and are derived from this important study. First, it is important to emphasise the study's main objective, which reflects the undesired effects of hospitals not having an appropriate workload distribution or necessary nursing staff. Likewise, it is important to highlight the significant disparity in the consumption of resources that exists between the public and private health systems (at least in the studied sample). This is a central fact of countries in the region, where public hospital output relies on health-care teams often working at capacity limit, which could be a relevant factor in the perceived differences in quality between the two systems, with major inequities and a lack of regulation in the private sector, to which mainly individuals with greater resources have access.5Atun R de Andrade L Almeida G et al.Health-system reform and universal health coverage in Latin America.Lancet. 2015; 385: 1230-1247Summary Full Text Full Text PDF PubMed Scopus (284) Google Scholar A second aspect we might derive from these results, without having all the necessary evidence, is that the deficit of nurses and other health professionals is an issue of the system as a whole.6Organisation for Economic Co-operation and DevelopmentThe World BankHealth at a glance: Latin America and the Caribbean. OECD Publishing, Paris2020Google Scholar Both high-income and lower-income countries are known to show relevant gaps in terms of their coverage of diverse preventive and curative services in primary health care, leading to, among other effects, the existence of preventable hospitalisations for conditions managed in primary health care7Organisation for Economic Co-operation and DevelopmentRealising the potential of primary health care: OECD health policy studies. OECD Publishing, Paris2020Google Scholar or even in the access to basic care services in countries with fewer resources.8Wagstaff A Neelsen S A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49Summary Full Text Full Text PDF PubMed Scopus (43) Google Scholar In that sense, the known shortage of health-care teams in all parts of the system will not only affect each level of the health-care system (primary, secondary, or inpatient care), but also in all the health-care network, reducing capabilities for coordination, collaborative work, and monitoring complex cases, roles for which nursing professionals are particularly qualified and who have the flexibility of assuming additional duties through advanced practice nursing training. Therefore, improvements in the availability of nurses throughout the health network will surely produce very relevant positive effects in quality and costs for the the entire system. A third aspect worth mentioning is the use of information that has the potential to support analysis and decision making in hospital system management in LAC, such as the database for diagnosis-related groups (DRG). One of the issues faced by health systems in the region is the low availability of information that can routinely be used for performance control and monitoring, planning delivery of services, and compared efficiency analyses, which, despite the availability of electronic clinical registry systems in high-income regions, has not been implemented with the same success in LAC.9Pan American Health OrganizationElectronic medical records in Latin America and the Caribbean: an analysis of the current situation and recommendations for the Region. Pan American Health Organization, Washington2016Google Scholar Unfortunately, in LAC, only Chile and Mexico have partially progressed in the use of DRG. A study published by WHO found few examples of DRG implementation in the region.10Mathauer I Wittenbecher F Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries.Bull World Health Organ. 2013; 91: 746-756Crossref PubMed Scopus (97) Google Scholar Additionally, an unpublished study done by our research team for PAHO on payment mechanisms in LAC countries did not find DRG use as a payment or clinical management mechanism, except in Chile.11Poblete F Bastías G Informe: Estado actual de mecanismos de pago en el sector salud en países escogidos de América Latina y el Caribe. Para oficina Regional de Organización Panamericana de la Salud/Organización Mundial de la Salud. Pan American Health Organization, Washington2017Google Scholar This instrument has been available for more than 30 years, so it is evident the level of delay in its use. In this way, multiple factors come together, operating as obstacles to achieving greater access to quality health care in the region, such as the excessive workload experienced by nurses, especially in the public health-care sector, as well as little progress toward the use of information and analytical tools that improve health response capacity. Aiken and colleagues' study contributes in the necessary direction for research in LAC and in low-income and middle-income countries overall, producing evidence and information that contributes to identifying areas in which to invest for improving the health response with viable options. Although this will not always translate into improvement in current policies, it is a necessary step for offering decision makers clear and precise information about existing avenues for progress. We declare no competing interests. Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional studyImproved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value. Full-Text PDF Open Access