It could be accepted that maternal and child health in Latin America and the Caribbean faces problems that respond to the degree of aggressiveness of the environment, the level of development reached by the community, the health resources available to it and the level of perception that the community has of its health problems. These problems may or may not occur at the same time in all countries, or even in different areas of the Region.
Schematically, they are as follows:
· Medical-environmental problems. The aggressiveness of the environment is manifested at its highest degree because of the lack of environmental sanitation and basic hygiene measures, causing enteric infections, respiratory diseases, malnutrition and other conditions. This type of problem is solved through actions carried out on the environment, such as the provision of running water and sewerage, and the application of basic medical technology that is easily accessible. However, many countries remain immersed in this type of problem. The response must be provided through programs aimed at extending the coverage of basic health services.
· Medical-care problems. These require highly differentiated medical technology. They can be summarized as the care of high-risk mothers and newborns, the detection of congenital malformations and the care of disabling chronic diseases that require highly complex medical technology. The response could be provided in centers of increasing complexity, according to the magnitude of the damage that the mother and child present or may present.
· Medical-educational problems. These are factors that limit the training and education of the child and that demand pediatric medical care. Mental retardation and behavioral disorders are the most conspicuous examples of this type of problem, which requires a close relationship between the educator and the health team. Ultimately, the educator is a member of this team and, as such, is responsible for the health of the child and, by logical extension, for the health of the mother and the family.
· Medical-psychosocial problems. These are psychosocial disorders that require medical care and are related to objective components of the community and the family: family structure, urbanization, group organization, use of free time and other factors. This scheme, insofar as it defines concrete problems, suggests the sectoral and extra-sectoral mechanisms that must be implemented in order to carry out health actions.
In this search for means that allow the rapid execution of sets of programs, the classical division of mortality in children under one year of age is into neonatal mortality, under 28 days, and postneonatal mortality, from 28 days to 11 months and 29 days. The former is more closely related to biological factors, or endogenous mortality, while the latter is linked to socioeconomic factors and those derived from the aggressiveness of the environment, or exogenous mortality.
Postneonatal mortality undergoes significant reductions with the application of primary healthcare measures, whereas the reduction of neonatal mortality is more difficult because it requires considerable efforts to promote more complex institutionalized services. A significant step in child health levels is the crossing of the values of these two components of infant mortality. The observation that neonatal mortality is higher than postneonatal mortality, also called late infant mortality, does not initially imply that the greatest efforts should be directed toward perinatal care.
When the infant mortality data provided by the countries of the Region for the evaluation of the Ten-Year Health Plan are analyzed, it can be observed that one group of countries shows a crossing of these values, while other groups are very close to achieving it. The first group has already reached the goal set for the year 2000, while within a few years a second group will reach the goal. A third group is certainly far from achieving that objective.
This difference in figures, in addition to having substantive meaning with respect to health problems and the strategies for solving them, points to an unequal quality of life among the inhabitants of the countries of the Region. Moreover, the gap between them is progressively widening.
It is striking that it seems easier to establish care schemes requiring high technology in wealthy countries than to implement primary care measures and service organization in poor countries. Therefore, estimating the possibility of reaching the proposed goals for the year 2000 by following the trend achieved by each indicator would leave many countries with a negative balance.
However, political decision-making bears its greatest responsibility at this level, not only in the health sector but also in the redistribution of wealth. A set of measures is urgently required to allow the articulation of all productive and social sectors in order to achieve health for all by the year 2000.
