Is Health for All Possible?

Abstract

There are two ways to get health for all: combating structural poverty by social justice and combating circumstantial poverty by sanitary justice. The present work shows how we can do these two ways with examples that come from Latin American countries. Alma Ata enunciated the way, through primary health care, solving through it the essential problems of local health, which would be achieved through the strategy of healthy communities and those that seek universal coverage of health services. Healthy communities promote the satisfaction of basic needs for a dignified life, and therefore the inequalities in health determinants. Thus by improving family nutrition will disappear, and if the barriers to access to health services are reduced, universal access to them will be achieved, of equal quality in the face of equal need. Social justice interventions are potentially emancipatory. There are a lot of significant interventions as law 100 of Colombia to obtain universal access to has social justice, but very few of them break the barriers to access, meaning a lack of sanitary justice. Therefore, even after satisfying universal access to health services, differences in health equity persist.

1. Introduction

Childhood anemia, primarily caused by iron deficiency, affects 47% of children under the age of 4 in Peru, with higher rates observed in municipalities with unsatisfied basic needs and lower rates in developed areas [1]. To address these disparities, social development is crucial in reducing the inequalities reflected in these health outcomes.

In 1978, Alma Ata introduced the concept of health for all, focusing on primary health care at the local level. However, despite efforts, essential health problems remain unresolved, and the recent pandemic has disproportionately impacted the less educated and economically disadvantaged populations, exacerbating circumstantial poverty (Figures 1 and 2) [2]. As a result, social determinants and access to health services remain unjustly denied to urban populations, calling for corrective measures. The pandemic has further highlighted social exclusion, particularly for vulnerable populations residing in marginalized areas. Many of them relied on informal jobs, which became scarce due to economic constraints, pushing them deeper into poverty. Thus, addressing health equity becomes crucial in mitigating health inequalities and fostering healthy communities.

Figure 1.

Deaths from COVID-19, according to level of education, Lima, Peru (first wave, no vaccination available).

Figure 2.

Deaths from COVID-19 according to poverty level, (first wave, no vaccination available).

This work aims to explore strategies to combat health disparities, focusing on the importance of social development, equitable access to health services, and the significance of healthy communities in fostering health for all. By addressing these issues, we can work toward reducing health inequality and ensuring a more just and equitable healthcare system for all individuals, regardless of their socioeconomic background or geographic location.

Achieving health for all involves striving for health equity, which means reducing extreme social gaps and ensuring the highest level of health for every individual. Health equity recognizes the needs of those disadvantaged by social, economic, or environmental factors, allowing them a fair opportunity to achieve their full health potential, regardless of their social position. Previous studies in England revealed that even with universal access to health services, health inequities persist, highlighting the importance of addressing underlying social determinants of health [3].

This chapter focuses on studies conducted in Colombia, Venezuela, and Paraguay, examining the relationship between basic needs, health services, and various pathologies in different populations. It demonstrates how social injustice has resulted in poor living conditions and a higher prevalence of diseases associated with structural poverty, reflecting historical exclusion by the state. Additionally, the lack of health justice is evident in population groups facing barriers to accessing healthcare services. The chapter presents successful case studies of achieving health equity and emphasizes how health inequity affects crucial factors such as low birth weight, infant mortality, and reduced life expectancy. Addressing health equity is imperative for reducing health disparities and improving the overall well-being of populations. By dismantling barriers to access and addressing social determinants, we can strive toward a more just and equitable healthcare system where everyone has an equal chance to lead a healthy life.

2. Types of exclusion

This study examines two significant categories of exclusion: (a) stemming from structural disparities in various aspects of life, such as peace, education, food security, housing, employment, and access to essential services, termed social injustices; and (b) arising from unequal and inadequate access to healthcare services, referred to as sanitary injustices.

2.1 Methods for investigating structural poverty

Studies were conducted in Venezuela and Colombia [4, 5] to analyze the correlation between unsatisfied basic needs within municipalities and the prevalence of diseases associated with structural poverty, including neonatal tetanus, diarrhea, malnutrition-related mortality, and median age at death.

The five basic needs are as follows:

1. Inadequate housing: This pertains to deficiencies in the physical conditions of urban or rural residences.

2. Lack of basic public services: This refers to households without access to fundamental amenities.

3. Critical overcrowding: This is defined as having more than three people per room, excluding the kitchen, bathroom, and garage.

4. Lack of school attendance: This includes families with at least one child aged 7–11 years, related to the head of the household, who does not attend school.

5. High economic dependency: This applies to homes where there are more than three individuals per employed person, with the head of the household having completed a maximum of 2 years of primary education.

A household meeting any of these conditions is classified as poor, and if two or more conditions are met, both the household and its members are considered to be in a state of extreme poverty [5].

The analysis performed was limited to descriptive statistics. As these studies were based on primary data sources gathered by the Department of Statistics of the Public Ministry and the Ministries of Health, they do not involve individuals but rather communities. Obtaining informed ethical consent was not necessary unless specific large populations were explicitly named.

The distribution of the neonatal tetanus was concentrated in the more underdeveloped areas of the country. Then the Minister of Health prioritized its control in those districts, through the vaccinations of pregnant women (Figure 3).

Figure 3.

Neonatal tetanus incidence per 100,000 births according to living conditions.

These studies also revealed five different strata of infant mortality in Colombia that determined a 50-year difference in chronological development between the extreme strata [5], meaning that Valle had at that time 22.8 per 1000 against Choco with 91.4 per 1000 of infant mortality (Figure 4).

Figure 4.

Mortality rates by UBN strata in Colombia.

In Paraguay, maternal mortality showed a distribution in which the delay in arriving at the service and deaths at home were the main causes of it (Table 1) [6].

Cause	2001		2002
	F	%	F	%
Delay in arrival at service	60	46	66	41
at home	41	31	30	18
Resolving deficiency of services	30	23	66	41
Total	131	100	162	100

Table 1.

Maternal mortality in Paraguay.

Source: Inf.de la “vigilance epidemiological of health and mother mortality” Min de Salud [6].

Social exclusion, as evidenced by the neglect of rural communities by the state, creates barriers to accessing timely healthcare services, leading to social injustice. To address this, promoting universal access to social and environmental conditions that significantly impact health becomes essential. The life opportunity approach, centered around ensuring minimum survival conditions for all individuals, offers a viable solution [7]. It is worth noting that a significant proportion of illnesses and excess mortality stem not from personal habits or lifestyles but rather from the lack of opportunities for improvement [8]. The pursuit of a social minimum entails providing essential requirements for all individuals over time, a concept advocated by Rawls as the basic structure of society. Key components, such as school attendance, nutrition security, and efficient communication routes, are pivotal in affording individuals a chance at life [9].

In 1978, the primary health care strategy emerged as a vital means to achieve health for all by the turn of the millennium. This approach focused on addressing essential health issues at the local level, with full social participation, intersectoral collaboration, appropriate technologies, and cost-effectiveness within the community. The overarching objective was to attain health equity and narrow gaps in crucial health indicators, including child mortality, chronic child malnutrition, maternal mortality, and life expectancy [10]. The 1986 Ottawa Charter, developed by advanced nations, outlined fundamental prerequisites for health, encompassing peace, education, decent employment, food security, housing, and basic sanitation—qualities that define social justice and provide the foundation for dignified living [11]. The Charter of Bogotá further emphasized the importance of access to welfare [12].

The Ottawa Charter articulated five core lines of action: formulation of healthy public policies, reorientation of health services to prioritize prevention and health promotion, creation of favorable environments, reinforcement of community action, and the development of personal skills to facilitate lifestyle changes. This perspective was later enriched by incorporating the concept of life opportunity, particularly relevant for populations living in poverty across the continent. The result was the emergence of a new public health paradigm that delved into health determinants, intervening in risk factors and promoting protective factors. The United States Institute of Medicine, in 1988, explicitly stated the mission of public health: to ensure conditions conducive to good health [13].

Marchand et al. [8] elucidated the mission’s objectives as follows:

• Achieve the highest level of health across the entire population.

• Reduce extreme health disparities.

• Direct attention toward the most vulnerable social groups in the community.

• Once the above objectives are met, extend interventions to the wealthier populations.

To address social injustice effectively, we have implemented a systematic intervention procedure:

• Selection of excluded communities.

• Collaborative brainstorming with the community to identify problems and potential solutions.

• Identification and prioritization of concerns.

• Conducting comprehensive household surveys to establish intervention baselines.

• Engaging with financing organizations for project support.

• Presentation of projects to the entire community.

• Execution of projects.

• Rigorous evaluation of intervention impacts [14].

A healthy community is defined by its collective efforts, where citizens, institutions, and organizations work together to ensure the health, well-being, and quality of life of all its inhabitants.

Peru has a comprehensive characterization of unsatisfied basic needs, encompassing crucial socioeconomic data of families, such as marital status, family group, land tenure, access to drinking water, excreta disposal, electricity, education level of the mother, occupation of the head of the family, family income, and the number of people per bedroom (Figure 5). Correlating this data with chronic malnutrition in the municipality of Pachacamac revealed a significant correlation between life quality and chronic malnutrition rates among 4-year-old children in four communities [15]. These findings have led us to select Manchay as the district for developing a strategy focused on nurturing healthy communities, which will be further elaborated in this chapter.

Figure 5.

Family classification sheet of the Ministry of Health, Peru.

2.1.1 Experience in Biscucuy, Portuguesa, Venezuela

A successful initiative to combat structural poverty and improve living conditions was observed in Biscucuy, Portuguesa. The town faced a significant health challenge with a double incidence of bronchial asthma and four times the national average of infectious respiratory diseases, attributed to severe air pollution caused by coffee threshers [16]. In response to this critical issue, a healthy policy was devised and implemented by the local government, with the mayor leading the efforts.

The intervention plan aimed at relocating 80% of the coffee threshers within 3 years and diversifying crops by 30%. This decision was not without its challenges, as it involved convincing the largest roasters and coffee grinders to move away from the town’s perimeter area. The local government’s commitment to the well-being of its citizens was evident, with a firm stance that Biscucuy could not be left without coffee cultivation. The mayor at that time said: we must reconcile economic activity with the health of the population, and we believe that this is possible.

By successfully executing this intervention, Biscucuy witnessed a notable improvement in air quality and a subsequent decline in bronchial asthma and infectious respiratory disease cases. The positive outcome of this endeavor underscored the importance of addressing environmental factors and fostering a conducive atmosphere for the overall health and prosperity of the community.

This experience in Biscucuy serves as a valuable example of how intervention measures focusing on improving living conditions can lead to tangible and positive impacts in the fight against structural poverty. By prioritizing the well-being of the population and taking proactive steps to address environmental challenges, local governments can play a crucial role in fostering sustainable development and enhancing the quality of life for their citizens.

This municipality, Development besides: soup kitchens, self-construction of houses, ecological farms with kitchens based on natural gas, an educational radio, etc. [17].

2.1.1.1 Argentina-Paraguay healthy borders

This process involved three essential networks:

1. Community: The selection of beneficiaries was a collective effort undertaken by the entire community rather than being solely controlled by political authorities. An exemplary program, “Hands to the Garden,” distributed 20 four-week-old laying hens or 10 seeds to establish a 10 × 10 meter garden, fostering self-reliance and community involvement. This program, initially existing in Argentina, served as a model for Paraguay.

2. Bridge: The White Garbage initiative enabled the exchange of recyclables such as cardboard, plastic, and glass for milk, inspired by a successful program observed in Brazil during a prior Argentine-Paraguayan delegation visit.

3. Binding: Notably, the President of the Republic of Paraguay extended cooperation to support this initiative, emphasizing the importance of government involvement in fostering healthier communities [18].

2.1.1.2 Manchay gardens healthy community experience

Collaborating with Ricardo Palma University, Manchay implemented several health promotion projects, with a primary focus on food security. The most developed project centered on raising laying hens, which commenced with a generous $5000 donation from the Proniño Foundation, entirely managed by the university. Training in backyard bird handling and cooperatives was provided to community members, leading to the successful distribution of over 6000 laying hens among more than 100 families between November 2014 and February 2020. The impact was evident when the first production campaign positively affected childhood anemia. Initial examinations showed 44% of 16 children to be anemic, while by the end of production, there were no cases of anemia among these children [14, 19]. Furthermore, a subsequent sample of 30 children from the local early education school revealed zero instances of anemia.

Subsequently, the breeding of guinea pigs was promoted to improve the traditional dish “arroz tapado,” commonly consumed in the community. The project distributed 100 guinea pigs to 20 homes, providing four females and one male in each household (Figure 6). This initiative exemplified a sustainable approach to enhance dietary diversity and nutrition. In conclusion, the experience in Manchay highlights the transformative potential of interventions that harmonize economic activities with public health initiatives. By engaging communities, fostering self-sufficiency, and promoting innovative projects, it is possible to uplift living standards and create healthier, empowered societies.

Figure 6.

Breeding Guinea pigs.

The community of Manchay, under the guidance of Pastor Julio Piña, has been actively engaged in several projects aimed at improving the well-being of its inhabitants and fostering sustainable development. Among the initiatives implemented are food security projects, canine bite control, adolescent pregnancy prevention, and judo training for children. To address food security, Pastor Julio Piña conducts vegetable-growing courses every 6 months, encouraging community members and residents from neighboring areas to establish family orchards. As a result of these efforts, a thesis is currently being developed to assess the impact of these projects on the population’s food security. Recognizing the high incidence of canine bites, the community took proactive measures to control the issue. With an estimated 615 dogs in the population, averaging 1.25 dogs per household, and 70% being male dogs, the annual bite incidence was 6%. To mitigate the problem, a castration goal of 80 male dogs was set, and 18 castrations have been successfully performed. The initial surgery session received the support of Dr. Jack Weber, a recipient of the EMI Award.

Moreover, the community initiated an adolescent pregnancy control project with the aim of reducing the frequency of such pregnancies by 50%. To achieve this goal, activities were designed to utilize free time productively, including engaging in sports, reading (with the establishment of a library), recreational activities, and avoiding school dropout. For those who had already left their studies, the project focused on providing vocational training and promoting responsible parenthood. Counseling sessions were offered to educate adolescents on ways to prevent pregnancies and delay the onset of sexual relations. In addition to these vital efforts, the community sought to promote social equity among its children. In the first semester of 2017, a tatami (mat) was constructed in the community center, and from that point onward, the community encouraged children to practice judo every Saturday. This endeavor aimed to foster a sense of discipline, unity, and physical well-being among the young residents (Figure 7).

Figure 7.

Judo teaching.

The multifaceted approach taken by the community of Manchay reflects the power of community-led initiatives in driving sustainable development and improving the overall quality of life. Through their dedication, collaboration, and proactive measures, they have demonstrated that positive change is possible when communities come together to address critical issues and foster growth and prosperity for all residents.

In their unwavering commitment to fostering a safe and harmonious community, the residents of Manchay recognized the significance of reducing family and community violence. A multifaceted approach was undertaken, targeting the lack of lighting in a sports center, addressing concerns related to young smokers’ meeting spots, and enhancing safety measures throughout the area.

To create a safer environment, the community proactively addressed the issue of inadequate lighting in the sports center, which had become a meeting place for young smokers. The lack of proper illumination not only posed safety risks but also facilitated anti-social activities. The community came together to correct this situation, with residents actively participating in the process. They worked diligently to improve the lighting conditions, making the sports center more inviting and secure for all. Additionally, rounds were organized within the community, with residents collaborating and keeping a watchful eye on the area, especially in spots known to attract young smokers. By actively engaging with their surroundings, the community demonstrated their commitment to maintaining a safe and peaceful environment.

To further enhance safety, alarms were installed in strategic locations, providing a quick and effective means to alert residents in case of any potential threats or emergencies. This measure not only deterred potential offenders but also bolstered the sense of security among community members. Recognizing the importance of expert advice, retired officers from the police and army, along with a citizen of San Juan de Miraflores, offered valuable guidance on violence prevention. Their experience and knowledge in handling security matters proved invaluable in developing strategies to curb violence within the community. This comprehensive approach showcases the power of community-driven initiatives in tackling complex issues like violence. By actively collaborating, identifying problems, and implementing practical solutions, the residents of Manchay have exemplified the strength of communal effort in creating a safer and more secure environment for everyone. Their dedication to enhancing the quality of life within the community serves as an inspiring model for other neighborhoods to follow.

In 2016, a significant step was taken toward generating sustainable development in the community of Manchay. With the objective of creating productive projects that could contribute to the community’s prosperity, the Direction of Social Projection and Community Extension at the university, led by Professor Dominino Vilca, collaborated on an impactful initiative. Thanks to the generous donation of a ceramic oven by the Proniño charity foundation, community members were trained in the art of manufacturing molds and handicrafts. This endeavor opened up new economic opportunities for the community and the university alike. The handcrafted products were later sold within the community, enabling the participants to earn an economic income. This initiative proved transformative for five families, significantly improving their living conditions (Figure 8) [14].

Figure 8.

Productive projects, ceramics.

The project exemplifies the potential of productive endeavors in driving positive change and promoting sustainable development. By empowering individuals with valuable skills and providing them with the necessary tools, the collaboration between the university and the community showcased how economic opportunities can be harnessed to uplift the quality of life for families. Moreover, beyond the immediate financial benefits, the project fostered a sense of pride and self-sufficiency within the community. By creating marketable handicrafts, community members gained a deeper appreciation for their talents and cultural heritage. This interplay between economic empowerment and cultural preservation further strengthened the fabric of the community.

Through the collective efforts of the university, Professor Dominino Vilca, the Proniño charity foundation, and the participating families, the project exemplified the spirit of collaboration and the potential for sustainable development. It serves as a powerful testament to how community-driven initiatives can create a positive ripple effect, leading to lasting improvements in living conditions and overall well-being. The legacy of this project continues to inspire others to harness their skills and resources for the greater good of the community.

Indeed, the three examples demonstrate the efficacy of the healthy community strategy and emphasize the importance of full community participation, intersectoral collaboration, and seeking collaboration beyond the municipality. These key elements play a vital role in fostering sustainable development and enhancing the overall health and well-being of the community.

3. Public health policies

Public health policies play a pivotal role in shaping the health outcomes of populations, and their implementation may be overseen by various bodies beyond the Ministry of Health. Local governments and other ministerial departments also contribute to policies that have a profound impact on people’s health. These policies have demonstrated significant effects, particularly in urban centers, where certain health indicators are closely linked to specific initiatives. For instance, the mortality rate per 100,000 inhabitants due to firearms is notably higher in developed municipalities [20]. This highlights the role of urban policies and local governance in influencing public safety and well-being. By addressing the factors contributing to violence and firearm-related deaths, communities can create safer environments and protect their residents from harm. In Lima, specific evidence illustrates the effectiveness of healthy public policies in curbing mortality rates in various areas. A notable example is the establishment of a healthy public policy in December 2011, which led to a substantial decline in traffic-related fatalities, suicides, and homicides (Figure 9). Particularly noteworthy was the reduction in fatalities among young men. This positive impact was achieved through measures such as restricting liquor sales hours, which contributed to a safer and healthier urban environment [21].

Figure 9.

Results of the restriction of liquor sales hours in relation to violent deaths, metropolitan Lima.

The success of these public health policies underscores the importance of collaborative efforts and cross-sectoral cooperation. It demonstrates that positive health outcomes can be achieved when various stakeholders, including local governments and other ministerial bodies, align their efforts to address critical health issues. It is evident that public health policies extend beyond the healthcare sector and encompass diverse areas that impact community well-being. By adopting evidence-based approaches and prioritizing the health of their citizens, governments, and policymakers can create lasting positive change. These policies, when informed by research and tailored to local contexts, have the potential to enhance the overall health and quality of life for all members of society. The experiences in Lima and other cities highlight the transformative power of public health policies when implemented in a collaborative and coordinated manner, leading to healthier and more vibrant communities.

3.1 Methodology for studying circumstantial poverty: Understanding short-term poverty

Short-term or circumstantial poverty, as measured through the economic income of inhabitants, provides valuable insights into the division between extreme and non-extreme poor and the non-poor. This type of poverty can fluctuate over time, and to study it effectively, comprehensive assessments are conducted. In Paraguay, these studies are carried out through collaboration between the Directorate of Statistics and Censuses for economic statistics and the Ministry of Health for access to services.

4. Results

The findings of the study reveal stark disparities between different quintiles of the population. In the poorest quintile, the prevalence of extreme poverty is alarmingly high at 77.5%, while it did not exist in the fourth and fifth quintiles. This emphasizes the urgency to address the challenges faced by the most vulnerable members of the population. Access to essential services, including healthcare, also highlights significant inequities. In the poorest 20% of the population, there are only 1.6 doctors per 10,000 inhabitants, whereas the richest 20% enjoy a significantly higher ratio of 6.5 doctors per 10,000 inhabitants (Figure 10). This disparity in access to medical professionals underscores the need to bridge the gap between different socioeconomic groups.

Figure 10.

Health professionals and number of hospital beds according to current poverty levels.

Furthermore, inequitable access to healthcare is evident in vaccination coverage. The poorest 20% of the population had a vaccination schedule coverage of only 47.4%, while the richest 20% enjoyed a much higher coverage of 83.9% [22]. Such disparities must be addressed to ensure equal access to vital healthcare services for all segments of the population. Overall, there is a clear pattern where health services tend to reach higher coverage in large cities, leaving small and rural areas with significantly lower coverage rates. This disparity poses challenges for vulnerable communities residing in remote regions, highlighting the importance of implementing targeted interventions to improve access to healthcare services in underserved areas. To address circumstantial poverty effectively, it is essential for policymakers and relevant authorities to comprehend the root causes of these disparities and design targeted interventions that prioritize the needs of the most vulnerable segments of society. By leveraging data-driven insights and implementing equitable policies, countries like Paraguay can work toward reducing short-term poverty and promoting sustainable development for all citizens.

4.1 Understanding access to services: Disparities and correlations

In Venezuela, the correlation between mortality from tuberculosis and unmet community needs highlights the critical importance of access to services. The data revealed that areas with limited access to healthcare and essential services experienced higher mortality rates from tuberculosis [4]. This correlation underscores the urgent need to address disparities in access to healthcare resources and ensure that all communities have equitable access to life-saving services.

In Peru, the findings were equally revealing. The study demonstrated that infant mortality rates decreased in developed municipalities but increased in municipalities with lower levels of development. The disparity in median age of deaths was striking, with stratum 1 reaching 67 years and stratum 5 only reaching 44 years in 1999. This stark contrast in life expectancy emphasizes the profound impact of socioeconomic disparities on health outcomes (Figure 11) [23]. In regions characterized by both structural and circumstantial poverty, the challenges are compounded. The excluded departments, experiencing both forms of poverty, face complex barriers to improved health and well-being. Addressing these multifaceted challenges requires comprehensive and targeted interventions to uplift the most vulnerable communities and improve their access to essential services.

Figure 11.

Infant mortality gaps in different regions of the country, Peru.

The correlations observed in both Venezuela and Peru highlight the interconnectedness of access to services and health outcomes. Disparities in healthcare access can lead to differential health outcomes and contribute to health inequalities among different strata of the population. Understanding and addressing these correlations are crucial steps in advancing public health policies that promote equity, reduce poverty-driven health disparities, and foster a healthier and more equitable society. To address these challenges effectively, it is imperative for policymakers and stakeholders to prioritize efforts that improve access to essential services, healthcare, and resources in underserved communities. By targeting resources to areas with the greatest needs and implementing evidence-based interventions, countries can work toward reducing health disparities and promoting better health outcomes for all citizens, regardless of their socioeconomic status or geographical location.

4.2 Access barriers

Health service reforms that include universal insurance as a goal may produce more inequities in access, since the highest insurance was observed in municipalities with a lower prevalence of unsatisfied basic needs (Figure 12) [24].

Figure 12.

Insurance levels according to level of municipal life condition, in response to law 100 of Colombia.

Evidence suggests that resources allocated for the poor have not always reached the most excluded municipalities. Instead, these resources seem to have been primarily invested in municipalities with a higher percentage of basic needs satisfied. This disparity raises concerns about the effectiveness of resource allocation and the impact it has on addressing poverty-driven health disparities. In Colombia, the implementation of the SISBEN (Beneficiary Identification System) reflects the country’s efforts to ensure targeted assistance to those in need. However, concerns exist regarding the system’s accuracy in distinguishing between individuals who require assistance and those who do not. The goal of eliminating type 1 errors (inclusion of those who do not need assistance) can inadvertently lead to type 2 errors (exclusion of those most in need) [25]. Balancing these concerns and ensuring that resources reach the most vulnerable communities remains a crucial challenge. Ethnic barriers further compound the issue of access to insurance in some regions. In Guatemala, disparities exist between indigenous and non-indigenous populations (Figure 13), illustrating the need for targeted interventions that address the specific needs of different ethnic groups. To ensure equity in healthcare access, policies and interventions must be sensitive to the cultural and social contexts of diverse communities.

Figure 13.

Levels of health insurance according to ethnic groups, Guatemala.

Moreover, barriers related to education can hinder access to insurance and healthcare services. In outbreaks of immuno-preventable diseases, such as diphtheria, unvaccinated children and young people in certain areas faced the consequences, despite vaccines being available in health services. Educational barriers can lead to low vaccine uptake and hinder the reach of preventive measures. Addressing these disparities requires a multifaceted approach. Policymakers must be attentive to the specific needs of marginalized communities and develop targeted interventions that account for cultural, social, and educational factors. Investing in educational initiatives that promote health awareness and preventive measures can empower communities to make informed decisions about their health. Furthermore, transparent and efficient resource allocation processes are essential to ensure that assistance reaches those who require it the most. Rigorous evaluation and continuous improvement of existing identification systems, such as SISBEN, can help optimize the distribution of resources and ensure that they reach the most excluded municipalities and vulnerable populations. By working collaboratively with communities, healthcare providers, and stakeholders, countries can overcome barriers to insurance and healthcare access. Emphasizing equity, inclusivity, and evidence-based policy decisions will pave the way for a more equitable and effective healthcare system that leaves no one behind.

4.3 Combating circumstantial poverty: Challenges and interventions

Despite various interventions aimed at expanding services for underserved populations, they often fall short in breaking the barriers of circumstantial poverty. In Colombia, the recognition that advancements in insurance for the poor were primarily observed in large cities (Figure 12) prompted the Minister of Health to issue a decree directing resources toward insurance for the poorest municipalities with a high percentage of unsatisfied basic needs. However, further assessment was hindered by a change in the presidency, leaving the actual impact of this policy change uncertain.

5. Conclusion

• There exists a positive correlation between structural poverty and diseases associated with poverty, signifying the importance of addressing essential minimums in excluded populations. Health equity is achieved by allocating resources based on different levels of need, prioritizing those with the greatest need, rather than equal distribution for all. Interventions focused on social exclusion must address the specific needs of diverse communities.

• A positive correlation between risk factors for chronic and social diseases and the lowest percentage of unsatisfied basic needs was found. This suggests that public health policies should prioritize addressing inequalities prevalent in developed municipalities, such as implementing restrictions on liquor sales hours, to combat health disparities.

• A negative correlation between short-term poverty and social and sanitary justice highlights the urgency of targeting populations with the least satisfaction of basic needs. To ensure health justice, interventions should focus on improving access to basic sanitary measures and healthcare services for these vulnerable communities.

• Social injustice’s impact on health persists even when health services are equitably distributed. Understanding and addressing the root causes of social injustice are crucial for achieving meaningful health outcomes for all.

• Combating social exclusion requires a primary focus on structural poverty, followed by addressing circumstantial poverty. Targeted interventions that consider the specific needs of excluded populations are essential for reducing health disparities.

• Addressing individual exclusion can eliminate individual risks, and achieving high vaccination coverage through health education programs contributes to health justice. Lowering barriers to access to healthcare services, such as education and healthy public policies, is essential to ensuring equitable healthcare for all.

• Further studies should be conducted to address barriers to access to health services. Health education programs can address issues like low service utilization, and education and decent employment can help combat ethnic differences in healthcare access.

Acknowledgments

The author extends gratitude to their granddaughter Jade de Melo Malaga, a medical student, for her valuable collaboration in writing this manuscript.