While countries in Latin America and the Caribbean have expanded coverage and improved health outcomes over recent decades, there are persistent and large gaps by income, education, place of residence, ethnicity and other population characteristics. These inequalities are reflected in exposure to health risks, access to services, quality of care, financial protection and health outcomes. This chapter examines the main patterns of health inequalities in the region and reviews how countries are responding through policies on governance, financing, service delivery, workforce, digital health, data systems and emergency preparedness. Drawing on regional evidence and a 2025 survey of 14 countries, it finds that policy efforts have advanced further in expanding the availability and affordability of services than in addressing the conditions needed to make care equitable in practice. Reducing inequalities will not only require extending coverage to address remaining gaps in access, but also improving the quality, continuity and responsiveness of care.
Health at a Glance: Latin America and the Caribbean 2026
Abstract
Across Latin America and the Caribbean (LAC), progress in health coverage and outcomes over recent decades has been meaningful but uneven (OECD/The World Bank, 2023[1]). While many countries have expanded access to services and reduced mortality, large differences persist across population groups and territories. These inequalities are observed across multiple dimensions, including socio-economic status, geography, ethnicity, gender, age, migration status, disability, and health system affiliation, including segmented systems (Atun et al., 2015[2]; Cotlear et al., 2015[3]). As a result, national averages can obscure persistent gaps for specific groups and places.
These inequalities matter not only from a social perspective, but also for the performance of health systems. Where disadvantages accumulate, preventable illness and avoidable mortality remain concentrated, even when overall service contact is high, because effective coverage can remain unequal when service quality, continuity, or affordability differs across groups (Kruk et al., 2018[4]). Inequalities are often associated with delays in care, lower service quality, weaker financial protection, and higher downstream costs (Wagstaff et al., 2018[5]). They also reduce system resilience: shocks such as pandemics, economic crises, or climate‑related events tend to widen existing gaps. (PAHO, 2022[6]; WHO, 2025[7]).
Inequalities and inequities
This chapter distinguishes between health inequalities and health inequities, terms that are sometimes used interchangeably but serve different analytical purposes. Health inequalities (or disparities) refer to measured differences in health outcomes, service use, quality, financial protection, or exposure to health risks across population groups. Health inequities are those inequalities that are considered unfair, avoidable, and amenable to policy action, arising from social conditions and from how health systems and other institutions are organised (WHO, 2013[8]). Governments act on inequities, but they rely on the measurement of inequalities to identify problems, monitor trends, and assess progress toward universal health coverage (UHC) and related goals.
Inequalities “in what” and “for whom”
To organise the analysis, the chapter distinguishes what aspects of health and health systems are unequal (“inequalities in what”) and which population groups experience these differences (“inequalities for whom”).
These aspects correspond to key dimensions commonly used in monitoring progress toward UHC (WHO/IBRD, 2023[9]). They are closely related. Inequalities in exposure to health risks and social determinants shape patterns of health need across populations. Inequalities in access to services, quality of care, and financial protection influence whether those needs are met in a timely and effective way. Inequalities in health outcomes reflect the cumulative effects of these differences. Taken together, they help explain why progress measured at the national level may not translate into comparable gains for all groups, and why persistent inequalities can undermine health system performance and resilience.
Population categories considered in the chapter include demographic and socio-cultural characteristics (such as gender, age, ethnicity, and migration status), socio-economic position (such as income and education), geographic location (including rural, remote, and subnational variation), and other relevant groupings, including disability and health system or insurance affiliation in segmented systems (Table 2.1). These groupings reflect distinct mechanisms through which disadvantage can shape exposure to risks, access to timely and effective care, and protection from financial hardship.
This chapter first presents stylised facts on health inequalities in LAC across key domains, drawing on available international and regional evidence. It then examines how countries are addressing inequities through health system policies and interventions, highlighting common approaches, gaps, and opportunities. This analysis draws on information reported by countries through a regional survey, which documents the existence of policies, institutional arrangements, and mechanisms relevant to health equity, without assessing their effectiveness or the intensity of their implementation.
The ability to examine inequalities across these dimensions depends on the availability of disaggregated data, which remains uneven across the region. Many countries routinely report indicators by age, sex, and place of residence. However, disaggregation by ethnicity, migration or disability status, or health system affiliation is far less common and frequently reported in categories that are not comparable across countries. As a result, some inequalities are more visible than others, and gaps in data and reporting can limit both monitoring and policy action. These issues are taken up later in the chapter when examining countries’ approaches to data, monitoring, and equity reporting.
This section draws on the literature and international data to provide a context for the primary focus of the chapter: the status of policies addressing inequality. Inequalities in health outcomes and healthcare have been a persistent concern in the region and remain observable across multiple domains, although the available evidence on within-country inequalities remains limited to a relatively narrow set of population groups.
Higher status households are more likely to benefit from government- or employer-sponsored health programmes or insurance that provide privileged access to better-quality services than those with lower status, particularly those who are unemployed, employed in informal jobs, or pertain to disadvantaged or marginalised groups. Such programmes sometimes provide higher status families with more financial protection but, in many countries, it is the richer households that have high shares of out-of-pocket spending while poorer ones have unmet health needs or resort to low-cost alternatives or self-treatment. Thus, the inequalities in health outcomes reflect more than differences in household income or assets. They are also transmitted or amplified by the associations between income and fewer health risks, greater access to good quality healthcare, and shares of out-of-pocket health spending relative to household income.
Figure 2.1 presents a picture of gaps in access to care, quality of care, and health outcomes, proxied by Antenatal Care (ANC) use, ANC quality, and the Infant Mortality Rate (IMR). Using data from (Bancalari et al., 2025[10]), these figures show gaps between better off and worse off groups. The gaps are normalised, which eliminates the mean difference between countries and emphasises relative inequality rather than absolute inequality. The value of measuring relative inequality is that it measures the condition of disadvantaged groups compared to what is achieved for the advantage in that same country. For example, in Peru the IMR for the richest was approximately 5.7 per 1 000 live births, compared to around 18.1 for the poorest, a relative gap of 69%. In Haiti, the richest faced an IMR of 45.1 per 1 000 live births, compared to around 58.2 for the poorest, a relative gap of 22%. Thus, while the gap in Peru demonstrates a larger relative gap between rich and poor within that country, overall Peruvians face much lower infant mortality than Haitians.
Notes: Values report within-country inequality ratios for education, wealth, and place of residence across antenatal care (ANC) use (4+ visits), ANC quality, and infant mortality. For ANC outcomes, gaps are calculated as one minus the ratios of the disadvantaged to the advantaged (i.e. 1 – least educated/most educated; 1‑ poorest/richest; 1 – rural/urban). Larger values indicate worse coverage or quality among disadvantaged groups and 0 indicates equality. For infant mortality, gaps are calculated as one minus the ratio of advantaged/disadvantaged (i.e. 1 – most educated/least educated; 1‑ richest/poorest; 1 – urban/rural). This retains the interpretation of larger values as indicating a larger gap between disadvantaged and advantaged groups, with 0 indicating no difference. Country years refer to the survey year; data sources include Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and Peru’s National Demographic and Family Health Survey (ENDES). Asterisks denote statistical significance as reported in the source (*** p<0.01).
Source: Inequalities ratios are based on estimates reported in Bancalari et al. (2025[10]), “Health inequalities in Latin America and the Caribbean: child, adolescent, reproductive, metabolic syndrome and mental health”, https://doi.org/10.1093/ooec/odae028.
Health outcomes as measured by the IMR are much better for the richer and better educated than for the poorer and least educated in almost all countries. These gaps are also larger than the gaps in access to antenatal care and to the quality of care. This result is not surprising: infant mortality is affected by many factors beyond healthcare access and quality. The findings are somewhat like the proverbial glass that can be described as half full or half empty. Gaps in access to care and quality are not as bad as the health outcomes; but the gaps are still there. Thus, any factors associated with income or education that create higher risks for disadvantaged groups are not being offset by the healthcare system but, rather, amplified by them.
The urban and rural gaps in healthcare access, quality, and IMR are less well measured. Nevertheless, they present a similar story. For the most part, gaps in access to antenatal care appear to have been quite small in many of these countries, especially considering how dispersed their rural populations are. Bolivia, Colombia, Guatemala, Haiti and Honduras all have gaps in access that are less than 20%. Nevertheless, as with gaps by income and education, gaps in infant mortality remain large and significant between urban and rural areas. This appears to have been particularly true in Bolivia, Guyana and Peru, for which the IMR gap is more than 40%.
Coverage has expanded, but unmet need remains high and unequal
Despite improvements in service coverage in the 2000s, unmet healthcare needs – patients reporting they needed but did not seek appropriate care – remain widespread and highly unequal. Recent estimates suggest wide variation in unmet needs across the Americas, averaging 35%, with rates ranging from 3.2% in Costa Rica to 73% in Peru. Three countries report levels above 50%, and this rises to six countries when focussing on the lowest income quintile (PAHO, 2024[11]). These high rates are in part explained by the transition into successful universal coverage and higher health literacy. In Peru, for example, recent advances into the current 97% health coverage created new awareness of care needs that are still being optimized into the system (Bernal, Carpio and Klein, 2017[12]). Nevertheless, the sharp rise in unmet needs in the region during the COVID‑19 pandemic suggests that aggregate gains – including progress in narrowing gaps across and within countries – remain fragile when systems are disrupted, and that disadvantaged groups are more likely to experience deferred or forgone care during shocks.
Within countries, unmet need and service coverage follow clear socio-economic gradients. For instance, coverage of reproductive, maternal, newborn, and child health (RMNCH) services is typically 15‑20 percentage points (p.p.) higher among the richest quintile than the poorest. Women with secondary or higher education have markedly higher coverage than those with no formal schooling, and urban populations consistently report higher service coverage than rural residents (PAHO, 2024[11]).
Underlying this pattern there are differences in barriers to access, particularly regarding affordability. Across the region, about one in five individuals in the poorest quintile report unmet needs due to financial constraints, compared to roughly one in ten in the richest quintile (PAHO, 2024[11]).
Gaps in effective coverage and quality persist even where contact is high
As access has improved over time, gaps in quality of care have emerged as a major constraint to improving health outcomes in the region (Figure 1.2, see Chapter 1). A substantial share (an estimated 50‑75%) of avoidable mortality in the region is attributable to poor-quality care rather than lack of access (Kruk et al., 2018[13]) (see indicator “Avoidable Mortality (preventable and treatable)” in Chapter 7). Thus, even where service contact is high, effective coverage remains uneven, reflecting shortcomings in continuity of care, diagnostic accuracy, treatment adherence, and system responsiveness.
These quality gaps are not evenly distributed within countries. In maternal health, women with low education and those in the poorest wealth quintile are not only less likely to complete four or more antenatal visits, but also less likely to receive the full package of recommended services compared to more advantaged women. For chronic conditions, socio-economic differences in prevalence are often moderate, yet inequalities widen substantially along the care cascade – particularly in diagnosis, treatment, and effective control (see section “Integrated Care” in Chapter 1). As a result, disadvantaged groups experience lower-quality and less continuous care even in settings where service utilisation is widespread (Bancalari et al., 2024[14]). Limited evidence also suggests that men experience higher levels of avoidable mortality than women, although poor quality likely accounts for most avoidable deaths for both sexes (Vargas, Rios-Zertuche and Bauhoff, 2025[15]).
Financial protection remains stratified
Financial risk protection has improved in parts of the region but remains uneven and often regressive. In 2019, nearly 8% of people in the Americas incurred catastrophic health expenditures, with double‑digit catastrophic spending rates in some countries. Out-of-pocket (OOP) spending – often driven by spending on medicines – has declined as a share of total health expenditure since 2000 but still accounts for roughly one‑third of health spending regionally, leaving households exposed to financial hardship when care is needed (see indicators “Financing of healthcare from households’ out-of-pocket” and “Financial protection” in Chapter 6).
Financial hardship is not evenly distributed. Rural households and lower-income groups face higher risks of catastrophic and impoverishing health spending; in some countries, the share of rural households pushed into poverty due to health costs is several times that of urban households.
Public policy regarding health financing strongly influences these patterns by affecting who benefits. Countries like Peru (see Box 2.1) and Mexico have retained segmented health systems that provide formal sector workers with better access to higher-quality care than those seeking care at government-run facilities. Countries like Brazil have implemented reforms to unify their health system and incorporate everyone within the same common national pool; however, the country’s upper income classes have opted into private health insurance to get better coverage and care, effectively segmenting the system (OECD, 2021[16]). Only a few countries, like Chile, Costa Rica, Colombia and Uruguay, have programmes which incorporate the whole population in a single system with cross-subsidies; although, even then, benefits and access vary between rural and urban areas and between people who contribute to the system and those who are fully subsidised (Roberti et al., 2024[17]). For Colombia, the system is indeed structured on cross-subsidies and relevant collection capacity. However, persistent inequities are not solely a matter of financial coverage: territorial barriers, particularly between urban, rural and dispersed rural areas, together with constraints in service supply, institutional organisation and differential access conditions, remain key drivers. Recent policy instruments are addressing these gaps, including the National Rural Health Plan, advances in interoperability, differential payment mechanisms, strengthening of national medicines production and public hospital infrastructure projects in rural areas.
By 2023, insurance coverage in Peru had reached 97% of the population. Yet coverage does not translate into equal financial protection. The Seguro Social de Salud (EsSalud), a contributory scheme covering around 26% of the population, primarily formal sector workers, provides broader benefits than Seguro Integral de Salud (SIS), the non-contributory scheme covering around 62% of the population, mostly poor and vulnerable groups. EsSalud members access a full range of specialist and inpatient care, including costly interventions, without co-payments for medicines, while SIS has historically applied spending limits for higher-cost services beyond the basic package. The lack of infrastructure and an insufficient supply of health workers have further constrained what SIS affiliates can access in practice (OECD, 2025[18]).
In 2022, out-of-pocket (OOP) payments accounted for 27% of total health expenditure, 1.4 times the OECD average, despite declining by more than 20% over the preceding decade. Figure 2.2 shows that EsSalud affiliates account for the largest share of OOP, consistent with their higher utilisation of a more comprehensive scheme. By 2021, SIS affiliates had slightly surpassed them, a pattern that reflects direct payments for services covered under the benefit package but not available in SIS facilities. In other words, the increase in OOP among the poor signals a failure to provide care in public facilities along with inadequate mechanisms for financial protection. The trend in OOP spending among SIS affiliates serves as the baseline for Peru’s ongoing fiscal reforms. The government is actively strengthening FISSAL (the high-cost fund) and improving the supply chain for essential medicines to ensure universal coverage for the most vulnerable.
Note: OOP data by insurance scheme from ENAHO survey.
Source: OECD (2025[18]), OECD Reviews of Health Systems: Peru 2025, https://doi.org/10.1787/f3ddb6a4-en.
Governments can offset the inequity inherent in segmented systems through appropriate direct- and cross-subsidies. Somewhat surprisingly, public funding often flows in the opposite direction, favouring privileged groups. Public insurance programmes for formal sector employees can run deficits which are ultimately repaid from general revenues. Governments sometimes respond to public pressures over the cost of healthcare to higher income groups by subsidising private insurance and private provision (OECD, 2021[16]). These patterns show how health financing structures can offset or amplify inequalities in access to services and financial protection.
Exposure to health and climate risks follow strong socio-economic and territorial gradients
Across Latin America and the Caribbean, exposure to both health and climate risks is sharply stratified along socio-economic, territorial, and ethnic lines. Children in the poorest quintile face stunting rates that exceed those of the richest by 30 p.p. or more in Bolivia, Guatemala, Honduras and Peru, reflecting deep inequalities in nutrition, housing, food security, and access to safe water and sanitation (see indicators “Child malnutrition” and “Water and sanitation” in Chapter 4). Rural households consistently report lower access to electricity and basic infrastructure than urban households, and Indigenous populations often have systematically lower access to improved water and sanitation than non-Indigenous populations. A substantial share of urban residents lives in slum conditions, where overcrowding and inadequate services compound environmental, infectious, and climate‑related risks (Libertun de Duren et al., 2022[19]; PAHO, 2019[20]). Behavioural and injury-related risks follow similar gradients: smoking prevalence and road traffic mortality are consistently higher among men than women, highlighting persistent gender divides in preventable mortality. Overweight and obesity are widespread across the region, but patterns vary by sex and country, often intersecting with socio-economic and territorial inequalities (Bancalari et al., 2024[14]; PAHO, 2019[20]).
Exposure and vulnerability to climate hazards interact with social inequality. Neighbourhoods of higher socio-economic vulnerability are systematically more likely to be at risk of high temperatures, for example in cities such as Barranquilla, Santiago and Mexico City (World Bank, 2025[21]). Flood exposure follows similarly steep social gradients: residents of neighbourhoods in the lowest quintile of educational attainment are several times more likely to experience flooding than those in the highest quintile (Kephart et al., 2025[22]).
The burden of ambient air pollution reflects the same territorial and demographic gradients (Figure 2.3 and Figure 2.4). In 2019, DALYs attributable to ambient particulate matter ranged from under 5 per 1 000 inhabitants in Paraguay and Nicaragua to above 15 per 1 000 in Trinidad and Tobago and Guyana, with males showing a consistently higher burden than females across all countries (Figure 2.3). Children under 15 faced a persistent and largely unchanged burden from ambient particulate matter over the decade, with several countries recording increases (Figure 2.4, left panel). Adults aged 65 and over experienced approximately seven times more DALYs per person from ambient particular matter than children at the regional level, with only modest improvement since 2010 in most countries (Figure 2.4, right panel; see also indicator “Environmental and climate risks” in Chapter 4).
Notes: DALYs attributable to ambient particulate matter (PM2.5) per 1 000 inhabitants, all age groups combined. LAC = Latin America and Caribbean regional aggregate.
Source: OECD Environment Statistics, Mortality, morbidity and welfare cost from exposure to environment-related risks (2024).
Under 15 (left panel) and aged 65 and over (right panel), 2019 and 2010
Notes: DALYs attributable to ambient particulate matter (PM2.5) per 1 000 inhabitants aged under 15 (left panel) and 65 and over (right panel). LAC = Latin America and Caribbean regional aggregate.
Source: OECD Environment Statistics, Mortality, morbidity and welfare cost from exposure to environment-related risks (2024).
Health outcomes reflect cumulative disadvantage across groups
Differences in exposure, access, quality, and financial protection are reflected in unequal health outcomes. Adult mortality is consistently higher among individuals with lower education, with injuries contributing disproportionately to excess mortality among younger adults and noncommunicable diseases driving disparities among older cohorts (Buitrago et al., 2026[23]). Maternal mortality ratios vary dramatically across countries, from fewer than 20 to several hundred deaths per 100 000 live births. Infant and under-five mortality rates are consistently higher among Indigenous and Afro-descendant populations and among children in the poorest households; in several settings, under-five mortality among Indigenous children exceeds that of non-Indigenous children by 15‑35 deaths per 1 000 live births – in some cases nearly double. Early-life disadvantages are further reflected in markedly higher child stunting and adolescent fertility rates among girls from the poorest households (see indicators “Maternal mortality”, “Infant and neonatal mortality”, and “Under age 5 mortality” in Chapter 3).
These inequalities widened during the pandemic. Mortality rates for healthcare‑amenable conditions increased roughly twice as much in poorer states as in richer subnational units, underscoring how health shocks disproportionately affect already disadvantaged populations (Bernal Lara et al., 2023[24]; Pinto, Savedoff and Bauhoff, 2024[25]).
Disparities also deepen when considering the full cascade of care. Undiagnosed and untreated chronic conditions are disproportionately concentrated among lower income and lower education groups and in several countries among men. As a result, inequalities in health outcomes reflect not only differences in disease prevalence, but also gaps in detection, continuity of care and effective treatment – reinforcing socio-economic gradients across the life course.
In the context of persistent inequalities, this section examines how countries in Latin America and the Caribbean are addressing health inequities through policy and system reforms, such as governance arrangements, financing choices, service delivery models, workforce policies, and information systems. It also considers countries’ capacity to identify, measure, and monitor inequalities in healthcare, which shapes whether inequities are visible and can be acted upon. We focus on the main functional levers within the health system and at its interface with other sectors, and how they relate to the patterns of inequality described above. Through these levers, countries can influence whether existing disadvantages are mitigated or amplified. This analysis draws on a survey of health equity policies administered to Ministries of Health in 14 countries in the region: Argentina, Belize, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama, Paraguay and Peru. The survey covered governance, financing, workforce, digital health, data systems, and emergency preparedness, and collected information on the existence and implementation status of policies and institutional arrangements, without assessing whether these legal frameworks and policies translate into effective action and impact for the populations facing the greatest barriers.
The Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies was administered online between October 2025 and February 2026 to officials in Ministries of Health participating in Health at a Glance Latin America and the Caribbean 2026. Six countries responded directly to the survey: Argentina, Colombia, Costa Rica, Ecuador, Paraguay and Peru.
The survey documented how countries in LAC address health inequities through policy, governance, and operational practice. It consisted in three parts: Part I mapped the policy and governance context for equity, such as laws, strategies and financing arrangements. Part II examined the operational enablers of equity, such as data collection and disaggregation, monitoring and evaluation practices, and digital health capabilities. Part III explored cross-cutting and emerging areas, including targeted interventions for disadvantaged populations, and intersectoral action.
Additional information was compiled for the Dominican Republic, El Salvador, Guatemala, Haiti and Honduras. For these countries, the information was collected by the OECD using public sources and interviews with national researchers, rather than through direct completion of the survey by Ministry of Health officials. As such, these country profiles have a different status from the direct survey responses. They reflect, to the best of the Secretariat’s knowledge, the most recent publicly available information on the topics covered. The survey and the list of sources used for country profiles collected by the OECD are provided in the annex of the report.
In addition, ad hoc information was gathered for a small number of countries that did not take part in the survey, to illustrate specific policy approaches and to place the chapter’s comparative findings in context. This material was compiled from public sources and national authorities for illustrative purposes only. It does not form part of the survey dataset and is therefore not reflected in the survey-based figures and tables, which remain restricted to the 14 surveyed countries.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Governance and legal frameworks for equity
Countries in the region have built equity commitments into their legal frameworks through two distinct instruments, which operate through different logics and reach different populations. The first establishes comprehensive rights to healthcare, typically anchored in constitutional provisions, giving individuals enforceable claims to services regardless of group membership. For example, in Colombia and Costa Rica, constitutional provisions have been cited in judicial proceedings to expand access to medicines and treatments that public systems had restricted. These judicial mechanisms are not necessarily neutral across socio-economic groups since they tend to be utilised by those who are able to navigate the legal system. The second instrument is group-specific, when governments create programmes to target particular populations such as Indigenous peoples, Afro-descendant communities, migrants, or people with disabilities. Such programmes operate through differentiated entitlements or adapted service obligations rather than universal claims, as in Paraguay’s Law 5469 on indigenous peoples’ health.
Table 2.2 shows that both instruments are used across the region. The specific instruments that operationalise these commitments include, for example, Colombia’s 1991 Constitution (Art. 49), Law 100 (1993), and Decreto 858 (2025) as part of a people‑ and territory-centred model; Ecuador’s 2008 Constitution (Art. 32) and the Ley Orgánica de Salud, alongside ministerial agreements; and Belize’s Constitution and sector acts (e.g. Public Health Act) plus strategy documents (BHSSP 2025‑2034). Several countries also have multiple instruments within the same category (e.g. more than one statutory or regulatory reference), which suggests that equity commitments are often anchored through layered legal and administrative frameworks rather than a single law. Chile’s legal framework illustrates the same layered pattern. The right to health protection is anchored in the Constitution and operationalised through a range of statutory and regulatory instruments governing public and private health coverage.
Notes: Cells show a checkmark and, when available, the latest year reported for the legal instrument. Empty cells mean no answer was reported in the survey. Years come from the survey and may reflect updates or amendments rather than the first adoption year.
Figure 2.5 highlights which population groups countries identify as facing the greatest health inequities. Among the 13 countries that provided a ranking, income is the most consistently prioritised (12 countries), followed by place of residence (11 countries). Ethnicity is prioritised in about half of countries (7), while gender is rarely prioritised (2). Colombia, links inequities to persistent poverty and gaps in financial protection, alongside barriers for ethnic groups including weak articulation with traditional medicine and infrastructure and workforce constraints in dispersed rural areas. Belize highlights limited social protection and rural vulnerability to shocks. Paraguay points to financial protection barriers for lower-income groups; uneven service availability outside urban areas; and language and distance barriers affecting ethnic communities. Haiti and Honduras both identified education, linking it to health literacy and service use. Gender appears only in the Dominican Republic and Nicaragua, where it is framed through maternal and reproductive health and gender-based risks. Costa Rica is the only country that identifies disability among the top three inequities, related to structural barriers (e.g. transport and access constraints).
Notes: Cells indicate whether each population group was ranked among the top three groups facing the greatest health inequities. “Yes” means the group appears in the country’s Top 3. “No” means the country provided a Top 3 but did not rank that group in the Top 3, yet it may still be reported as facing inequities. “No answer” means no response was provided.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Financing policies for equity
Figure 2.6 shows the financing mechanisms countries use to reduce inequities in access to care. Across the 14 countries, subsidised or free services are near-universal (13 of 14).
Notes: Cells indicate whether each financing mechanism was reported. “Yes” means the mechanism is in place; “No” means it was explicitly reported as not in place; “No answer” means it was not reported in the survey.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Copayment exemptions are also common (8 of 14), while targeted insurance coverage is reported by six countries. By contrast, catastrophic expenditure funds are reported by four countries, and both income‑based sliding-scale fees and cash transfers or vouchers are reported by only two countries each. The relatively limited use of these more targeted financial protection mechanisms across the 14-country sample is notable given broader OECD evidence that out-of-pocket spending remains an important source of financial hardship, particularly among poorer households (See Box 2.3).
Financial protection remains a major equity issue across OECD health systems. In 2023, households in OECD countries spent on average 3.2% of total household consumption on healthcare goods and services, but the burden varied widely: it was below 2% in Poland, Luxembourg, Colombia and Türkiye, and above 5% in Switzerland, Korea and Chile. Across the OECD, the largest component of out-of-pocket spending was pharmaceuticals and other medical goods (41%), followed by outpatient care (22%), dental care (16%) and long-term care (13%).
The incidence of catastrophic health spending also differs markedly across countries. It affects fewer than 2% of households in Sweden, Slovenia, the United Kingdom, Ireland and the Netherlands, but more than 10% in Lithuania, Latvia and Hungary. In all countries, poorer households are the most exposed. OECD evidence suggests that lower financial hardship depends not only on lower reliance on out-of-pocket payments, but also on how coverage is designed: countries with stronger protection tend to use copayment exemptions for low-income groups, annual caps on payments, and more comprehensive coverage of primary care. Portugal is cited as an example where removing flat-rate charges for primary care and publicly prescribed services may have helped reduce catastrophic spending in recent years.
Source: Chapter 5 in OECD (2025[26]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
Countries with subsidised care tend to implement this policy through a subsidised insurance regime or through free public provision that is intended to eliminate financial barriers for low-income groups. Costa Rica describes “Seguro por el Estado” (“Insurance from the State”) as the channel for insuring people who lack sufficient income, while Colombia offers a subsidised insurance package to people who meet a poverty-based eligibility standard (SISBEN). Copayment exemptions are typically provided as protections for specific vulnerable groups or priority services and appear to reduce point-of-service barriers within otherwise standard benefit structures. For example, Colombia reports exemptions in the subsidised regime, with additional exemptions for specific vulnerable groups (e.g. victims of internal conflict and people with disability certificates). Belize reports no direct user fees for covered services within the National Health Insurance programme in participating regions and reports that it also issues waivers for indigent patients and emergencies. When countries report mechanisms to reduce catastrophic health expenditures, they tend to refer to dedicated arrangements for high-cost conditions. Peru, for instance, notes it has a specialised fund for costly diseases (FISSAL) alongside subsidised insurance coverage. Finally, the few cases reporting transfers or vouchers (Argentina and Paraguay) indicate a complementary route for financial protection, using income support to facilitate access, rather than relying only on reducing user charges within the health system. In Paraguay, this is linked to Tekoporã (cash transfers for households in poverty), described as indirectly helping mitigate health-related spending. Chile, identified in Box 2.3 among the countries with comparatively high out-of-pocket spending, illustrates how such countries are nonetheless strengthening equity-sensitive financing: recent measures include the elimination of copayments in public provision (Copago Cero), the financial-protection guarantee embedded in the Garantías Explícitas en Salud regime, and schemes to lower the price of medicines.
Access and service delivery
Policies to reach underserved populations are widely reported, with the strongest emphasis on expanding service availability. Infrastructure expansion is nearly universal (13 of 14 countries) and mobile clinics or outreach are also common (11 of 14), while telehealth and intercultural health policies are each reported by 9 of 14 (Figure 2.7). By contrast, measures that strengthen culturally appropriate delivery capacity and reduce practical access barriers are less frequently reported. Transport support is reported by 7 of 14, and recruitment and training of bilingual or community staff are each reported by 6 of 14. Colombia links rural access and telehealth to recent national instruments, including the Plan Nacional de Salud Rural (Decreto 351 de 2025) and the national Telesalud framework (Ley 1 419 de 2010). Belize describes mobile clinics and outreach teams delivering primary care and vaccinations in hard-to-reach villages (including Mayan communities) and telemedicine initiatives in rural clinics. Paraguay provides concrete examples such as a mobile health clinic serving multiple Indigenous communities (Ley N.º 5469/2015 on Indigenous Peoples’ Health). Nicaragua frames outreach through the Modelo de Salud Familiar y Comunitario (MOSAFC), organised via territorial networks (SILAIS) and community brigades. The Dominican Republic emphasises territorial network strengthening and decentralisation under the SNS, and links digital transformation plans (PLANDES 2030) to reducing geographic access barriers.
Notes: Cells indicate whether each policy to reach underserved populations was reported. “Yes” means the policy is in place; “No” means it was explicitly reported as not in place; “No answer” means it was not reported in the survey”, even though plans for future integration may exist.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Workforce distribution and culturally appropriate care
A factor in ensuring effective access to healthcare is the location of medical professionals in relation to the population. To achieve an equitable distribution of the health workforce, countries report that they use geographic distribution strategies more often than rural retention strategies. The status of these efforts in terms of implementation also varies widely (Table 2.3). Among countries that reported policy status, geographic distribution is most often described as partially implemented (4 countries), followed by “under development” (2), “actively implemented” (2) and “no strategy” (2). For programmes to improve rural retention of the workforce, the dominant pattern is “no strategy” (6 countries), with fewer reporting “under development” (2) or “partial implementation” (2). Ecuador, Nicaragua and Haiti are among the few reporting an actively implemented geographic distribution strategy. Paraguay reports partial implementation for both distribution and rural retention, suggesting a more coherent workforce approach even if not fully implemented. By contrast, Guatemala and Panama report that they have neither of these strategies and Colombia reports a distribution strategy under development without a rural retention strategy, reflecting a common gap between planning for distribution and retaining staff in rural areas.
Although few countries reported formal rural retention strategies in this survey, it may understate the range of measures actually in use. A separate review of six countries in the region found that Colombia, Costa Rica, Jamaica, Panama and Peru had introduced financial incentives for rural and remote service, local recruitment, and approaches that strengthen intercultural and community-oriented competencies among health workers (Carpio and Santiago Bench, 2015[27]). This suggests that some workforce measures may exist without being formalised or reported in the survey as explicit national equity strategies.
Notes: Cells indicate whether countries reported a national strategy on geographic distribution and rural retention of health professionals, and, when provided, the reported implementation status. “No strategy” indicates the country reported that no strategy is in place. A check mark (✓) without status indicates a strategy was reported but no status category was selected. Empty cells mean no answer was reported in the survey.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Data systems, monitoring and equity reporting
Data production: digital infrastructure and health information systems
Figure 2.8 shows that digital inclusion policies to help vulnerable groups are not common. Only four countries report at least one inclusion measure (from among subsidised connectivity, devices/kiosks, community access points, or digital literacy). Peru reports using all of the mentioned digital inclusion measures through recent telecom regulations, delivery of kiosks and IT equipment to support electronic health records, expanding access through the National Telehealth Network, and integrating 29 Community Mental Health Centers (CSMC) into that telehealth network. Paraguay reported that it has community access efforts and targeted digital literacy for rural and indigenous women (e.g. programme “Nanum, mujeres conectadas”). Costa Rica created a Virtual Office within the Ministry of Health, conducted a pilot for kiosks in health areas, and developed a teleconsultation decree to regulate use for the population, alongside initial actions to support digital literacy.
Notes: Cells indicate whether countries indicated specific digital inclusion measures for vulnerable groups in the survey. “Yes” lists countries reporting the measure; “No” indicates the measure was explicitly reported as not in place; “No answer” indicates it was not reported.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
While all countries report capturing socio-demographic data that is useful for measuring inequality, routine equity disaggregation is only reported for five countries (Argentina, Costa Rica, Dominican Republic, Ecuador, and Guatemala). Furthermore, interoperability of data systems across public – private or subnational systems is also uneven (Figure 2.9; see indicator “Health data availability” in Chapter 5). Costa Rica anchors its system in EDUS (Expediente Digital Único en Salud) and reports routine production of disaggregated outputs via the CCSS statistics unit. Paraguay describes its health information systems (HIS) as the backbone for routine service reporting but notes that it has incomplete geographic coverage and lacks interoperability. Ecuador reports it has more centralised data systems at the primary care level and more decentralised data arrangements for hospital care. Chile reports recent investments in its health information infrastructure that are relevant to equity-oriented monitoring, including the 2024 rollout of an open-source platform for the collection, analysis, and dissemination of health data, and the 2025 adoption of an interoperability standard to link records across systems and support a shared clinical history.
Notes: Cells indicate whether countries indicated selected EHR/HIS features in the survey. “Yes” lists countries reporting the feature; “No” indicates it was explicitly reported as not in place; “No answer” indicates it was not reported.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
When collecting data, only three countries report routinely gathering information across a wide range of categories: Costa Rica, Ecuador and Argentina (Figure 2.10). Among the other countries, Guatemala is the only one that explicitly collects information on ethnicity. Several countries reported that they only collect standard administrative fields (sex, age and place of residence) or include, in addition, one or two other equity-related categories.
Countries like Honduras and Haiti did not select specific population groups in the structured survey response but provided contextual information through open-ended responses. Honduras reported that its surveillance platforms (ESAVI/EVADIE) typically capture age and sex but notes limited documentation on broader socio-demographic fields or interoperability standards, and Haiti similarly describes routine capture of age, sex and geography for surveillance and reporting, but no routine capture of variables such as income, education, disability or insurance affiliation in the documents reviewed.
Notes: Cells summarise which population groups are reported as captured in the EHR / HIS systems. Countries reported the population groups in the EHR/HIS features; grey cells indicate the information was not reported.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Figure 2.11 shows that all surveyed countries collect disaggregated information for service access and coverage and health outcomes, while data gathering is more uneven for risk factors (10 countries), quality of care (6 countries), and financial protection (5 countries). Argentina links disaggregation to a mix of programme monitoring and sector information systems, including SITAM. Colombia describes national production of disaggregated indicators for access and outcomes, and notes that quality monitoring is closely tied to evaluations of EPS performance and related regulatory instruments rather than being systematically embedded in routine disaggregated indicator reporting across domains. Costa Rica highlights EDUS and the CCSS statistical function as the backbone for routine disaggregation, and notes that some equity metrics are derived from household data. Paraguay grounds disaggregated data in the national HIS, where indicators are generated mainly from facility service records (e.g. consultations), and notes that incomplete coverage and interoperability constrain broader routine disaggregation. The Dominican Republic references indicator production under PLANDES 2030, while Honduras and Haiti describe data collection that is largely organised around standard administrative breakdowns (age, sex, and territory), with more limited documentation of routine disaggregation for broader equity stratifiers (e.g. ethnicity, income, disability, or migration status).
Notes: Cells indicate whether countries reported having disaggregated indicators available for each monitoring domain. “Yes” means the country reported disaggregation in that domain; “No” means the country reported not having it; “No answer” means it was not reported in the survey. “Yes” may reflect disaggregation produced from administrative systems and/or household surveys, depending on the country.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Data use: Monitoring and reporting on inequalities
Figure 2.12 summarises whether countries report producing regular equity reports. In the survey, topic-focussed reporting is the most common format (10 of 12 countries), followed by group-focussed reporting (8 of 12). By contrast, fewer countries report a national inequality monitoring report (5 of 12), and subnational reporting is rare (2 of 12). Ecuador cites a national inequality report (“Informe país sobre desigualdades en salud”, 2025) and uses it both as a national monitoring product and to inform topic-focussed reporting. Panama similarly references a national equity study (“Estudio Nacional de Equidad en Salud Sostenible”) used for national monitoring and for reporting by topic and group. Argentina reports national and subnational reporting, noting that topic-focussed products are often produced on request and that group-focussed reporting is channeled through institutions such as DNAPSySC and PNSPI. Costa Rica reports group-focussed reporting and clarifies that INEC mainly publishes results rather than issuing dedicated technical reports, while several institutions (e.g. CONAPAM, CONAPDIS, INAMU) produce reports focussed on specific groups (e.g. gender, age, rural/urban, and disability). Paraguay reports topic- and group-focussed reporting and attributes regular reporting to the MSPBS, centred on routine reporting of health outcomes.
Notes: Cells indicate whether countries have national or subnational regularly reports on health inequalities; at least once every 2 years, rather than ad hoc or one‑off publications.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Intersectoral action and social determinants
All countries that responded to questions about intersectoral co‑ordination reported at least two mechanisms for implementation. Across the 14 countries, formal agreements were reported by 12, interministerial committees or taskforces by 12, ad hoc co‑ordination by 11, and joint planning/budgeting by 9 (Figure 2.13). In Ecuador, intersectoral action is linked to specific inter-institutional bodies, including committees on violence against women, maternal and neonatal health, and adolescent pregnancy prevention, and to national co‑ordination around chronic child malnutrition (“Ecuador Crece sin Desnutrición Infantil”). Colombia did not report a specific mechanism for intersectoral co‑ordination but highlighted intersectoral action in its National Development Plan, explicitly framing health as being articulated with education, housing, safe water, basic sanitation, digital connectivity, and decent employment. In Argentina, the survey response highlighted active co‑ordination between the national and subnational level and noted that formalisation often occurs through specific agreements and legal instruments (laws, resolutions, or administrative provisions); it also references co‑ordination with Indigenous and civil registry agencies for territorial implementation. Costa Rica points to a single operational entry point, its Unidad de Planificación Sectorial, describing participation through commissions across multiple co‑ordination modalities. Paraguay reports both interministerial groups and formal instruments, citing co‑ordination around the Sistema de Protección Social and joint planning for large investments (e.g. between MOPC and MSPBS), while also noting that co‑ordination can remain project-based rather than fully institutionalised. Peru highlights the Consejo Nacional de Salud as an articulation space across levels of government and civil society, noting the creation in September 2024 of a working commission on social determinants and the role of subnational councils and district committees in priority-setting. The Dominican Republic frames intersectoral action through formal legal and planning instruments, while Haiti links co‑ordination primarily to emergency-oriented multisectoral planning (including RSI action planning and the health ministry’s co‑ordination role).
Notes: Cells indicate whether countries report each type of intersectoral co‑ordination mechanism. “Yes” and “No” reflect the survey response for that item; “No answer” means it was not reported in the survey.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Food security/nutrition linkages are the most frequently reported of joint programmes (9 of 14 countries) that connect social protection and other sectors with health objectives, followed by conditional cash transfers (5 of 14) and integrated delivery platforms (4 of 14) (Figure 2.14). Paraguay references Tekoporã (Ministry of Social Development), describing conditionalities linked to health actions such as vaccination and prenatal care, and situates these efforts within the Sistema de Protección Social (SPS); it also notes that joint work is not always present across all categories. Peru cites JUNTOS as a conditional transfer programme promoting access to health, education and nutrition for poor households, particularly those with pregnant women and children, and highlights Programa Nacional PAIS, described as delivering multisectoral “caravanas” and co‑ordinated service packages that include health, food security and access to social programmes through service platforms. Ecuador points to the “Bono de los 1000 primeros días" as a mechanism linked to early-life nutrition and health. Colombia links joint action to Hambre Cero, described as coordinated implementation across institutions and regions, prioritising territories facing more severe food insecurity. Costa Rica and Belize frame the nutrition-health linkage more through service and guidance packages (e.g., dietary guidance and first-1,000-days materials in Costa Rica; and integrated nutrition and food support initiatives linked to service access in Belize), rather than through cash transfer instruments. Chile anchors intersectoral action in long-standing platforms such as the Chile Crece Más integrated early-childhood protection subsystem (formerly Chile Crece Contigo), together with cross-sectoral strategies linking health with education and social protection, as well as regulatory measures on risk factors, such as the marketing, labelling and advertising of alcoholic beverages.
Notes: Cells indicate whether countries report joint intersectoral programs linked to health (e.g., social protection, nutrition/food security, or integrated platforms). “Yes” and “No” reflect the survey response for that item; “No answer” means it was not reported in the survey.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Emergencies and disaster preparedness
Figure 2.15 indicates that four countries (Belize, Costa Rica, Dominican Republic and Paraguay) report equity as systematically integrated into preparedness planning, while eight countries (Argentina, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and Panama) report more partial integration. In Belize, emergency planning is described as combining vulnerability mapping, community-based preparedness, and targeted risk communication tailored to vulnerable groups. Paraguay anchors its approach in the Plan Nacional de Respuesta ante Emergencias con Enfoque Multiamenazas, which sets an operational model for health-sector response across multiple threats (including floods, epidemic outbreaks, heatwaves, droughts, wildfires and multi-casualty events). Costa Rica also reports systematic integration and explicitly points to the inclusion of specific vulnerable groups, such as people experiencing homelessness, people deprived of liberty, and populations in remote territories (e.g. Alto Telire). The Dominican Republic similarly reports systematic integration, describing risk-based and vulnerability-focussed preparedness frameworks. In contrast, Ecuador notes that its Plan de Respuesta Multiamenaza references equity in general terms but does not explicitly specify population groups. Among other countries reporting partial integration, Guatemala and Panama emphasise vulnerability and territorial inequities as planning considerations, while Honduras, Haiti and Nicaragua describe preparedness frameworks that recognise vulnerable populations but provide more limited detail on how equity is operationalised in routine preparedness instruments. Peru is currently updating its emergency preparedness framework to incorporate vulnerability mapping and to make equity a central pillar of its multihazard response plans, with the aim of prioritizing marginalized communities during national crises. Chile provides a related example through its Chilean Model of Mental Health in Disaster Risk Management, in place since 2019, which integrates mental health and psychosocial support into disaster preparedness and response. The model combines intersectoral coordination, community strengthening, support for response personnel, and targeted assistance for specific vulnerable groups within the national disaster-response system.
Notes: Cells indicate equity is reported as integrated into emergency and disaster preparedness plans. “Systematically integrated” indicates equity is described as a routine element of preparedness planning; “Partially or occasionally considered” indicates equity is referenced but not consistently embedded across instruments or implementation. No answer means there was no survey response.
Source: Health at a Glance Latin America and the Caribbean 2026 Survey of Inequality and Inequity in Healthcare Policies.
Countries in Latin America and the Caribbean have built recognisable equity policy frameworks, but the transition from commitment to consistent implementation remains the central challenge. The survey documents a region where legal mandates for equity are common, subsidised services are widespread, and countries are expanding outreach, telehealth, and intersectoral co‑ordination. It also documents that the institutional conditions needed to make these commitments effective over time are frequently weak or absent: consistent monitoring of population groups and sustained territorial reach. Health inequalities in the region remain a direct expression of broader social inequality, and disadvantage accumulates across the care pathway, through prevention, diagnosis, treatment, and follow-up, producing wider gaps in outcomes than in access alone.
The survey points to a consistent pattern across policy domains: the strongest responses are those that expand the availability and affordability of services, while measures that address the deeper conditions needed to make services equitable in practice, such as cultural adaptation, workforce retention, digital inclusion, and routine monitoring of key population groups, are systematically less developed. Equity attention is also narrower than the evidence warrants, focussed primarily on income and rural-urban gaps, with much less systematic attention to ethnicity, disability, migration status, and gender.
Access strategies prioritise expansion over depth. Infrastructure expansion is reported by 13 of 14 countries, outreach by 11, and telehealth by 9, yet transport support is available in only 7, bilingual or community staff recruitment in 6, and digital inclusion policies in just 4. Geographic distribution of the health workforce is more commonly reported than rural retention strategies, and for rural retention the dominant pattern is no strategy at all. Digital health is advancing more as a modernisation agenda than as an equity strategy: only four countries report at least one concrete measure to help vulnerable groups overcome barriers related to connectivity, devices, or digital literacy, and uneven interoperability further limits whether digital tools narrow or widen existing gaps.
Countries are building the basic architecture for monitoring access and coverage, but disaggregation for quality of care is reported by only 6 of 14 countries and for financial protection by only 5. Routine disaggregation by ethnicity, disability, and migration status are available in only a small number of countries. With an estimated 50‑75% of avoidable mortality in the region linked to poor-quality care rather than lack of contact, reducing inequalities in health and healthcare now requires improving the content, continuity and performance of health systems, while tackling remaining deficits in access (Kruk et al., 2018[13]).
Overall, the region has made important progress in bringing services closer and making them more affordable but has been less consistent in adapting delivery to the practical, cultural and organisational barriers faced by underserved groups. The common strengths are real: broad legal recognition, expanding service delivery for underserved populations, and growing intersectoral action. The recurring weaknesses are equally clear: incomplete monitoring of the population groups where inequalities are greatest, insufficient rural retention of health workforce and cultural adaptation of services, and shallow digital inclusion. Progress in the next phase depends less on adopting additional equity initiatives than on making existing ones more coherent, better targeted, and held to account.
The survey responses do not cover all dimensions of health equity; however, based on what countries reported, the most consistent gaps point to the following priorities:
Deepen access strategies to reach underserved groups effectively. Countries have established broad infrastructure and outreach, but measures that address the practical, cultural, and organisational barriers that determine whether services are actually used by the most marginalised populations remain less consistently in place. The survey captures only a subset of such measures, yet even these show a systematic gap between availability and effective reach.
Extend monitoring to quality of care and financial protection, and key population groups. Monitoring systems that capture access, but not quality or financial protection, cannot assess whether improvements are reaching those who need them most. Routine disaggregation by ethnicity, disability, and migration status remains the most actionable data gap across the region.
Strengthen rural workforce retention alongside geographic distribution. Distribution strategies do not resolve workforce shortages in remote areas. Incentives, career pathways, and working conditions that make rural posts sustainable over time require dedicated investment.
Treat digital inclusion as an equity investment. Digital health investments should be paired with concrete inclusion measures, such as connectivity, devices, and digital literacy, targeted at the populations least likely to benefit otherwise. Paraguay’s Nanum programme and Peru’s telehealth expansion illustrate that this is achievable.
Move intersectoral co‑ordination from agreements to joint action. Formal co‑ordination structures are widespread, but joint planning and budgeting which are the mechanisms most likely to produce sustained action on social determinants, remain the exception.
Integrate equity into climate adaptation and emergency preparedness. Only four of 14 countries embed equity systematically in preparedness planning. Given that health shocks consistently widen existing inequalities, vulnerability mapping and targeted response plans for marginalised groups should be standard, not exceptional.
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