Despite major gains in care coverage over the past decade, large quality gaps in Latin America and the Caribbean continue to drive avoidable mortality, inefficiency and inequality. This chapter examines policy and institutional arrangements for healthcare quality in 19 countries across six domains: governance, external assurance, evidence‑based care, workforce capability, patient safety, and integrated and people‑centred care. While many countries have established the basic foundations of quality governance, few have built the learning systems needed to turn compliance into better outcomes. Large cross-country differences suggest unevenly organised acute and chronic care, with prevention generally performing better than treatment. Measurement systems, patient safety tools and incentives are increasingly in place, but are not yet routinely used to guide protocols, payment or accountability. People‑centred and integrated care remain the least developed areas. Priority actions include strengthening governance, workforce quality, patient safety, public reporting, quality-linked financing, equity monitoring and interoperable digital infrastructure.
Health at a Glance: Latin America and the Caribbean 2026
Abstract
Universal health coverage (UHC) has advanced with giant steps in Latin America and the Caribbean, alongside historic expansions in health spending, although health gains have often remained uneven and modest (Dmytraczenko and Almeida, 2015[1]). The regional index of essential service coverage rising from 66 in 2000 to 80 in 2019, before falling back to 74 in 2021, reflecting both progress and persistent fragilities (WHO, 2021[2]).
However, expanding coverage alone is not enough to deliver better health outcomes. Translating nominal coverage into better outcomes requires high-quality care, defined by the World Health Organization and the OECD as care that is effective, safe, people‑centred, timely, equitable, integrated, and efficient (OECD/WHO/World Bank Group, 2018[3]). Quality concerns not only whether people can access services, but whether those services are organised and delivered in ways that contribute to better outcomes.
Quality of care has become the central challenge for health systems in Latin America and the Caribbean (LAC). Persistent quality gaps continue to weaken the promise of universal health coverage, contributing to avoidable deaths, wasted resources, wider health inequalities and undermining trust (Kruk et al., 2018[4]). Many of these quality gaps reflect how care is organised across fragmented and segmented health systems, where differences in access and quality across income groups, territories and population groups, undermine both confidence in institutions and the fairness of care (Roberti et al., 2024[5]). Persistent weaknesses in care co‑ordination and regulatory oversight, limited measurement of clinical outcomes and patient experience, and insufficient use of data for improvement further constrain the delivery of high-quality care (OECD/The World Bank, 2023[6]; Lorenzoni et al., 2019[7]). For chronic conditions, multimorbidity and acute episodes requiring transitions between levels of care, quality increasingly depends not only on what happens within individual facilities, but on continuity across the patient journey, supported by functioning referrals, shared information, multidisciplinary care and clear accountability.
High-quality care is also a lever for efficiency and value for money. In fiscally constrained environments, improving care quality increases the return on health spending by aligning practice with evidence, preventing complications, and reducing unwarranted variation that is unrelated to patient need. Improving quality is therefore both a health and a fiscal objective: by aligning care more closely with evidence and reducing avoidable harm, health systems can improve outcomes while increasing the value obtained from existing spending and freeing resources to address unmet needs (OECD, 2017[8]).
Many countries in the region have now established important foundations for quality assurance, including regulatory frameworks, standards, quality policies and institutional responsibilities. The next phase is more demanding: it requires connecting these elements more effectively so that measurement informs action, regulation supports implementation, and financing and accountability reinforce better care rather than operate as separate mechanisms. Countries are not starting from the same point, and their position may differ across policy areas. Some are still consolidating core governance and quality-assurance mechanisms, while others can increasingly focus on implementation, organisational learning, accountability and the more systematic use of quality information and incentives.
The chapter examines these issues by combining internationally comparable quality outcomes with a stock take of the policies, institutions and implementation mechanisms that shape delivery of high-quality care with the focus on implications for policy and improving system performance. The stock take considers governance, professional and service quality assurance, health technology assessment, measurement and patient safety, financial incentives, and people‑centred and integrated care. By linking observed performance to the underlying policy architecture, the chapter identifies policy options to support the development of more resilient, equitable and high‑performing health systems capable of responding to the region’s evolving health needs and strengthening trust in public institutions.
The analysis asks not only which quality mechanisms countries have adopted, but how far these mechanisms form a coherent system capable of translating standards, measurement and oversight into better care and outcomes. Comparing countries at different starting points also creates opportunities for benchmarking and peer learning within the region, while drawing on OECD experience to identify how more established quality systems connect governance, implementation and continuous improvement.
Assessing the quality of care across countries has historically been difficult in Latin America and the Caribbean due to fragmented health information systems, uneven reporting practices and limited availability of comparable data. Earlier analyses of health system performance in the region often relied on mortality statistics, facility-level studies or country-specific administrative data, limiting the possibility of systematic cross-country benchmarking. Over the past two decades, however, important progress has been made. Many countries have strengthened routine health information systems, expanded digital health records and improved the reporting of hospital, mortality and service utilisation data. At the same time, growing investments in health intelligence capacities and the secondary use of health data have enabled more consistent monitoring of health system performance. These developments have significantly improved the availability of internationally comparable indicators on healthcare quality, making it increasingly possible to assess outcomes, care processes and patient experiences across countries. While these indicators provide valuable insights into the state of quality of care in the region, their interpretation must also consider differences in data systems, reporting practices and health system organisation across countries (Kruk et al., 2018[4]).
International efforts to measure and compare healthcare quality have been strengthened through the development of conceptual frameworks and standardised indicators. The OECD Health Care Quality and Outcomes (HCQO) framework provides a structured approach to assessing health system performance across countries, organising indicators across key dimensions of quality including effectiveness, safety and people‑centredness, and across levels of care such as primary care, hospital care and public health (OECD, 2024[9]). The framework emphasises the use of internationally comparable indicators to monitor how well health systems prevent disease, deliver effective treatment and minimise harm to patients. Within this approach, indicators can capture different stages of care processes and outcomes, ranging from preventive interventions to treatment results and health outcomes. By providing a common measurement framework, the HCQO indicators support cross-country benchmarking and help identify areas where health systems perform well or where further improvement may be needed.
A multidimensional picture of healthcare quality in Latin America and the Caribbean
Building on the OECD HCQO framework, the quality of care data chapter in Health at a Glance: Latin America and the Caribbean 2026 (Chapter 7) presents a set of indicators covering key dimensions of healthcare quality across the region. It starts with avoidable mortality indicators, an overall measure of the ability of the health system to minimise deaths from causes that should not occur with effective public health policies and timely healthcare, distinguishing between preventable causes that can be reduced through population-wide prevention and treatable causes that depend more directly on the performance and quality of healthcare services. Second, the chapter evidences health prevention performance through vaccination coverage indicators. These indicators assess the reach and effectiveness of childhood immunisation programmes, including coverage for diphtheria, tetanus and pertussis (DTP3), measles-containing vaccines, and hepatitis B, which together capture essential components of preventive care and population protection against communicable diseases. Avoidable hospital admissions for chronic conditions such as asthma, chronic obstructive pulmonary disease, congestive heart failure and diabetes provide insights into the effectiveness and accessibility of primary care in preventing complications that require hospital treatment. Indicators of in-hospital case fatality following acute myocardial infarction and stroke assess the quality and timeliness of acute hospital care for major cardiovascular emergencies. Complementing the performance assessment for acute care, the chapter presents indicators for cancer care, including treatable cancer mortality and 5‑year survival for childhood cancers. In addition, indicators of patient safety and safe prescribing examining both the policy foundations for patient safety – including alignment with the WHO Global Patient Safety Action Plan – and patterns of antimicrobial consumption, which provide signals on prescribing practices and potential risks related to medication-related harm.
Table 1.1 and Table 1.2 present a summary of internationally comparable quality of care indicators for countries in Latin America and the Caribbean. The figures provide a synthetic overview of relative performance across countries and dimensions of care, allowing broad patterns to be identified across the region.
Note: All indicators show values for 2024 or the latest available year, except mortality from avoidable causes, for which the latest year is 2023. Indicator specifications, clarifications and notes for further interpretation can be found in their respective sections of Chapter 7. OECD and LAC averages are simple averages computed with a minimum of 7 available countries. The number of countries in the averages for each indicator may vary. For further specifications please visit the corresponding section of Chapter 7. The colour scale is constructed based on the LAC average. Darker grey cells indicate progressively worse performance relative to the LAC average, while darker green cells indicate progressively better performance.
Source: See Chapter 7.
While each of these indicators is examined in detail in Chapter 7, considering them together allows broader patterns and insights to be identified. Indicators reflecting health outcomes and acute care quality show considerably wider variation across countries. Mortality from treatable causes – deaths that should be avoided with timely and effective healthcare – varies markedly across the region, ranging from around 62 deaths per 100 000 population in Chile to more than 230 per 100 000 in Guyana. This nearly fourfold difference suggests substantial disparities in the capacity of health systems to diagnose, treat and manage conditions that should be amenable to medical care. Such variation may reflect differences in access to timely treatment, the availability of specialised services, and broader health system quality factors including workforce capacity, infrastructure and care co‑ordination. In contrast, preventive services tend to perform relatively well in many countries in LAC. Average coverage of core childhood immunisation programmes – including diphtheria, tetanus and pertussis (DTP3), measles-containing vaccines (MCV1 and MCV2) and hepatitis B – remains high in several countries, reflecting the long-standing priority given to vaccination programmes and the strong legacy of national immunisation initiatives across the region.
Indicators related to patient safety and safe prescribing suggest that many countries in the region are still strengthening the institutional foundations for safer care. The degree to which countries meet the policy and governance criteria outlined in the WHO Global Patient Safety Action Plan 2021‑2030 varies considerably, indicating differences in the maturity of patient safety frameworks, reporting systems and national strategies aimed at reducing avoidable harm in healthcare. Strengthening patient safety governance, promoting learning health systems and improving the monitoring of medication use are increasingly recognised as central elements of high-quality health systems (WHO, 2024[10]).
Age‑sex standardised rate per 100 admissions
1. Patients 45 years old and over. 2. Patients 15 years old and over.
Note: All indicators present values for 2024 or the latest available. Indicator specifications, clarifications and notes for further interpretation can be found in their respective sections of Chapter 7. OECD and LAC averages are simple averages computed with a minimum of 7 available countries. The number of countries in the averages for each indicator may vary. For further specifications please visit the corresponding section of Chapter 7. The colour scale is constructed based on the LAC average. Darker grey cells indicate progressively worse performance relative to the LAC average, while darker green cells indicate progressively better performance.
Source: See Chapter 7.
Indicators of acute hospital care point to marked differences in the capacity of health systems across the region to deliver timely and effective treatment for major cardiovascular emergencies (Table 1.2). Variation in case‑fatality rates following acute myocardial infarction and stroke suggests uneven performance in emergency response, clinical pathways and hospital management, including access to rapid diagnosis, specialised treatment and co‑ordinated care. At the same time, they can also relate to internal discrepancies in diagnostic coding practices. Cross‑country evidence indicates that stronger performance in these areas is often associated with organised service delivery models, such as integrated cardiac and stroke care networks, specialised units and systematic quality monitoring, highlighting the role of system organisation and governance in shaping outcomes (OECD, 2025[11]). These initiatives, together with efforts to standardise diagnostic coding, are currently being prioritised in countries such as Peru to strengthen clinical pathways and emergency response times. The indicators reflect both the quality of care within hospitals and the organisation of the patient pathway, including timely recognition, referral and transfer to the appropriate level of care.
Admission rates for ambulatory care sensitive conditions further illustrate differences in how health systems manage chronic disease outside hospital settings. Wide variation across countries reflects differences in the effectiveness, accessibility and continuity of primary care, particularly in the prevention and management of conditions such as congestive heart failure, diabetes, asthma and COPD. Lower admission rates can signal stronger primary care performance, including timely diagnosis, regular follow‑up and appropriate treatment; however, they may also reflect constrained hospital capacity or access barriers in some contexts. Read alongside the acute‑care results and broader system indicators, these patterns underscore that quality depends on both care within individual facilities and continuity as patients move between providers and levels of care. Interpretation should nevertheless account for differences in access, hospital capacity, coding and data completeness.
Interpreting these measures requires careful consideration of health system characteristics and data availability across countries
Observed differences often reflect not only the quality of care provided but also variation in access, reporting and data systems. Differences in diagnostic coding, admission practices, referral pathways, case severity at admission and the completeness of hospital reporting can all influence results across countries. For example, differences in case‑fatality rates may be influenced not only by the quality of clinical care but also by patterns of referral, delays in accessing treatment and variations in case severity at admission. Understanding these contextual factors is therefore essential when comparing quality of care indicators across countries and when identifying priorities for policy action.
An important limitation remains the large number of missing values across countries and indicators. The set of countries included in Table 1.2 represents a subset of countries in the region with relatively stronger health information systems and available data for international comparison. In many countries, the routine collection and reporting of performance measures remain incomplete or fragmented across health system subsystems. As a result, the available indicators provide only a partial view of the quality of care delivered across the region.
Moreover, interpreting quality of care indicators in Latin America and the Caribbean requires particular caution because health system performance is often shaped by both access constraints and quality differences. For example, low hospital admission rates for chronic conditions may reflect effective disease management in primary care but may also signal limited access to hospital services. For these reasons, analysing outcomes and service utilisation indicators alone may not fully capture the underlying drivers of healthcare quality in the region.
To better understand patterns in this data, it is therefore necessary to complement quantitative indicators with information on health system policies, governance arrangements and quality improvement strategies. The next section draws on the results of a policy survey conducted across 19 countries in Latin America and the Caribbean to examine the institutional frameworks, monitoring systems and policy instruments that countries have adopted to strengthen quality of care. This deeper examination of quality of care policies provides important context for interpreting the indicators presented above and offers insights into the policy levers available to improve healthcare quality across the region.
Policies to advance quality of care aim to ensure services are effective, safe, and person-centred. Quality remains a concern even in systems with broad coverage, since access alone does not guarantee that care is delivered in ways that consistently achieve the desired outcomes or meet acceptable standards. To improve health outcomes while making better use of limited resources, countries need clear national quality of care strategies that translate coverage and investment into safer, more effective and more responsive services (OECD/WHO/World Bank Group, 2018[3]).
The joint survey conducted in 2025 by the World Bank, the OECD, and the Inter-American Development Bank, described in Box 1.1, provides a current snapshot of national quality of care strategies, institutional arrangements and implementation approaches in the region. To do so, the survey examined 23 policy mechanisms that countries use to define standards, organise quality governance, set and enforce standards, support professional and organisational improvement, monitor and report performance, strengthen patient safety, and promote people‑centred and integrated care. These mechanisms can be grouped into six broad policy areas:
Governance and accountability, which establish leadership, oversight and system-wide direction for quality of care. This includes clinical governance; public reporting; performance‑based financing.
Regulation and external assurance, which set minimum requirements for safe and acceptable care and assess whether providers meet them. This includes licensing of healthcare providers; accreditation; inspection of institutions for minimum safety standards.
Evidence‑based care and technology governance, which promote more effective and consistent care by aligning decisions and practice with evidence. This includes clinical decision support; clinical standards, pathways and protocols; health technology assessment.
Workforce capability and service improvement, which strengthen professional competence and support quality improvement in clinical teams and organisations. This includes training and supervision; clinical audit and feedback; morbidity and mortality reviews; collaborative and team-based improvement cycles.
Patient safety and safe clinical practice, which aim to reduce preventable harm and embed safer care processes in routine service delivery. This includes medicines regulation; safety protocols; safety checklists; adverse event reporting.
People‑centred and integrated care, which seek to make care more responsive to people’s needs, preferences and capabilities, while improving continuity across settings. This includes formalised community engagement and empowerment; health literacy; shared decision making; peer support and expert patient groups; patient feedback and experience of care; patient self-management tools.
The OECD Health at a Glance Latin America and the Caribbean 2026 Survey of Quality of Care 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. Twelve countries responded directly to the survey: Argentina, Belize, Brazil, Chile, Colombia, Costa Rica, Ecuador, Grenada, Mexico, Paraguay, Peru and Saint Lucia.
The survey collected information on the main institutional and policy arrangements to support quality of care. It covered: the overall policy framework for quality of care; legal and regulatory arrangements; workforce planning and professional certification and recertification; accreditation and other external quality assessment mechanisms; clinical practice guidelines; health technology assessment and the regulation of medical devices, blood products and pharmaceuticals; audit and performance review; financial incentives to improve quality of care; patient safety, medical malpractice and infection control; and mechanisms for patients to influence healthcare quality, including the measurement of patient experience. A second section of the survey collected information on the availability of selected health data sources and indicators at national and/or subnational level.
Additional information was compiled for the Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and Panama. For these countries, the information was collected by the OECD using public sources and interviews with national officials, 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.
Finally, an in-person workshop was held in Buenos Aires, Argentina, in November 2025, bringing together representatives from six Latin American Ministries of Health to validate survey responses and discuss their interpretation in depth.
Figure 1.1 maps the implementation status of quality of care mechanisms across 19 Latin American and Caribbean countries. It points to a pattern of relatively strong institutionalisation for regulatory and safety foundations. alongside more limited development of mechanisms that support learning- and patient-centred governance.
Across the six policy areas, the survey suggests that most countries in Latin America and the Caribbean have made consistent progress in the foundational functions of regulation and external assurance. Provider licensing and medicines regulation are reported as implemented in 17 of the 19 countries assessed, indicating that most systems have established the basic rules needed to authorise providers and regulate core inputs to care. By contrast, accreditation is reported to be in place in only 9 countries, demonstrating a potential disconnect between policies and implementation. A similar pattern emerges in patient safety and safe clinical practice. Several countries have moved beyond basic regulation to adopt concrete harm-reduction tools, but implementation is still uneven: surgical safety checklists are reported to be implemented, or in the process of implementation, in 12 of 19 countries; adverse event reporting systems are implemented in 11 countries; and safety protocols are in place in 9 countries, with a further 5 reporting that they are being implemented. This distribution is consistent with international experience, where national quality efforts often begin with regulatory controls and patient safety instruments before evolving into more mature systems of measurement, learning and continuous improvement (WHO, 2017[12]).
The picture is more mixed in the policy areas that depend on institutional learning, active use of evidence and stronger patient involvement. Under governance and accountability, public reporting is implemented in 13 countries, but remains planned in five – Brazil, Costa Rica, Haiti, Nicaragua and Saint Lucia – while performance‑based financing is reported in only four, indicating that strategic use of incentives is still far from systematic. In workforce capability and service improvement, training and supervision are relatively common (14 of 19 countries), but mechanisms that rely on routine reflection and feedback are less consistently embedded: clinical audit and feedback are reported to be implemented in 11 countries, and collaborative improvement cycles in 9, suggesting that many systems still have limited capacity to convert information into continuous improvement. A similar gradient appears in evidence‑based care and technology governance. Clinical standards, pathways and protocols and health technology assessment are each reported in 13 countries, but clinical decision support is implemented in only 6, with a further 10 still in process, pointing to an important gap between setting standards and embedding them in day-to-day practice. The least developed area remains people‑centred and integrated care. While community engagement and empowerment mechanisms are present in 12 countries, more operational tools that bring patients directly into decisions and quality improvement remain limited.
Looking across the 23 policy mechanisms in Figure 1.1 provides a simple indication of countries’ different starting points. Argentina, Brazil, Chile, Colombia, Ecuador, Grenada, Mexico, Panama, Paraguay and Peru report full or partial implementation of at least 11 of the mechanisms assessed, suggesting a more established implementation base from which attention can increasingly turn towards consistent application, learning and accountability. Belize, the Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and Saint Lucia are still consolidating a broader set of these mechanisms, while Costa Rica, with 10 mechanisms implemented or under implementation, sits close to the boundary between these two broad groups. The distinction is particularly visible for mechanisms that move beyond basic system foundations towards external assurance, routine safety management and patient involvement: accreditation is in place in 7 of the 10 countries in the first group compared with 1 of 8 in the second, while safety protocols are reported in all 10 compared with 3 of 8, and patient feedback mechanisms in 7 compared with none. At the same time, variation within countries across individual policy areas, illustrated by Costa Rica’s comparatively established accreditation and patient safety arrangements, reinforces the importance of treating these as different starting points rather than as fixed categories of national quality systems. Among countries for which data are available, average treatable mortality is also lower in the first group, at around 106 deaths per 100 000 population, compared with 141 in the second, although this descriptive association should not be interpreted as evidence of a causal relationship.
The remainder of this chapter examines these six policy areas in greater depth, moving from the system-wide foundations and national policies for quality to the mechanisms used to improve care in practice and service‑level policies. It begins with governance and accountability, including national policies, legal and regulatory frameworks, and the institutions responsible for quality of care. It then turns to regulation and external assurance, covering the quality assurance of health professionals and health services, as well as accreditation and related external assessment mechanisms. The chapter next examines evidence‑based care and technology governance, including practice guidelines, health technology assessment, and the safety assurance of pharmaceuticals, blood products and medical devices, before addressing workforce capability and service improvement through indicators, audit, public reporting and other performance review mechanisms. This policy area is also complemented with financial incentives and purchasing reforms to support better care, an area that remains less developed in many countries in the region but are increasingly important for mature quality systems. As follows the chapter delves into patient safety and medical malpractice policies, and finalises with patient-centred and integrated care. Together, these sections trace the policy-to‑implementation pathway for advancing care that is safe, effective and people‑centred.
Policy mechanism implementation status
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
Across the 19 countries assessed, quality of care is increasingly being incorporated into the overall architecture of health policy, although many countries are still in the process of translating that recognition into formal governance arrangements, implementation plans and sustained institutional capacity.
The stock take indicates that most countries have national quality of care policies or strategies at varying stages of development, but these differ markedly in scope and maturity (Figure 1.2).Quality is treated as a cross-cutting element across sectoral strategies in a majority of surveyed countries (14 of 19), including Peru, Paraguay, Mexico, Grenada, Saint Lucia, Chile, Costa Rica, Brazil, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the Dominican Republic. Within this group, only a smaller number appear to have moved towards a more operational model, demonstrating shortcomings in institutional structures: Peru and Chile have fully costed implementation plans with monitoring frameworks, whereas Grenada has formal mandates without dedicated budgets or costed plans. In the remaining countries: Ecuador, Argentina, Belize and Haiti quality is addressed through thematic policies-such as patient safety, surgical safety, medication safety, and hospital accreditation-rather than a single overarching national plan. Colombia occupies a somewhat different position: while quality-related policies are often organised around thematic areas, these sit within a broader regulatory quality architecture, notably the Mandatory Quality Assurance System for Healthcare (SOGCS) within the General System of Social Security in Health.
Note: Answer to the question: How are the quality department and quality strategy positioned within your Ministry of Health?
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
The regulatory landscape for quality of care in Latin America and the Caribbean remains centred on the traditional stewardship functions of the health system: health service and provider regulation, setting minimum standards through accreditation and establishing external assurance mechanisms such as licensing, and clinical governance mechanisms.
Across the region, most countries report having implemented core quality of care policies, including facility accreditation, clinical guidelines, infection prevention and control, and surgical safety indicating that the basic architecture for assuring acceptable standards of care is in place in most systems. However, more specialised domains associated with learning health systems (Institute of Medicine, 2013[13]) remain less consistently developed-such as patient safety incident reporting systems, digital health quality standards, and public performance reporting. Patient safety incident reporting systems, which are essential for moving from a culture of compliance to one of learning and prevention, are implemented in Paraguay, Ecuador, Saint Lucia, Chile, Belize, Colombia and El Salvador, but remains partial or planned in Peru, Mexico, Grenada, Costa Rica, Brazil and Panama, and is absent in several countries. A similar pattern is visible for digital health quality standards, which are implemented in Peru, Paraguay, Mexico, Saint Lucia, Belize, Colombia, Costa Rica, Brazil, El Salvador, Nicaragua and Panama, but remain planned in Ecuador, Grenada, Chile, Guatemala, Honduras and the Dominican Republic. These two aspects are sometimes directly linked, as we can see in the Peruvian plans to implement an interoperable digital health record system that includes the documentation of safety events.
Ministries of Health are the principal national actors
Typically operating through dedicated quality units (e.g. Mexico’s Dirección General de Calidad y Educación en Salud) or specialised departments (Ecuador, Argentina, Saint Lucia, Chile, Colombia, Costa Rica, El Salvador, Haiti and the Dominican Republic). Paraguay, Guatemala, Honduras, Nicaragua and Panama do not report dedicated quality units within the Ministry of Health but address quality through other ministerial structures. These structures co‑ordinate national ministry programmes and priorities, supported by other national bodies including public health institutes (Peru, Mexico), independent quality agencies or superintendencies (Colombia, Ecuador), and social security payers (Peru, Colombia), which exert significant influence. Professional councils, such as medical and nursing colleges, also contribute to the regulatory landscape, particularly in Grenada and Chile. This institutional diversity reflects the organisation of health systems in the region, but also highlights a common challenge: quality improvement requires not only a nominal lead institution, but also effective co‑ordination across regulators, purchasers, providers and professional bodies if policy is to translate into more consistent improvements in care.
Note: Answer to the question: “Does your country have regular, institutionalised mechanisms to recognize and spread success in healthcare quality improvement – including the identification of best practices and high performing positive outliers?”
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
An important dimension of the stewardship role is its reach across public and private provision. Health services in LAC are commonly delivered through a mix of public, social security and private providers, but national quality arrangements do not always extend consistently across these sectors. As the sections below illustrate, gaps are particularly visible in workforce planning and patient safety. Effective national quality governance therefore requires standards, information and oversight mechanisms that apply across providers, while recognising differences in how public and private services are financed, regulated and organised.
Mechanisms to identify good performance exist, but learning systematically from success remains difficult
Figure 1.3 suggests that, beyond establishing rules and standards for quality, relatively few countries in the region have institutionalised mechanisms to learn systematically from success. While several countries report activities to showcase good practice, such as national quality forums or conferences, these are more common than formal systems to identify, document and spread effective approaches across the health system. National quality forums or conferences are reported in 9 countries: Peru, Paraguay, Mexico, Argentina, Saint Lucia, Chile, Colombia, Brazil and El Salvador. Likewise, 9 countries: Peru, Ecuador, Argentina, Grenada, Saint Lucia, Brazil, El Salvador, Haiti and Panama report formal mechanisms to identify positive outliers or high-performing teams. However, fewer countries appear to have more routine knowledge‑sharing arrangements: the regular publication of quality improvement case studies is reported in 8 countries: Paraguay, Mexico, Ecuador, Brazil, El Salvador, Haiti, Nicaragua and Panama. Taken together, these findings suggest that, although some countries have begun to recognise and promote successful quality improvement efforts, the systematic diffusion and scaling of good practice remain uneven. This matters because mature quality systems depend not only on detecting poor performance, but also on identifying what works, rewarding improvement, and enabling effective practices to spread across organisations and levels of care.
From quality policies to implementation and learning
Considering both how quality of care is positioned within overall health system strategies and the institutional mechanisms available to learn from success, countries show different starting points in the governance of quality of care. Argentina, Brazil, Chile, Colombia, Ecuador, El Salvador, Mexico, Peru and Saint Lucia combine relatively established national quality structures with institutional mechanisms for implementation, co‑ordination or learning, suggesting that attention can increasingly focus on strengthening accountability, ensuring consistent implementation and spreading effective practices across the health system. Belize, Costa Rica, the Dominican Republic, Grenada, Guatemala, Haiti, Honduras, Nicaragua, Panama and Paraguay have important elements of this architecture in place but are still consolidating the links between policy commitments, institutional responsibilities, implementation capacity and systematic learning. The key distinction is therefore less whether countries have adopted quality policies than how far they have developed the full pathway from policy and institutional responsibility to implementation, learning and diffusion of effective practice. These distinctions are not absolute, as several countries in the latter group already have established arrangements in particular dimensions.
The quality of care that a health system can deliver depends heavily on how it develops and governs its health workforce. Countries need not only enough health professionals, but a workforce whose training matches population needs and whose competence is maintained throughout professional life. Assuring professional quality is therefore not simply a matter of controlling entry to practice; it requires a broader policy approach that links workforce planning, professional regulation and ongoing skills development to the delivery of safe, effective and people‑centred care.
Note: Answer to the question: “Does your country have a comprehensive national health workforce strategy that addresses gaps in numbers, distribution, and retention of physicians and nurses in both the short and long term?”
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
In several countries in the region, these priorities are now reflected in formal policy documents. Chile’s Estrategia Nacional de Salud 2021-2030 places workforce issues within a broader agenda of management, quality and innovation, while Colombia’s Política Pública del Talento Humano en Salud 2025-2035 sets out a long-term framework for strengthening professional capability, continuous development and territorial capacity in service delivery. Yet, as Figure 1.4 shows, this strategic commitment is not matched by equally comprehensive planning across the health workforce. In many countries, workforce strategies do not cover both doctors and nurses consistently, and coverage is even less complete for other professional groups. Gaps are also more pronounced when both the public and private sectors are considered together. This matters not only for preparedness in periods of system stress, as highlighted during the COVID‑19 pandemic, but also because healthcare in Latin America and the Caribbean is often delivered through a mix of public and private providers. In practice, this means that workforce policies focussed too narrowly on one part of the system may leave important gaps in quality assurance, continuity of care and effective service capacity.
Peru, Paraguay, Ecuador, Grenada, Saint Lucia, Chile, Belize, Brazil and Haiti all report plans that address the distribution and numbers of health workers in the public sector. Yet only Grenada, Belize and Costa Rica report a similarly comprehensive approach for the private sector. A second group has established forecasting and planning mechanisms, but with more limited sectoral coverage. Policies for workforce forecasting and planning in the public sector are reported in Peru, Paraguay, Mexico, Ecuador, Saint Lucia, Chile, Belize, Colombia, Brazil, Haiti, Nicaragua and Panama, while only Mexico and Grenada report such mechanisms for both the public and private sectors. By contrast, Argentina, El Salvador, Guatemala, Honduras and the Dominican Republic report no workforce forecasting and planning policies (OECD/IDB/The World Bank, 2026[14]). Given the mixed nature of health systems across the region, the gaps between public and private workforce strategies further demonstrates the need for a comprehensive and integrated model of stewardship to ensure equitable access to quality health services in both public and private sectors.
Continuous updating of knowledge and skills is essential for quality improvement and patient safety and should play a vital role in licensure maintenance. Certification is the formal process through which a competent authority confirms that a professional has met the education, training and assessment requirements needed to enter practice. Recertification is the periodic process through which that authority confirms that the professional continues to meet the required standards for practice, typically through continuing professional development and, in some systems, additional assessment. In turn, continuing medical education (CME) and continuous professional development (CPD), together with quality improvement training, are essential and can be embedded in pre‑service curricula or delivered through in-service training and recertification requirements.
In Latin America, regulatory approaches to professional certification and development vary (Figure 1.5);
Certification and recertification: Initial certification for doctors is mandatory in most countries. Mandatory recertification for physicians is required in Peru (every 5 years), Mexico (every 5 years), Grenada (every 5 years), Panama (every 5 years), Saint Lucia (every 2 years), Belize (annually), and Colombia. In several countries: Paraguay, Chile, Costa Rica, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and the Dominican Republic only initial certification is required, with no mandatory recertification. Argentina maintains a voluntary recertification system. Ecuador reports no formal certification requirement for physicians.
National certification exams: Requirements vary widely. Mexico, Grenada, Saint Lucia, Belize and Panama mandate national certification exams for both public and private practice. Peru, Paraguay, Ecuador, Colombia, Brazil, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and the Dominican Republic have no standardised national exam for initial certification. Despite these differences, certification pathways for foreign-trained physicians are reported in Peru, Mexico, Grenada, Saint Lucia, Chile, Belize, Colombia, Costa Rica, Brazil and Panama.
Continuous professional development (CME/CPD): Fully mandatory CME/CPD with quality improvement training integrated into curricula exists in Paraguay, Saint Lucia and Chile. Panama requires mandatory CME/CPD but without quality improvement integration. In most other countries: including Peru, Mexico, Ecuador, Grenada, Costa Rica, Brazil, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and the Dominican Republic CME/CPD is encouraged but not legally required to continue practicing. Belize requires CME only.
Note: Answer to the questions: “Which of the following best describes the policies for certifying, and re-certifying physicians and nurses in your country?” and “Are there national policies requiring continuous professional education (CME/CPD) and quality improvement training for physicians and nurses, and are these integrated into the training curricula?”
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
These findings suggest that greater emphasis is still placed on controlling entry into medical practice than on assuring professional competence over time, but they also reveal different starting points in the development of professional quality-assurance systems. Belize, Chile, Colombia, Costa Rica, Grenada, Mexico, Panama, Paraguay, Peru and Saint Lucia have relatively more established arrangements, combining mandatory entry requirements with additional mechanisms such as recertification, CME/CPD, national examinations or pathways for foreign-trained physicians. Argentina, Brazil, the Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras and Nicaragua are still consolidating this broader architecture, with professional assurance relying more heavily on initial certification and voluntary or more limited mechanisms for maintaining competence over time. The distinction is therefore not simply whether certification exists, but how far countries have moved from a single entry-to-practice control towards a more comprehensive framework covering entry, continuing competence and professional mobility. For countries with more established arrangements, the challenge increasingly lies in ensuring that these mechanisms translate into meaningful updating of skills and improvements in clinical practice; for those still consolidating the foundations, strengthening the breadth and enforceability of professional quality-assurance mechanisms remains an important priority.
Accreditation is a structured process of external quality assessment through which healthcare organisations are evaluated against defined quality and safety standards and formally recognised when those standards are met. Originating largely as a profession-led mechanism, accreditation has evolved with greater government involvement while generally remaining accountable to independent governing bodies. In practice, it relies on healthcare‑specific standards and combines self-assessment, peer review and external reporting to promote continuous improvement. Its main contribution is to strengthen the conditions for better care through facilitating enforcement of nationally defined quality standards: it clarifies expected standards, reinforces internal governance and safety culture, and encourages organisations to monitor performance and address gaps systematically. Evidence suggests positive associations between hospital accreditation and safety culture, as well as with process and efficiency measures such as shorter length of stay though, although findings for other quality-of-care measures are mixed. Overall, accreditation appears most consistently to improve organisational processes and adherence to standards. Yet better patient outcomes do not follow automatically: these depend on whether accreditation is coupled with effective quality improvement, robust measurement systems and sustained organisational support to turn compliance into better clinical practice (Hussein et al., 2021[15]).
In LAC, accreditation processes are largely led by governments
Ministries of Health or specialised units are the sole authorities responsible for hospital accreditation in Peru, Paraguay, Ecuador and Saint Lucia. In contrast, Mexico, Colombia and Brazil use hybrid models involving government and private organisations. Notably, private organisations exclusively lead the process in some provinces of Argentina (Misiones, Chubut and Mendoza), while Chile and Costa Rica utilise specialised private or social security entities for specific oversight. Among the broader set of surveyed countries, Guatemala, Haiti, Honduras, Nicaragua, Panama and the Dominican Republic do not have formal hospital accreditation programmes.
Note: Answer to the questions: “Are there national standards used in the accreditation process, and are these programs voluntary or mandatory?”
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
Accreditation standards in the region are comprehensive, however, regulatory intensity of accreditation across care settings is mostly lacking or voluntary
Peru, Paraguay, Mexico, Ecuador and Chile evaluate clinical management, patient safety, infrastructure, equipment, and administrative processes. Patient satisfaction and staff competence are also high priorities. Emerging areas like the use of Information Technology (IT) are integrated into the standards of almost all countries except Chile and Belize.
Nevertheless, regulatory intensity of accreditation across care settings is mostly lacking or voluntary (Figure 1.6). For hospitals it is only mandatory in Paraguay; and voluntary in Peru, Mexico, Argentina, Chile, Colombia and Costa Rica; no formal national programme reported in Ecuador, Grenada, Saint Lucia, Brazil, Belize, Guatemala, Haiti, Honduras, Nicaragua, Panama and the Dominican Republic. In primary healthcare, accreditation is mandatory in Paraguay and Panama, while voluntary in Peru, Mexico and Chile; most other countries reported no formal programme. Long-term care remains the least regulated sector in terms of accreditation: Colombia reported the existence of mandatory requirements, while most other countries stated that they do not have a formal program.
In Paraguay, the legal basis for accreditation-related requirements dates back to Law No. 1032/1996, which created the National Health System and established accreditation and quality control as part of the organisation of services. The strongest whole‑system policy push, however, came later with the National Quality Policy in Health 2017‑2030, which made the policy mandatory for the entire National Health System, and with its subsequent operationalisation through the 2021 National Strategy for Quality Management in Health. Resolution S.G. No. 117/2021 assigned responsibility for implementation, monitoring and evaluation, and set out a more explicit governance structure for quality management at national, regional and hospital level.
This strong institutional framework contrasts with the country’s more mixed performance on quality of care outcome indicators. Paraguay remains in the worst-performing quartile in the region for avoidable mortality in 2022 and also records high in-hospital case‑fatality within 30 days after admission for acute myocardial infarction and for haemorrhagic stroke. At the same time, this contrast should be interpreted with caution: There has been an improvement in treatable mortality since 2021 when it was the highest rate in the region. Further, the National Quality Policy in Health only took effect from 2021, meaning that any effects on system performance may not yet be fully visible.
Evolution of treatable and preventable mortality in Paraguay and LAC average
Source: WHO mortality database (2026).
Different interpretations of accreditation requirements
The current Superintendence of Health defines accreditation as a voluntary and periodic process intended to verify compliance with quality levels above the minimum mandatory requirements. This helps explain why Paraguay may appear to have a “mandatory” accreditation approach in some policy mappings while the regulator’s own public description presents accreditation as voluntary. In practice, the system appears to distinguish between mandatory categorisation and basic operating requirements, on the one hand, and voluntary accreditation to higher quality standards, on the other. This distinction is also reflected in the Superintendence’s guidelines, where categorisation is obligatory whereas accreditation is voluntary. Paraguay illustrates that formal quality policies and accreditation-related requirements do not by themselves guarantee stronger outcomes. Implementation capacity, time lags and the effective use of quality information also matter, and outcome indicators should be interpreted with these limitations.
Source: Superintendencia de Salud de Paraguay (1996[16]), Ley N° 1032 que crea el Sistema Nacional de Salud; Ministerio de Salud de Paraguay (2021[17]) Resolución S.c. N 117 por la cual se aprueba la estrategia nacional de gestión de la calidad en salud, del Ministerto de Salud Púbiica y bienestar social, https://informacionpublica.paraguay.gov.py/public/3156632-RESOLUCIONSGN117DE2021ESTRATEGIADELACALIDADENSALUDpdf-RESOLUCIONSGN117DE2021ESTRATEGIADELACALIDADENSALUD.pdf; Superintendencia de Salud de Paraguay (2026[18]), Funciones – Superintendencia de Salud – Paraguay, https://superintendenciadesalud.gov.py/funciones/.
The region relies heavily on inspectorate models to establish baseline safety
In contrast to the independent, external assessment against voluntary standards encompassing accreditation, inspectorates enforce compliance with mandatory legal and regulatory requirements. Acting as a government-mandated oversight body, their primary role is to enforce minimum requirements. In this stocktake, 15 of the 19 countries confirmed the use of an inspectorate model to enforce mandatory minimum standards: Peru, Paraguay, Mexico, Ecuador, Argentina, Grenada, Chile, Costa Rica, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama and the Dominican Republic.
Accreditation marks the shift from minimum regulatory compliance to continuous external quality assurance
Countries in the region occupy different starting points in external quality assurance. Argentina, Chile, Colombia, Costa Rica, Mexico, Panama, Paraguay and Peru have moved beyond baseline inspection by establishing formal accreditation arrangements in at least one care setting, although these differ in scope and whether participation is mandatory or voluntary. In these countries, the policy challenge increasingly lies in extending accreditation across care settings and ensuring that external assessment drives continuous improvement rather than compliance alone. Belize, Brazil, the Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Haiti, Honduras, Nicaragua and Saint Lucia still rely more heavily on inspectorates and minimum regulatory standards, making the development or consolidation of formal accreditation mechanisms a more immediate priority. The distinction is therefore between systems focussed primarily on assuring minimum standards and those beginning to layer continuous external quality assurance on top of those foundations.
Institutionalizing Health Technology Assessment (HTA) is foundational to health system quality. When embedded in national decision‑making, HTA prioritises high‑value interventions and sets conditions for safe, appropriate adoption. Following market authorisation, robust post‑market surveillance is required to ensure ongoing safe use of pharmaceuticals and technologies. In recent years, surveillance has expanded to include herbals, traditional and complementary medicines, blood products, biologicals, medical devices, and vaccines (WHO, 2002[19]).
In LAC, HTA responsibility is largely centralised within government
Dedicated government agencies conduct assessments to inform coverage decisions in 13 countries: Peru, Paraguay, Mexico, Ecuador, Argentina, Chile, Costa Rica, Brazil, El Salvador, Guatemala, Haiti, Nicaragua and Panama. Argentina has a mixed model where some provinces have incorporated the use of HTA through dedicated agencies and others such as Santiago del Estero and Buenos Aires do not have dedicated formal agencies. HTA is not formally organised in Grenada, Saint Lucia, Belize, Honduras and the Dominican Republic, indicating a key area for institutional development.
HTA helps determine not only whether a technology is safe and effective, but also whether it improves care relative to existing practice, is affordable, and can be integrated into routine service delivery.
Germany combines federal regulation with statutory health insurance self-governance. BfArM, the federal authority under the Ministry of Health, oversees the regulation and post-market surveillance of medicines and medical devices, including vigilance and safety reporting. IQWiG, an independent scientific institute commissioned by the Ministry or the Federal Joint Committee, supports evidence assessment for reimbursement decisions. This links HTA directly to national coverage and pricing rules, helping ensure that adoption is driven by evidence. For digital health applications, assessment also covers usability and accessibility, including support for people with disabilities. The medicines pathway considers benefit for different patient groups, though broader equity considerations are less explicit.
Korea’s HTA model is vertically integrated. The Ministry of Food and Drug Safety (MFDS) regulates both medicines and medical devices and oversees market approval, quality and safety control, market compliance, and post-market surveillance and vigilance. The National Evidence‑based Healthcare Collaborating Agency, founded by the Korean Government as an independent agency collaborating with the Ministry of Health and Welfare, leads HTA, while the Health Insurance Review and Assessment Service, under the ministry, reviews claims, manages benefit standards and conducts quality assessment. HTA is tied to national coverage and reimbursement decisions, helping steer adoption through system-wide review. Official guidelines are not explicit about a formal requirement to assess differential effects on vulnerable groups.
Spain’s HTA model is network-based rather than centred on a single national agency. RedETS (Spanish Network of Agencies for Health Technology Assessment and Services of the National Health System) brings together seven regional agencies and one state agency under the co‑ordination of the Ministry of Health, with a permanent technical secretariat and a common methodology to support decisions on the incorporation, disinvestment and appropriate use of medical technologies in the National Health System. The state‑level HTA unit is the Health Technology Assessment Agency within the Instituto de Salud Carlos III. Post-market surveillance sits mainly outside HTA and is led by the Spanish Agency of Medicines and Medical Devices, which is responsible for the evaluation, authorisation and continuous monitoring of medicines and for the control and surveillance of medical devices. On equity, RedETS’ strategic framework support decisions that promote equity, cohesion and sustainability.
Although their institutional models differ, all three countries use HTA to make technology adoption more systematic, transparent and evidence‑based. These arrangements illustrate the value of linking assessment to decisions about whether and under what conditions technologies are adopted, covered or reimbursed. They also incorporate equity considerations and post-market learning to varying degrees.
Source: Chapman (2025[20]), “Towards identifying good practices in the assessment of digital medical devices: Insights from several OECD countries”, https://doi.org/10.1787/b485ee1f-en; OECD (2005[21]), Health Technologies and Decision Making, https://doi.org/10.1787/9789264016224-en; OECD (2022[22]), Towards an Integrated Health Information System in Korea, OECD Publishing, Paris, https://doi.org/10.1787/c4e6c88d-en; O’Rourke, Oortwijn and Schuller (2020[23]), “The new definition of health technology assessment: A milestone in international collaboration”, https://doi.org/10.1017/S0266462320000215.
Post-market surveillance is standardised for pharmaceuticals and medical devices but varies for blood products
Peru, Paraguay, Mexico, Ecuador, Argentina, Chile, Costa Rica, Brazil, Guatemala and Panama consistently assess pharmaceuticals; medical device assessments are conducted in Peru, Paraguay, Mexico, Ecuador, Chile, Costa Rica, Brazil, Guatemala and Panama. Blood product assessments are less common, reported in Peru, Mexico, Argentina, Costa Rica, Guatemala and Panama. Nearly all countries conducting assessments have formal norms to evaluate compliance, ensuring technologies meet safety requirements in use. Direct links between HTA findings and reimbursement decisions are less common.
Peru is the only country that reports HTA results are linked to reimbursement decisions across three domains: medical devices, pharmaceuticals, and blood products. Chile and Paraguay connect HTA to reimbursement only for pharmaceuticals, while all other responding countries report no linkage at all.
Peru and Paraguay systematically require equity considerations in HTA
A key component of modern HTA is determining whether the differential impact on vulnerable populations is considered during the assessment process. Peru and Paraguay systematically require equity considerations, while Mexico, Ecuador, Argentina, Grenada, Chile and Brazil consider them only occasionally. Saint Lucia, Belize, Colombia, Costa Rica, Guatemala, Haiti, Honduras, Nicaragua and Panama report that equity is not yet integrated into formal HTA processes.
From establishing HTA to integrating assessment, surveillance and reimbursement
Countries also show different starting points in the governance of health technologies. Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, Mexico, Panama, Paraguay and Peru combine an institutionalised HTA function with routine post-market assessment of pharmaceuticals and, in most cases, medical devices, providing a more established basis for technology quality assurance. Belize, the Dominican Republic, El Salvador, Grenada, Haiti, Honduras, Nicaragua and Saint Lucia are still consolidating one or both of these foundations. For countries with more established arrangements, the next challenge is increasingly to connect assessment and surveillance more systematically to reimbursement, appropriate use and equity considerations; Peru, and to a lesser extent Chile and Paraguay, illustrate progress in this direction.
National audit studies
National audit studies are a critical tool for examining care quality in high-risk areas where clinical errors or adverse events are most likely to occur. By systematically reviewing care processes, outcomes and medical records, they can reveal preventable harm, identify departures from recommended practice and support corrective action at provider, facility and system level. They are particularly valuable for tracking major surgical complications, anaesthesia related mortality, and maternal deaths. Systematic review of medical records enables health systems to identify preventable harm and implement corrective actions (OECD/WHO/World Bank Group, 2018[3]).
Across Latin America and the Caribbean, countries are assembling the foundations of a national quality measurement infrastructure, but few have embedded these measures into routine accountability and governance
Standardised national quality indicators are in use across the region to track structure, process, and outcomes. Six countries: Mexico, Saint Lucia, Colombia, Haiti, Nicaragua and Panama report comprehensive national indicator sets, while most others including Peru, Paraguay, Ecuador, Argentina, Grenada, Chile, Costa Rica, Brazil, El Salvador, Guatemala, Honduras and the Dominican Republic describe theirs as partial or still under development. Belize reports no national quality indicator set. The breadth of national indicator sets should not, on its own, be interpreted as a measure of measurement-system maturity. Countries may differ in how they assess whether their frameworks are comprehensive, and systems with narrower indicator sets may still use them effectively for reporting, benchmarking or accountability. What matters is not only the scope of measurement, but also data quality, coverage and its routine use for improvement.
Public reporting of provider performance is fully implemented in Peru, Chile and Colombia, and partially implemented in Paraguay, Ecuador, Grenada, Brazil, El Salvador, Panama and the Dominican Republic. Regular national quality performance reports are published in Peru, Mexico, Chile, El Salvador, Haiti and Panama. The mechanisms that convert indicators into action remain uneven: eight countries: Paraguay, Ecuador, Grenada, Colombia, Brazil, Nicaragua, Panama and the Dominican Republic use indicators for routine audit and feedback to providers; six (Paraguay, Grenada, Chile, Haiti, Honduras and Panama) use them for benchmarking across facilities; and only Peru and Paraguay tie them to pay-for-performance. The most common use reported by six countries (Paraguay, Mexico, Ecuador, Argentina, Costa Rica and Brazil) is to feed indicators into learning collaboratives, a softer approach that relies on voluntary engagement. Taken together, most countries have many of the building blocks for quality measurement, but measurement is not yet consistently linked to contracting, supervision, budgeting, or financial incentives.
To drive clinical improvement, several countries measure the impact of practice guidelines on patient outcomes. Eleven countries: Paraguay, Mexico, Argentina, Chile, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama and the Dominican Republic maintain national monitoring systems for this purpose; Peru and Grenada use local or regional tracking. Ecuador, Saint Lucia, Belize, Costa Rica and Brazil report no formal monitoring systems. Despite these efforts, barriers to effective guideline implementation include limited resources (reported by 16 countries), inadequate dissemination mechanisms (15 countries), resistance to change in clinical practice (11 countries), lack of awareness (11 countries), and insufficient incentives (13 countries). To encourage adherence, countries are implementing monitoring and evaluation systems, although national coverage remains uneven and some rely on local or regional arrangements. Common barriers include limited resources and infrastructure, inadequate dissemination, resistance to changes in clinical practice, lack of awareness and insufficient incentives.
Evidence‑based practice guidelines
Evidence‑based clinical practice guidelines are central to strengthening quality and reducing adverse events. Drawing on the best available research, they support clinicians and patients in making appropriate, effective care decisions and standardise high‑value interventions to reduce clinical inertia and unwarranted care variation.
In LAC, guideline development and implementation are largely institutionalised through expert groups under direct government co‑ordination
In Peru, Paraguay, Mexico, Ecuador, Argentina, Costa Rica, Chile, Colombia, Belize and Brazil, Ministries of Health or delegated national authorities lead the technical groups that draft and update standards, aligning guidelines with national priorities and coverage policies.
Most countries integrate equity considerations into guideline design. Eight countries: Peru, Paraguay, Mexico, Ecuador, Argentina, Saint Lucia, Costa Rica and Brazil systematically include recommendations to address disparities in diagnosis, treatment, and follow-up for disadvantaged groups. Nine countries: Grenada, Chile, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama and the Dominican Republic occasionally include such considerations. Belize reports that equity is not included in guideline design.
Update cycles for major conditions, including cancer and cardiovascular disease (CVD), vary in frequency. Paraguay reports systematic updates of clinical practice guidelines every 2‑3 years for both cancer and CVD; Chile updates cancer guidelines every 2‑3 years but does not regularly update CVD guidelines. Peru, Mexico, Argentina and Colombia update guidelines approximately every 4‑5 years. Ecuador, Costa Rica, Brazil and the Dominican Republic report that guidelines are not regularly updated. El Salvador, Guatemala, Honduras, Nicaragua and Panama update guidelines only when significant new evidence emerges. Grenada follows a similar evidence‑driven approach. The scope of clinical practice guidelines varies across countries. For cancer, Peru, Ecuador, Argentina, Saint Lucia, El Salvador, Guatemala, Haiti, Nicaragua and the Dominican Republic report guidelines that incorporate a patient journey perspective, addressing co‑ordination and integration of care across facilities and levels of the health system. Paraguay, Mexico, Grenada, Chile, Honduras and Panama report cancer guidelines that are primarily limited to facility-level clinical specifications. Belize, Costa Rica and Brazil similarly focus on facility-based clinical aspects. For cardiovascular disease, the patient journey perspective is more widespread: Peru, Paraguay, Ecuador, Argentina, Grenada, Saint Lucia, El Salvador, Guatemala, Haiti, Nicaragua and the Dominican Republic incorporate it, while Mexico, Chile, Honduras, Panama, Belize, Costa Rica and Brazil focus on facility-level specifications.
Despite high‑quality guidelines, implementation faces barriers. To encourage adherence, countries are implementing monitoring and evaluation systems
Limited resources and infrastructure, resistance to changes in clinical practice, and inadequate dissemination are the most common barriers for implementation of guidelines (Figure 1.8). To encourage adherence, countries are implementing monitoring and evaluation systems: Paraguay, Mexico, Argentina and Chile have established national systems to track the impact of practice guidelines on patient outcomes. Others, like Peru and Grenada, rely on local or regional monitoring. These systems help identify gaps in compliance and prompt targeted training or resource allocation.
Note: Answer to the questions: “What are the main barriers to the implementation of practice guidelines in your country? ”
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
Importance of health data and digital infrastructure
Health data and digital infrastructure are essential enablers of quality improvement, but their contribution depends not only on data availability, but also on interoperability, linkage capacity, routine use for performance assessment, and meaningful access for patients. As shown in Chapter 5, many countries in Latin America and the Caribbean have established digital health data systems and some capacity for governance and monitoring, yet important gaps remain in data integration across care settings, in the routine use of data for quality improvement, and in patient access to their own information. These limitations weaken continuity of care, constrain performance measurement and reduce the ability of health systems to support safer, more efficient and more people‑centred care. Further details are presented in Chapter 5, in the sections on Health data availability and Health data use and capacities.
Financial incentives and provider payment reforms can improve care quality and foster integration across levels of care when embedded in coherent, data‑enabled, strategically purchased financing systems. Payment methods shape provider behaviour by influencing what is rewarded in practice: they can encourage better co‑ordination, prevention and continuity of care, but can also reinforce volume and fragmentation if poorly designed. OECD work has emphasised that purchasing arrangements are most effective when financial incentives are linked to clear quality objectives, reliable measurement and accountability mechanisms, so that payment supports better outcomes and patient experience rather than activity alone (OECD/WHO, 2023[24]).
The degree to which quality is integrated into payment systems varies significantly across the region
Peru and Chile weight quality over 10% of payments for hospital services; Peru extends this to integrated care networks. Saint Lucia, Chile and Brazil apply major quality-linked payments primarily within primary healthcare (PHC). Paraguay, Mexico and Argentina weight quality under 10% of payments in hospital and PHC reimbursement. The remaining 12 countries: including Colombia, Ecuador, Grenada, Belize, Costa Rica, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama and the Dominican Republic report no implementation of quality-linked payment reforms at the national level, though this does not preclude their use at the payer or subnational level.1 In Colombia, for instance, insurance agencies (EPS) are known to apply performance‑based contracting and quality-linked payment modalities unevenly across their provider networks, even in the absence of a nationally standardised policy.
Countries deploy several mechanisms to drive performance. Pay-for-performance (P4P) is used in Peru, Mexico, Saint Lucia, Chile (PHC) and Brazil, linking rewards to quality targets. Results-based financing (RBF) is used in Paraguay, Argentina and Brazil, tying funding to verified outputs and outcomes. Mixed models include Chile’s diagnosis-related groups (DRGs) and mandatory contributions, and Grenada’s block grants and procurement-based financing. It is worth noting that several of these mechanisms may also operate below the national level through individual insurers, subnational governments, or specific programmatic initiatives in ways that are not captured by a survey instrument focussed on national policy.
International experience suggests that payment reform is most effective when quality-linked incentives are introduced as part of a broader package rather than as a stand-alone lever. Financial incentives alone were generally insufficient to produce major changes in provider behaviour. More promising results were associated with accompanying measures such as training, non-financial incentives, better risk adjustment, clearer quality metrics and greater certainty over payment levels. This reinforces the message that purchasing for quality depends as much on design and implementation capacity as on the existence of incentives themselves (Barber et al., 2025[25]).
To determine these payments, health systems track a variety of performance metrics and indicators
Health outcomes, such as mortality or readmission rates, are utilised in Paraguay, Mexico, Saint Lucia, Chile, Costa Rica and Brazil to determine financial allocations. Success in preventive care measures is a priority for Paraguay, Grenada, Saint Lucia, Chile and Brazil. Furthermore, adherence to evidence‑based clinical practice guidelines serves as a formal payment indicator in Paraguay, Chile and Brazil, ensuring that standardised protocols are followed in practice. While less common, patient experience and satisfaction measures are factored into the payment processes in Paraguay, Chile and Panama.
These patterns point to different starting points in quality-linked purchasing. Argentina, Brazil, Chile, Mexico, Paraguay, Peru and Saint Lucia have introduced quality-linked payment mechanisms at the national level, shifting the policy challenge towards improving their design, measurement and alignment with quality objectives. In the remaining countries, where national quality-linked payment reforms are not yet implemented, strengthening the measurement and strategic purchasing foundations needed to introduce such incentives remains a more immediate priority. These distinctions refer to national policy and do not exclude more advanced arrangements operated by individual payers, subnational authorities or specific programmes.
The following examples show how quality indicators can be incorporated into purchasing and payment decisions rather than collected separately from them.
Paraguay has introduced results-based financing in seven health regions, establishing clear targets and linking resources to quality indicator compliance across maternal-child health, hypertension, diabetes, women’s cancers, HIV/STIs, and tuberculosis.
Chile employs a hybrid system that integrates diagnosis-related groups with performance elements, leveraging clinical guideline compliance and outcome data to drive hospital performance. Chile also operates a P4P scheme in primary healthcare that rewards PHC teams with bonuses for achieving pre‑defined targets on quality of care indicators.
Peru applies substantial quality weighting across hospitals and integrated networks through results-based budgeting, pilot pay-for-performance schemes targeting specific conditions, and capitation-based contracting at the primary care level, reflecting a progressive incorporation of financial incentives as opposed to a consolidated national system.
Brazil concentrates payment reforms in primary care, using results-based financing to promote preventive care and community health outcomes.
Source: Health at a Glance Latin America and the Caribbean 2026: Survey of quality of care policies.
Patient safety is a core principle of healthcare. While complications cannot be fully eliminated given clinical complexity, systematic safety measures can substantially reduce harm. High-quality systems adopt a “systems approach”, treating errors as opportunities to address latent failures in processes, protocols, and organisational design (McNab et al., 2020[26]). By prioritizing prevention of avoidable harm, medication errors, surgical complications, and healthcare‑associated infections (HAIs) systems protect patients and staff and reduce the financial and psychological burdens of unsafe care (WHO, 2024[10]).
Most countries have established national patient safety leadership, but formal programmes remain uneven
Ministries of Health lead patient safety in 18 of 19 countries, with regional and local health authorities playing a supporting role in 13. Only Panama reports a dedicated national patient safety agency, all other countries lack this institutional layer, which may limit the authority and technical depth available for sustained safety improvement.
National patient safety programmes are present in 12 of 19 countries. Seven countries: Argentina, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and Panama report no formal program. Among countries with programmes, the most widely adopted elements are infection prevention and control, and safe use of medical devices (each reported by 12 countries), followed by surgical safety (11), medication safety and safe blood transfusion (11 each), reporting and learning from adverse events and patient identification (10 each). Prevention of falls, though less common, is addressed by 8 countries.
Adverse event reporting is stronger in the public sector but not yet used systematically for learning
Adverse event and medical error reporting is a key indicator of a maturing safety culture, though implementation differs markedly across sectors. In the public sector, six countries maintain mandatory reporting systems (Paraguay, Ecuador, Colombia, Brazil, El Salvador and Haiti), while eight operate voluntary systems (Mexico, Ecuador, Grenada, Saint Lucia, Chile, Belize, Costa Rica and Brazil with Ecuador and Brazil operating both mandatory and voluntary channels). Six countries report no national public-sector reporting procedure: Argentina, Guatemala, Honduras, Nicaragua, Panama and the Dominican Republic.
In the private sector, the picture is thinner: only Ecuador and El Salvador mandate adverse event reporting from private providers, and five countries offer voluntary systems (Paraguay, Mexico, Ecuador, Belize and Costa Rica). Seven countries report no national reporting procedures for the private sector: Peru, Saint Lucia, Guatemala, Honduras, Nicaragua, Panama and the Dominican Republic. However, subnational standards may exist within the oversight capacities of the regulatory agencies. When adverse event data are collected, their most common use is to inform quality improvement initiatives (9 countries: Peru, Paraguay, Mexico, Ecuador, Grenada, Chile, Colombia, Brazil and El Salvador), followed by professional education (5). However, only four countries use reported data for public reporting (Paraguay, Chile, Colombia and Brazil), and only Paraguay and Haiti apply regulatory measures or sanctions based on reported events. Three countries: Paraguay, Belize and Costa Rica report that collected data are not systematically used. More broadly, the use of adverse event information for learning, public reporting and regulatory action remains uneven.
Most countries have built infection prevention and control programmes, but reporting gaps remain
Robust Infection prevention and control (IPC) programmes are critical to reducing healthcare associated infections (HAIs) and are prioritised across the region. In the public sector, 18 of 19 countries report having IPC guidelines (Argentina is the exception due to missing data); dedicated infection control specialists are present in 16, surveillance systems for hospital-acquired infections in 15, mandatory infection control committees in 16, and regular staff training in 17. The private sector lags modestly: IPC guidelines are in place in 13 countries, surveillance in 12, and infection control specialists in 10, though two countries (Grenada and Panama) report no formal IPC policies for private facilities.
The use of standardised HAI indicators at the hospital level is widespread in the public sector. Surgical site infections (SSI) are tracked by 14 countries, while catheter-associated urinary tract infections (CAUTI) are monitored by 11. Central line‑associated bloodstream infections (CLABSI) and ventilator-associated pneumonia (VAP) are each monitored by 12 countries. Hand hygiene compliance rates are tracked by 11 countries, and antibiotic stewardship indicators by 8, though this remains a gap worth noting given rising antimicrobial resistance in the region. Public transparency of these data varies across the region: seven countries report that HAI data in the public sector are nationally standardised and publicly reported (Paraguay, Mexico, Ecuador, Saint Lucia, Chile, Colombia and Brazil). Five countries: Peru, Grenada, Costa Rica, El Salvador and the Dominican Republic maintain nationally standardised data but do not report them publicly. Five countries report no standardised HAI data at all in the public sector (Belize, Guatemala, Haiti, Nicaragua and Panama). In the private sector, public reporting is less common: five countries publish nationally standardised data (Paraguay, Mexico, Ecuador, Colombia and Brazil), while four maintain nationally standardised but non-public data (Chile, Costa Rica, El Salvador and the Dominican Republic). Six countries report no standardised private‑sector HAI data (Grenada, Belize, Guatemala, Haiti, Nicaragua and Panama).
Only four countries report having a standardised coding system for safety incidents and near misses
Only four countries (Peru, Argentina, Saint Lucia and Belize) report having a standardised coding system for safety incidents and near misses, such as SNOMED-CT or the WHO International Classification for Patient Safety. Peru notes that its Patient Safety Committees currently use a national framework for adverse event notification and analysis, with SNOMED-CT planned for the next phase. The limited adoption of standardised coding for near misses is significant: capturing events that almost caused harm (but did not) is widely recognised as one of the most effective tools for proactive risk management, and its absence in most LAC countries suggests that safety systems remain oriented toward reactive investigation rather than prospective learning (Alfayez et al., 2025[27]).
People‑centred care is a defining feature of high-quality health systems, shifting from paternalism to partnership, providing care that is respectful of and responsive to individual preferences, needs and values. This approach empowers patients to participate in care decisions, strengthened by health literacy to enable informed choices and enhance safety. Beyond clinical encounters, well-designed systems create opportunities for patient participation in policymaking and systematically solicit consumer feedback, increasing accountability and revealing systemic gaps. Literature tells us that OECD elements of people‑centred health systems improve accountability, reveal gaps that matter to users, and help align services more closely with what people need (OECD, 2021[28]). Recent evidence from the OECD PaRIS survey also shows that more people‑centred care is associated with better patient-reported outcomes and experiences, particularly for people living with chronic conditions, underlining that patient partnership is not only a matter of responsiveness but also an important contributor to better care (OECD, 2025[29]).
National satisfaction surveys are implemented in 10 of 19 countries
LAC countries employ diverse mechanisms to capture the patient voice, with varying levels of institutionalisation. National satisfaction surveys are implemented in 10 of 19 countries (Paraguay, Mexico, Ecuador, Grenada, Saint Lucia, Chile, Belize, Colombia, Costa Rica and Brazil). Digital transformation has facilitated the rise of online platforms or hotlines for complaints and suggestions in 15 countries, providing a direct channel for user feedback. More formal structures like patient advisory councils or committees are less common but active in Paraguay, Mexico, Chile, Brazil and Haiti. Chile presents a particularly robust model through Law 20.500, which mandates Civil Society Councils and User Consultative Councils in hospitals and Local Development Councils in primary care. By contrast, Argentina, Saint Lucia, El Salvador, Guatemala, Honduras, Nicaragua and the Dominican Republic report limited or no formal national satisfaction survey mechanisms, indicating gaps in how patient opinions influence policy.
Patient organisations are essential advocates, though roles vary. Groups focussing on condition-specific advocacy exist in all surveyed countries except Belize. General patient defense organisations are more prominent in Mexico, Colombia and Brazil. Their influence on care quality is strongest where they are embedded in formal monitoring or policy cycles. For instance, organisations in Paraguay, Chile, Colombia and Costa Rica participate in monitoring and evaluation of services; groups in Paraguay, Ecuador, Argentina, Chile, Costa Rica, Brazil and Panama contribute directly to policy formulation. Belize reports no formal patient organisations, limiting structured representation of patient interests.
Systematic measurement of patient experience remains challenging
Nationwide standardised measurement is reported in Ecuador, Chile and Colombia. In Mexico, Grenada and Brazil, measurements are currently restricted to specific regions or health facilities rather than being a universal national requirement. Nine countries: Paraguay, Argentina, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama, and the Dominican Republic report that measurement is not standardised, and Saint Lucia and Costa Rica report that patient experience is not measured at all. Peru employs the SERVQUAL methodology to evaluate user satisfaction, focussing on the alignment between patient expectations and perceptions.
Data collection is primarily led by Ministries of Health (9 countries) and individual health service providers (9 countries). In some contexts, specialised bodies such as SUSALUD in Peru or the Quality Assurance Agency in Ecuador take the lead. Independent research organisations and patient groups rarely collect or report experience data; Paraguay is the only country identifying independent researchers as key stakeholders in this process.
Patient-reported data complement conventional indicators by showing how people experience care and how health systems respond to their needs. However, their routine, standardised use remains limited across much of the region. In Latin America, five countries participate in the Quality Evidence for Health Systems Transformation (QuEST) Network, a global partnership that promotes high-quality, people‑centred and equitable health systems through better measurement and evidence‑based practice. A core instrument of this initiative is the People’s Voice Survey (PVS), a population-based mixed-mode survey that captures what people value and experience in health systems.
Findings from 2025 in Argentina, Colombia, Mexico, Peru and Uruguay show that, while contact with health services is common, access to high-quality primary care remains limited. Only around 30‑35% of adults report having a usual source of care that meets basic quality criteria, and fewer than half strongly believe they would receive high-quality or affordable care if seriously ill. About two‑thirds received some preventive care in the past year, but delivery to at-risk groups lags: only around 42% of adults aged 50 and over report cardiovascular risk screening. Results also point to problems with waiting times and continuity, while mental healthcare stands out as a major gap, with only around one‑quarter of those reporting need receiving appropriate care.
The OECD Patient-Reported Indicator Surveys (PaRIS) provide a different, more in-depth lens. PaRIS focusses on primary care users, especially people living with chronic conditions, and links patient responses to information from their primary care practices. Across PaRIS countries, 87% of respondents reported a positive overall experience of care and 66% reported good general health.
Note: Weighted estimates. Argentina (Mendoza) N=1 190, Colombia N=1 237, Mexico N=1002, Peru N=1 255; Uruguay N=1 237.
Source: People’s Voice Survey Quest Network 2025.
E‑cohorts: Extending people’s voice through longitudinal follow-up
E‑cohorts complement the cross-sectional People’s Voice Survey by tracking experiences, care pathways and outcomes over time. Implemented in Peru and Uruguay, they combine repeated follow-up with patient-reported and clinical data to assess continuity, responsiveness and effectiveness of care. In Peru, results show this approach is feasible, with over 95% retention, and can improve blood pressure control while exposing persistent gaps in continuity of care.
Source: People’s Voice Survey Quest Network 2025; OECD (2025[29]), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), https://doi.org/10.1787/c8af05a5-en.
Integrated care
Integrated care is central to improving quality in LAC. It organises services into a seamless continuum-from prevention and health promotion through treatment, rehabilitation, and palliative care across all levels and settings. As a strategy to elevate quality, integrated care reduces fragmentation, strengthens provider co‑ordination and co‑operation, and aligns services with patient needs and preferences, bridging primary, secondary, and tertiary care to avoid siloed delivery and ensure smooth transitions. PAHO has long framed integrated health services networks (RISS) as a key operational expression of primary healthcare, designed to improve access, efficiency and quality (PAHO, 2026[30]). The outcome indicators presented earlier are consistent with this concern: preventive services generally perform comparatively well, whereas acute and chronic-care indicators where co‑ordination may be important, vary widely across countries. These patterns should be interpreted cautiously because of differences in access and data completeness.
The transition toward integrated care in LAC faces profound systemic barriers across hospital, primary healthcare, and long-term care settings. The most significant and widespread obstacle is underdeveloped health data infrastructure, limiting real-time exchange of patient information, reported by 17 countries for PHC and 18 for hospitals. There is widespread lack of systematic monitoring of integration’s impact on quality and outcomes (noted in 15 countries in PHC; 14 in hospitals). Financial constraints are significant, with 16 countries in PHC and 15 in hospital settings citing insufficient funding and incentives for collaboration. Beyond these structural issues, Mexico highlights a specific gap in the development of management skills for medical unit leaders, while Grenada points to the fragmentation between public and private sectors and the limited integration of mental health and social services as major impediments to a sustainable continuum of care.
Despite these obstacles, countries are advancing policies to strengthen care co‑ordination. Multidisciplinary teams are used in 15 of 19 countries: Paraguay, Mexico, Grenada, Saint Lucia, Chile, Colombia, Costa Rica, Brazil, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama and the Dominican Republic. Eleven countries: Paraguay, Mexico, Grenada, Chile, Costa Rica, Brazil, El Salvador, Guatemala, Haiti, Honduras and the Dominican Republic have formal strategies and integrated care protocols. Shared electronic health records (EHRs) between providers operate in Paraguay, Mexico, Costa Rica, Brazil and Panama. Financial incentives and regular monitoring systems to promote and assess co‑ordination are in place in Peru, Paraguay, Mexico, Chile and Brazil, with monitoring systems also reported in El Salvador, Guatemala, Haiti, Honduras, Panama and the Dominican Republic. Chile and Brazil also employ patient navigation programmes to support transitions across levels of care.
Countries are at different starting points in the transition from care co‑ordination to system-level integration. Paraguay, Mexico, Chile, Costa Rica, Brazil and Panama have begun to complement organisational mechanisms with structural enablers such as shared electronic health records and/or financial incentives for co‑ordination. In these countries, the challenge increasingly lies in extending these arrangements across providers and care settings and assessing whether they improve continuity and outcomes. Elsewhere, multidisciplinary teams, protocols and monitoring provide important foundations but strengthening the information and financing infrastructure needed to support integration across the system remains a more immediate priority.
The Latin American and Caribbean region stands at a critical juncture. As this chapter has detailed, a foundational infrastructure for quality of care is emerging, with most countries having established basic regulatory frameworks and quality policies. However, the journey from establishing structures to achieving high-quality outcomes is far from complete.
Quality of care policy in Latin America and the Caribbean has moved beyond isolated initiatives and now rests on a recognisable institutional base, but the transition from basic quality assurance to fully operational, learning and people‑centred quality systems remains incomplete. Importantly, countries are not starting from the same point, nor do they occupy a single position across all dimensions of quality. A country may have relatively established accreditation or technology-governance arrangements while still consolidating measurement, integrated care or quality-linked purchasing. The next phase is more demanding. It requires stronger use of data, more systematic feedback and transparency, deeper organisational learning, and better alignment between regulation, financing and care delivery across care settings and schemes. This also requires quality to be addressed not only within individual facilities, but across the patient journey, where continuity, referrals, information exchange and accountability across providers increasingly determine whether high-quality care is actually delivered. How countries pursue these shifts, however, will depend on the foundations already in place in each policy area.
The cross-cutting challenges of inequity and weak digital infrastructure require focussed attention. Investing in interoperable data systems is not a technical afterthought but the core enabler for targeting interventions effectively, the identification of hidden disparities and the routine use of patient-reported measures. Closing the quality gaps in LAC depends on connecting robust governance, data systems and strategic incentives, while committing to equity in both public and private sectors. This direction is consistent with the international evidence on high-performing health systems, and it provides the clearest frame for interpreting both the progress already made and the gaps that remain.
Large performance gaps point to unevenly organised care
The region’s quality profile is not uniformly weak, but uneven: some indicators show solid performance, while others reveal very large gaps in the delivery of timely and effective care.
Cross-country differences are largest in indicators that depend on organised treatment pathways and timely clinical management, with nearly fourfold gaps in both treatable mortality and 30‑day in-hospital case‑fatality after acute myocardial infarction.
Preventive services, particularly childhood immunisation, tend to perform more strongly than acute and chronic care pathways.
These indicators remain essential for benchmarking, but they do not measure quality in isolation: differences in access, hospital capacity, coding, referrals and data completeness also shape observed results.
The institutional findings provide some hypothesis-generating patterns, but not a simple relationship between the presence of individual quality mechanisms and outcomes. In several policy areas, particularly quality governance, accreditation and technology governance, countries with more established arrangements also tend to record lower treatable mortality than countries still consolidating these foundations. However, this pattern is neither universal nor sufficient to infer causality. Paraguay illustrates the limitation particularly clearly: despite having comparatively extensive quality policies and institutional mechanisms, treatable mortality and several acute‑care outcomes remain relatively poor. Conversely, favourable outcomes can coexist with less developed arrangements in particular policy domains.
Taken together, this suggests that better outcomes are unlikely to depend on any single quality mechanism. Rather, the chapter points towards the importance of combinations of effective governance, organised care pathways, reliable measurement, professional capability and the capacity to implement policies consistently. The next stage of quality improvement lies less in expanding the menu of indicators or policy instruments than in using them to identify where care pathways break down and ensuring that institutional arrangements translate into better care. International evidence points in the same direction: high-performing systems combine outcome measurement with stronger service organisation, transparent performance review and explicit mechanisms to translate results into improvement (OECD/WHO/World Bank Group, 2018[3]).
The region has built the foundations of quality governance, but not yet full learning systems
Progress across all other quality priorities depends on a clear institutional home for quality, with an explicit mandate, sufficient authority and stable implementation capacity across both public and private sectors. While many countries have established these building blocks, strengthening their scope and ability to translate policy into implementation remains a central priority.
Most countries in the region have already established a basic institutional architecture for quality of care. Quality is now widely recognised as a policy priority; Ministries of Health generally lead the agenda; and core regulatory functions are present in many systems. There is however an important distinction between establishing quality structures and developing the full pathway from policy and institutional responsibility to implementation, learning and accountability.
Licensing, medicines regulation and other baseline stewardship functions are generally advanced, while accreditation, clinical audit, public reporting, decision support and patient-reported measurement are less consistently embedded in routine practice.
Workforce quality assurance still places greater emphasis on entry into practice than on competence over time: Initial certification is common, but recertification, national examinations and mandatory CME/CPD are much less widespread.
Health technology assessment and external quality assurance are becoming more institutionalised, but links to reimbursement, equity and broader quality-improvement cycles remain challenging.
The reach of quality governance across public and private provision remains uneven. Workforce planning is substantially more developed for the public sector, while adverse event reporting and infection prevention and control are also less consistently institutionalised among private providers. In health systems where care is delivered through multiple public and private arrangements, national stewardship needs to ensure that core quality standards, measurement and accountability extend across sectors.
For countries still consolidating these foundations, priorities include clearer governance and accountability, more systematic external quality assurance, stronger mechanisms to maintain professional competence over time, and basic institutional capacity for measurement and patient safety. Countries with more established arrangements face a different challenge: ensuring that existing mechanisms are applied consistently, extend across public and private providers and care settings, and generate learning and accountability rather than compliance alone.
Across these different starting points, however, the broader policy direction is shared: moving beyond regulation and voluntary models towards more institutionalised quality assurance. Mature quality systems combine clear national stewardship with operational plans, regular feedback, professional development, external assessment and stronger use of evidence in decision making, ideally systematically implemented in both public and private sectors, and explicitly linked to financing and public reporting. OECD experience also suggests that professional quality improves when health systems modernise the role of health workers and move from one‑off authorisation towards continuous development and accountability. Countries such as France (Haute Autorité de Santé, 2025[31]), where hospital certification is a mandatory external evaluation for all public and private hospitals, and Australia, where national safety and quality standards are embedded in a structured accreditation scheme, illustrate how standards and external assurance can be integrated more systematically with broader quality governance.
The missing bridge is the routine use of measurement, safety information and incentives for improvement
The region is advancing on measurement and safety. Many countries have introduced quality indicators, audit studies, practice guidelines, patient safety structures and, in a few cases, quality-linked payment reforms. The challenge is to organise these tools in an improvement system.
National quality indicators, audit studies and guidelines are increasingly present, but in many countries they are not routinely linked to supervision, contracting, budgeting or payment. The progression is therefore from establishing reliable measurement and review mechanisms towards embedding their results in routine management, accountability and decision making.
Patient safety systems are more advanced in infection prevention and control than in organisational learning from harm: adverse event reporting remains uneven, public reporting is limited, and standardised coding of incidents and near misses is rare. The progression is therefore from establishing safety rules and reporting mechanisms towards using information prospectively to prevent recurrence and spread effective practice.
Argentina, Brazil, Chile, Mexico, Paraguay, Peru and Saint Lucia have introduced quality-linked payment mechanisms nationally, shifting their challenge towards improving design, measurement and alignment with quality objectives. In the remaining countries, stronger measurement and strategic purchasing foundations are generally needed before financial incentives can become a meaningful system-wide quality lever. In both cases, the evidence reinforces the same conclusion: data and incentives are most effective when embedded in broader systems of governance, feedback and implementation support.
The broader literature suggests that this pattern is typical of systems that have assembled the components of quality policy but not yet the feedback loops that make them effective (Institute of Medicine, 2013[13]). The logic of a learning health system is that indicators, audits, incident reports, clinical standards, digital tools and payment should reinforce each other through a continuous cycle of measurement, review and action. OECD work on payment reform similarly shows that financial incentives work best when they are part of a broader purchasing strategy based on reliable data, clear quality objectives and implementation support, rather than a stand-alone lever (Lindner and Lorenzoni, 2023[32]).
People‑centred and integrated care remain the least institutionalised dimensions of quality
Countries increasingly recognise that quality must extend beyond individual facilities and episodes of care to the full patient journey. This is particularly important for chronic conditions, multimorbidity and ageing populations, where outcomes depend on continuity across providers and levels of care. People‑centred and integrated care are central to this transition, although the institutional mechanisms needed to sustain them can still be strengthened across the region.
Many countries have some way of capturing patient views, such as satisfaction surveys, complaints mechanisms or patient organisations, but fewer use standardised patient-reported measures or embed patient participation in routine policy and service improvement cycles. Stronger practice in the region is seen where patient voice moves beyond complaints and ad hoc surveys towards more institutionalised arrangements. Chile stands out for its formal participation structures, Peru for regular national measurement of user satisfaction, and Colombia for integrating people‑centred information into broader quality observatories and monitoring systems.
Integrated care shows a similar progression. Multidisciplinary teams, protocols and co‑ordination arrangements are increasingly common, while shared records, aligned financing and systematic assessment of continuity remain less widespread. Brazil, Chile, Costa Rica, Mexico, Panama, Paraguay and Peru have begun to complement organisational mechanisms with structural enablers such as shared electronic health records and/or financial incentives for co‑ordination. Elsewhere, strengthening the information and financing infrastructure needed to support integration remains a more immediate priority.
Weak data infrastructure and fragmented financing continue to limit continuity of care across providers and levels of care.
OECD and PAHO emphasise that high-performing systems organise care around people, with patient voice, co-production, integration and continuity across the care pathway as core features; PaRIS further links more people‑centred care with better patient-reported outcomes and experiences, particularly for people with chronic conditions (OECD, 2025[29]). The next step is to strengthen referrals, co‑ordination, patient participation and information exchange where these foundations remain limited, while more established arrangements can be extended across providers and linked more systematically to patient-reported measurement. Across the region, interoperable data systems and better-aligned financing remain essential to overcoming fragmentation and sustaining continuity of care.
Actionable priorities for the region
The following strategic priorities offer a roadmap for institutionalising quality across LAC. They do not imply a single classification of countries: starting points differ across policy areas, and a country with relatively established arrangements in one dimension may offer opportunities for peer learning while still consolidating foundations in another. For each transition below, starting points are therefore defined by the specific mechanisms already in place, rather than by an overall assessment of the country’s quality system.
From basic quality assurance to learning and accountability
For this transition, starting points depend on how far the mechanisms underpinning quality assurance have moved from establishing rules and institutional responsibilities towards implementation, external assurance and systematic learning. Where foundations are still being consolidated, quality responsibilities may remain dispersed, accreditation may be absent, HTA not formally institutionalised, and patient-safety arrangements centred mainly on basic standards. More established arrangements combine clearer national governance with mechanisms that go beyond minimum assurance: formal accreditation complements inspection, HTA operates alongside post-market surveillance, and systems increasingly identify good performance and learn from safety information. Different countries may be further along in some of these mechanisms than others. Examples include primary-care accreditation in Paraguay and Panama, Peru’s links between HTA and reimbursement, and mandatory adverse event reporting across sectors in Ecuador and El Salvador.
Consolidate national quality governance arrangements. Where quality responsibilities remain dispersed, formalise mandates, authority, resources and accountability, including oversight of private providers. For example, Guatemala and Honduras, where quality is addressed through broader ministerial structures without dedicated quality units, would benefit first from clearer mandates and co‑ordination. Where governance structures are already established, as in Argentina or El Salvador among others, strengthen implementation, co‑ordination, learning and accountability. These foundations are critical to the success of system-wide quality initiatives such as Salud Mesoamerica (Box 1.6).
Strengthen external quality assurance across care settings. Countries with no formal or only limited accreditation arrangements should progressively institutionalise external quality assurance, particularly in primary healthcare, private provision and other under-regulated settings. This remains particularly relevant for countries such as Brazil and the Dominican Republic, where formal accreditation is still limited. Where accreditation arrangements are already established, as in Chile or Costa Rica, the priority shifts towards extending their reach across settings and ensuring that external assessment supports continuous improvement rather than compliance alone.
Embed health technology assessment in routine decision making. Countries without formal HTA structures, such as Belize and Grenada, should focus first on institutionalising assessment capacity and linking it to national decision making. Where HTA is more established, as in Peru or Paraguay, the challenge increasingly lies in strengthening links between assessment, post-market surveillance, reimbursement, appropriate use and equity.
Develop stronger learning-based patient safety systems. Where basic programmes and reporting mechanisms remain incomplete, as in Nicaragua or the Dominican Republic, establishing reliable mechanisms for reporting and learning from adverse events remains an immediate priority. Where reporting arrangements are more established, including in Ecuador and Colombia, systems should increasingly strengthen standardised coding, analysis of incidents and near misses, and the use of safety information for learning across public and private providers.
From facility-based quality to quality across the patient journey
Improving quality increasingly requires moving beyond the performance of individual facilities or episodes of care towards the experience and outcomes of people across the full care pathway. This means combining patient participation and patient-reported information with effective referrals, continuity across providers and levels of care, and the information and financing arrangements needed to support co‑ordination.
Starting points in this aspect differ according to whether patient voice and care co‑ordination remain mainly episodic and facility-based or are becoming embedded across the patient journey. In countries such as Haiti and Honduras, multidisciplinary teams, protocols and monitoring provide important foundations, but stronger information exchange and financing arrangements are still needed to support continuity across providers. Where structural enablers are more developed, as in Brazil or Mexico, the next step is to extend these arrangements across providers and care settings and strengthen accountability for continuity, outcomes and patient experience.
From collecting information to using it for improvement
For this transition, starting points depend on how far quality information has moved from collection and reporting towards routine use in management, accountability and purchasing decisions. In some systems, measurement and audit mechanisms are still being consolidated and quality information remains only loosely connected to decision making. In others, indicators and audit results are already used for feedback, benchmarking or public reporting, while more advanced purchasing arrangements also link provider payment to quality objectives. These dimensions do not necessarily progress together: relatively developed measurement systems may coexist with limited use of financial incentives, and quality-linked payment may operate only in selected services or schemes.
Make measurement more consequential. This remains particularly relevant for countries such as Belize, which does not yet report a national quality indicator set, and Guatemala, where measurement arrangements remain more limited. Where these mechanisms are more established, as in Colombia or Panama, connect them more systematically to supervision, benchmarking, public reporting, contracting and other forms of accountability.
Align financing with quality and integration. Where national quality-linked payment mechanisms are not yet established, as in Colombia or Costa Rica, priorities include strengthening measurement, provider feedback and strategic purchasing capacity. Where such mechanisms already operate, as in Chile or Argentina, the focus should increasingly shift towards improving their design, risk adjustment and alignment with broader quality and integration objectives.
Strengthen conditions for transitions towards better care quality
Workforce capability, interoperable digital infrastructure and equity are enabling conditions across all three transitions. For these conditions, starting points differ independently rather than forming a single progression. In workforce quality assurance, arrangements range from a predominant focus on entry to practice towards combinations of recertification and continuing professional development, while system-wide workforce planning across public and private sectors remains less developed. Digital foundations in the region range from fragmented information systems towards interoperability, linkage, standardised coding and patient access. Equity is also incorporated unevenly, ranging from limited consideration in quality mechanisms to more systematic integration into guidelines, HTA, measurement and performance monitoring.
Build continuous workforce quality assurance. Where professional regulation remains focussed mainly on entry to practice, strengthen recertification and continuing professional development. This is particularly relevant in countries such as Ecuador or the Dominican Republic, where career-long assurance mechanisms remain more limited. Where arrangements are more established, as in Saint Lucia or Mexico, the emphasis can shift towards linking continuing competence more systematically to quality improvement and workforce planning across public and private sectors.
Strengthen equity-oriented quality monitoring. Where equity considerations remain limited within quality mechanisms, build the capacity to disaggregate quality information and incorporate equity systematically into assessment and performance review. Belize and Panama, for example, have scope to strengthen the integration of equity considerations in guidelines or HTA. Countries with stronger measurement and governance foundations, such as Chile or Peru, can increasingly use those systems to identify and act on disparities in quality and outcomes.
Invest in interoperable digital infrastructure for quality. Where digital foundations remain fragmented, prioritise common standards, connectivity and reliable exchange of information across providers, as remains important in countries such as Grenada or Honduras. Where stronger digital foundations are already in place, including Costa Rica or Panama, the next step is to expand data linkage, patient access and the use of digital information for continuity, measurement and quality improvement. Costa Rica’s EDUS provides an example of patient-facing digital access, while Argentina, Belize, Peru and Saint Lucia report standardised coding arrangements for safety incidents and near misses.
The Salud Mesoamerica Initiative (SMI) shows how quality improvement and equity can be addressed together. Launched as a public-private partnership led by governments with support from the Inter-American Development Bank and other partners, the initiative targeted the poorest populations in Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and Chiapas (Mexico). SMI operated through a results-based financing model in which performance awards were disbursed to Ministries of Health upon verified achievement of agreed targets, covering maternal and neonatal care standards, essential obstetric practices and service use, supported by independent measurement, common indicators and hands-on technical assistance to health facilities in the poorest areas for increasing access to quality indicators. Its aim was not only to expand access, but also to improve the quality of maternal and child healthcare in underserved areas through common standards, independent measurement, technical support and results-based financing.
SMI illustrates several of the quality levers discussed in the chapter: rigorous measurement and verification for accountability, learning and improvement, financial incentives tied to results, stronger co‑ordination across levels of care, in-facility quality improvement teams and hands-on support for implementation and closing gaps. Reported improvements included better quality of neonatal and obstetric care, wider use of essential maternal care practices, and gains in respectful care and service use among indigenous women in Guatemala and Chiapas.
The key lesson is that equity-oriented policies can also be quality-improvement policies. SMI suggests that when reforms focus explicitly on poor and excluded populations, quality gains can be achieved alongside reductions in disparities in access and service performance. Addressing these disparities simultaneously can improve health outcomes. This provides a useful bridge to the next chapter on equity policies, which examines more broadly how health systems in the region can reduce gaps in care for disadvantaged groups.
Source: Eichler et al. (2017[33]), “The Initial Prize in the Salud Mesoamerica Initiative Results-Based Aid Initiative”, https://doi.org/10.18235/0000854; Bancalari et al. (2024[34]), “Using subsidies to enhance access to maternal and newborn health care in remote villages”, https://doi.org/10.18235/0013208.
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← 1. Survey responses are self-reported by Ministry of Health officials and primarily reflect the public sector. Payment reforms implemented by private insurers or subnational entities may not be fully captured.