The Lancet
Mar 28, 2015 Volume 385 Number 9974 p1151-1260
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
Dementia: turning fine aspirations into measurable progress
The Lancet
Summary
“I look young, but I am actually quite old”, pronounced WHO Director-General Margaret Chan at the first Ministerial Conference on Global Action Against Dementia, hosted by WHO, the Organisation for Economic Co-operation and Development (OECD), and the UK Department of Health in Geneva on March 16–17. Dr Chan continued, with great clarity and sincerity, to describe her own desire to grow old gracefully and with dignity, contrasting her own aspirations with the plight of 47 million people worldwide who struggle to cope with the debilitating effect of dementia, a disorder that is expected to double in prevalence over the next two decades, and that comes with an estimated health bill worldwide in excess of US$600 billion.

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Editorial
1 year on—lessons from the Ebola outbreak for WHO
The Lancet
Summary
This week has seen what is likely to be the beginning of an onslaught of criticism levelled against WHO for its handling of the Ebola outbreak in west Africa. First, ahead of the 1-year anniversary of the outbreak’s start, an article by the Associated Press (AP) reported that WHO deliberately delayed declaring the Ebola epidemic as an emergency in early June, 2014, waiting instead until Aug 8 to finally make the announcement. AP obtained internal emails and documents suggesting that senior WHO officials were not only told of the desperate situation, but also received anguished pleas for help. Instead of taking urgent and decisive action, the article said WHO decided that managing the political repercussions in countries would outweigh the benefits that declaring an emergency would bring. It “could be seen as a hostile act”, said one memo. Downplaying the epidemic may have cost lives, said AP. In response, WHO insisted that the spread of the virus was unprecedented, and the lack of resources and intelligence on the ground hindered its ability to act.

Second, Médecins Sans Frontières (MSF), who did more than any other organisation to bring the world’s attention to Ebola and who led the operational response against the outbreak, published their searingly critical report—Pushed to the limit and beyond—this week. Despite early warnings about the severity of the outbreak and urgent calls for help, MSF were ignored by governments and WHO. They dubbed the response a “global coalition of inaction”. MSF described the horrors of having to turn patients away because their health centres and staff were simply overwhelmed.

This year will see at least three further international, independent investigations into WHO’s conduct in the Ebola response. Regrettably, it is likely that WHO’s reputation is going to suffer more wounds in the coming months. The Lancet’s focus will be to try and draw larger lessons from the Ebola outbreak. In early May, we will be publishing a collection of essays on global health security, together with one of the first analyses of the deeper consequences of Ebola.

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Series
Health-system reform and universal health coverage in Latin America
Prof Rifat Atun, FRCP, Prof Luiz Odorico Monteiro de Andrade, PhD, Gisele Almeida, PhD, Daniel Cotlear, DPhil, T Dmytraczenko, PhD, Patricia Frenz, PhD, Prof Patrícia Garcia, PhD, Octavio Gómez-Dantés, MPH, Felicia M Knaul, PhD, Prof Carles Muntaner, PhD, Juliana Braga de Paula, MSc, Felix Rígoli, MD, Prof Pastor Castell-Florit Serrate, PhD, Adam Wagstaff, PhD
Published Online: 15 October 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61646-9
Summary
Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens—with defined and enlarged benefits packages—and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.
Series
Overcoming social segregation in health care in Latin America
Dr Daniel Cotlear, DPhil, Octavio Gómez-Dantés, MD, Felicia Knaul, PhD, Prof Rifat Atun, FRCP, Ivana C H C Barreto, PhD, Prof Oscar Cetrángolo, MPhil, Prof Marcos Cueto, PhD, Prof Pedro Francke, MSc, Patricia Frenz, MD, Ramiro Guerrero, MSc, Prof Rafael Lozano, MD, Robert Marten, MPH, Prof Rocío Sáenz, MD
Published Online: 15 October 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61647-0
Summary
Latin America continues to segregate different social groups into separate health-system segments, including two separate public sector blocks: a well resourced social security for salaried workers and their families and a Ministry of Health serving poor and vulnerable people with low standards of quality and needing a frequently impoverishing payment at point of service. This segregation shows Latin America’s longstanding economic and social inequality, cemented by an economic framework that predicted that economic growth would lead to rapid formalisation of the economy. Today, the institutional setup that organises the social segregation in health care is perceived, despite improved life expectancy and other advances, as a barrier to fulfilling the right to health, embodied in the legislation of many Latin American countries. This Series paper outlines four phases in the history of Latin American countries that explain the roots of segmentation in health care and describe three paths taken by countries seeking to overcome it: unification of the funds used to finance both social security and Ministry of Health services (one public payer); free choice of provider or insurer; and expansion of services to poor people and the non-salaried population by making explicit the health-care benefits to which all citizens are entitled.