COVID-19: Argentina’s health system inefficiencies exaggerate flaws of health information system
"You can recover from a drop in the GDP, but you can’t recover from death,” was the straightforward mindset of Argentina’s President Alberto Fernández and defined the country's response to COVID-19. The South American nation imposed a strict lockdown and outperformed many of its neighbors for a couple of months in controlling the virus but Argentina has seen cases rise manifold since mid-May as the lockdown wasn't supplemented by advanced contact-tracing and other efforts to enhance the information available about the infection and its spread in the local communities of Argentina.
Argentina was deemed particularly vulnerable to COVID-19 due to its ties with Italy and China – one of which became the first Western country to be hit hard by the pandemic while the other was the original epicenter of the outbreak. Argentina also became the first Latin American country to register a COVID-19 related death when a 64-year old man who had traveled to France died on March 7. He had underlying health conditions and was tested positive only after he passed away.
The Latin American country receives a high number of visitors from Italy because of the large waves of immigrants in the past. With China, the country has developed strong commercial ties. The risk of Argentina becoming a hotbed for the spread of COVID-19 is also multiplied by the demographic profile of the population. Around 15.4 percent of the country's population is aged over 60 while almost 7.6 percent of people are over 70 years of age. In the United States, for instance, the number of deaths in the age group 65-74 years is 90 times higher compared to deaths in the age group of 18-29 years as of August 18.
These risks are also amplified, in turn, by the fact that Argentina is facing its worst economic crisis in almost two decades, which has resulted in substantial budget cuts in the public sector, including healthcare. This has had a negative impact on the country's capacity to deal with a pandemic of this magnitude as well as in the provision of basic public health supplies (including for vaccines).
COVID-19 in Argentina
As of September 2, a total of 428,000 people were confirmed to have been infected, and 8,919 people were known to have died because of the virus. What's even more concerning than this massive COVID-19 toll is that this situation comes after Argentina seemed to have done everything right.
Responses to the outbreak in the country have included restrictions on commerce and movement, closure of borders, and the closure of schools and educational institutions. Argentina implemented one of Latin America's strictest and longest lockdowns which began on March 20 and continue to date albeit with relaxations announced recently. At the start of the pandemic, Argentina stood out in the region for its no-nonsense, quick response to the virus. "You can recover from a drop in the GDP, but you can't recover from death," was the straightforward mindset of Argentina's President Alberto Fernández and defined the country's response to COVID-19.
The strategy worked and the South American nation outperformed many of its neighbors for a couple of months in controlling the virus with a tough lockdown. But Argentina has seen cases rise manifold since mid-May as the lockdown wasn't supplemented by advanced contact-tracing and other efforts to enhance the information available about the infection and its spread in the local communities of Argentina.
Numbers have surged over the past three months in the country, with the greater strain being placed on the health system. The country recently hit a new record of 11,000 cases a day and the update comes on the back of a mass anti-government rally in several cities across the country. Officials in the Alberto Fernández administration were critical of those who attended the rally, saying the protest could aggravate the number of infections. Nevertheless, the pressure is building on the government to relax quarantine restrictions, given the economic turmoil facing the country, which has been in recession since 2018. The economy is expected to contract by more than 10 percent this year.
Argentina's death toll due to COVID-19 is also surging. On August 24, the country recorded 381 COVID-19 related deaths – the highest single-day increase yet and a record that was double the prior day's tally. It's quickly climbing in the ranks among the deadliest outbreaks over the past week on a per capita basis. Over the past couple of weeks, Argentina's COVID-19 related deaths per million populations have increased from 116 to 179. Total deaths have now surpassed 8,000 since the pandemic began.
To top it all off, real case and death tallies are estimated to be much higher than the official ones as the percentage of COVID-19 tests turning up positive was hovering around 40 percent in the week before August 12. WHO recommends 5 percent positive tests out of total tests for 14 straight days before reopening economies.
Repeated lockdown extensions
On March 19, a nationwide lockdown was announced in Argentina. The restrictions were supposed to be in place till March 31 but were extended at least 9 times for the Buenos Aires metropolitan area (AMBA) while the rest of the country started gradually opening up after May 10.
The government has now relaxed lockdown in Buenos Aires as well but the decision came after widespread criticism including a mass rally against the restrictions. On August 28, President Fernández announced that outdoor get-togethers of up to 10 people wearing masks and maintaining two meters of distance were authorized throughout the country.
One of the longest lockdowns on the planet has sparked concerns about the consequences of those restrictions on Argentine citizens. Pan American Health Organization's (PAHO) director has said that "the COVID-19 pandemic has caused a mental health crisis in our region at a scale we've never seen before."
A study conducted by the psychology department at the University of Buenos Aires has revealed that the consumption of alcohol and stress medication has increased during the lockdown. Few other reports have claimed that the impact on the mental health of Argentine citizens is even worse as diagnoses of depression are five times higher than before the pandemic and six-in-ten Argentines say they have gained weight during the lockdown, according to the reports.
Another major problem for Argentine citizens is the challenge of staying financially afloat while sticking to isolation measures. Villa 31, a densely populated and poor neighborhood in the heart of Buenos Aires, was particularly hard hit by COVID-19. "We hear about neighbors who die every day," said Andrade, a 27-year-old community leader in Villa 31.
"It is very hard to comply with the mandatory quarantine. You have to go out because if you don't then you might end up not eating for three days."
Concerns about testing are mounting ever since the beginning of the outbreak in Argentina, which has lead many to believe that the real case and death tallies could be much higher than official tolls. During the week before August 12, the number of COVID-19 tests turning out positive was hovering around 40 percent, among the highest in the world along with countries where testing is deemed to be insufficient.
Argentina was widely praised for its quick and bold response to COVID-19 when it became the first country in the region to announce a COVID-19 associated lockdown. The country even successfully controlled the outbreak for the first couple of months but the situation has worsened since then. The government has been criticized for relatively low testing compared to other countries in the region, which puts in the bottom half of South American countries in terms of tests per 1,000 people.
Former Health Minister Adolfo Rubinstein has criticized the country's COVID-19 response for relying on COVID-19 as the only measure to control the outbreak and not supplementing it with early detection, contact-tracing, and isolation of patients. A robust health information system empowered with the latest technologies that enable the real-time flow of data to all stakeholders could lead the way for comprehensive pandemic preparedness.
Argentina health system
The health system of Argentina is among the most fragmented and decentralized on the South American continent. Each of the country's 23 provinces functions independently and the constitution makes them responsible for the leadership, financing, and delivery of health services, which explains the fragmentation of the health system.
The public sector provides free healthcare and caters largely to those who cannot pay for services – more than one-third of the population that lives in poverty. The sector comprises national and provincial health ministries that oversee a network of hospitals and public health centers.
The private sector, on the other hand, caters to only 5-8 percent of the population but 70 percent of health establishments are part of it. It includes health professionals and facilities that offer services to private clients and to beneficiaries of private insurers.
Health system inefficiencies
Argentina's constitution guarantees universal health coverage to its citizens, however, the highly decentralized and fragmented nature of its health system results in many challenges related to governance, resources, equity and also results in considerable inefficiencies.
While responding to COVID-19, doctors and other healthcare staff "have no rest", said Ana Alcoba, director of San Roque de Jujuy hospital, which is considered the best-prepared institution in the region. She added that healthcare professionals are working day and night to prevent a collapse of the healthcare system as COVID-19 cases have crossed the 400,000-mark in the country. Dr. Luis Camera, a member of the Argentine government's health advisory group, has said that even though intensive care admissions and hospital bed occupancy rates were not still climbing, they had settled at an unsustainable level.
Shortages of beds are becoming increasingly common and intensive care units (ICUs) are running at high occupancy. But the shortages aren't limited to beds as staffing levels are also insufficient in the country and provincial officials are trying to get reinforcements from the national governments and other regions.
According to PAHO, Argentina has 3.6 physicians per 1,000 people while the capacity of hospital beds stood at 3.2 per 1,000 inhabitants. Significant differences prevail between provinces, which further deteriorates the healthcare situation in the country. The Buenos Aires region, for example, fares much better than remote provinces at 10.2 physicians and 7.3 beds per 1,000 inhabitants, compared with 1.2 physicians and 1.1 beds in the province of Misiones.
In the initial stages of the outbreak, authorities had struggled to ensure the safety of scarce healthcare professionals and at one point, 14% of those infected with COVID-19 in Argentina were healthcare professionals.
To effectively respond to any disease outbreak, data provided by health information systems is essential for policymakers to understand where and how the disease is occurring and to craft national policy. Although Argentina has made it a priority to improve its health information system, the inefficiencies in its health system make it harder to realize the benefits of the progress in its health information system.
Health information system
Sistema Integrado de Información Sanitaria Argentina (SISA), which means Argentine Integrated Healthcare Information System, has been a turning point in the country's e-health journey and can pave the way for a more comprehensive and integrated health system in the country.
It aims at using information from multiple sources, primarily including the three components of the national health system (public, Obras Sociales, private insurance) and making them interoperable and associated in a coordinated system. It is also meant to improve the collection and management of information as well as information access. Paving the way for electronic health record (EHR), SISA has defined the Minimum Group of Basic Data (CMDB) and has created federal registers of health establishments and health professionals.
Apart from SISA, the National Statistical System gathers all entities that produce statistics in coordination with the National Institute of Statistics and Census. At the national level, the Ministry of Health's Directorate of Health Statistics and Information (Dirección de Estadísticas e Información de Salud, or DEIS) coordinates the information relevant to healthcare and is tasked to produce vital statistics related to the Argentine population's living conditions and health problems, and information on the availability and use of resources.
DEIS is also responsible for coordinating and regulating the collection of specific statistical data on health programs and monitoring basic health indicators along with coordinating with international public health bodies like PAHO/WHO.
Through the National Health Surveillance System initiative, Argentina's Health Ministry has also worked to strengthen health surveillance. The system, which operates through an online platform, integrates clinical and laboratory surveillance strategies and strategies involving sentinel units and specific programs, as a way to make information available online to various decision-making entities.
When it comes to health information systems, Argentina has made relatively more progress than other countries in the region but significant challenges remain in ensuring a comprehensive, integrated health information system. The development and management of a nationalized EHR are strictly constrained and thus interoperability remains a major challenge. Lack of legal and governance mechanisms also poses an operational challenge for Argentina's health information system.
The World Bank has provided a USD 35 million emergency loan to support Argentina's fight against COVID-19 while acknowledging that national law or data governance regulations may not be sufficient in ensuring adequate handling of large volumes of personal data and sensitive information that would be needed to effectively tackle the pandemic. Project components of World Bank's involvement in the country's COVID-19 response would include incorporating internationally-recognized practices for dealing with such data in such circumstances which can include assessments of current or development of new data governance mechanisms and data standards for emergency and routine healthcare, strengthening of health information systems, unique identifiers for health system clients, data sharing protocols, rules or regulations, revision of relevant regulations, training, and sharing of global experience.
Conclusion and agenda for discussion
The initial success of Argentina in controlling COVID-19 is quickly leveling off and COVID-19 cases in the country have crossed the 400,000-mark recently. Argentina depended on strict lockdowns that lasted for more than 5 months in Buenos Aires, which is home to one-third of the population and hosted around 90 percent of total COVID-19 cases of the country at one point in time.
"The only medicine we have found so far is to limit the movement of people and the face-to-face meeting of people as much as possible," President Alberto Fernandez said as the cases rose despite strict lockdowns. "The plan worked and it is working, but the risk always exists."
After months of strict limits on movement and activities, people were on edge in the country and many cases of people flouting lockdown were being reported a month prior to the government relaxing restrictions. Authorities have blamed the people flouting lockdown for the surging infections.
But critics including former health minister Adolfo Rubinstein, however, have blamed the government for overdependence on lockdowns without supplementing it with contact tracing, testing, and surveillance for early outbreak detection. Although Argentina has undertaken some notable initiatives over the last decade to improve its health information system, its benefits couldn't be realized in enhancing the country's pandemic preparedness due to inefficiencies of the health system. Due to a lack of information about active COVID-19 cases, clusters couldn't be identified and the virus was allowed to spread.
As with the case of any outbreak, data collected by health information systems is essential for policymakers to understand where and how the disease is spreading and craft policy responses including allocating resources to those who need it the most. Equipped with the necessary technologies, these systems can also create models to predict the future course of the pandemic and help in guiding the country's response in the most effective way.
A fragmented health system also poses a major challenge to the smooth functioning of Argentina's health information system or Sistema Integrado de Información Sanitaria Argentina (SISA), which means Argentine Integrated Healthcare Information System. While Argentina's health system guarantees universal health coverage, the highly decentralized and fragmented nature of its health system results in many challenges related to governance, resources, equity, and also results in considerable inefficiencies.
SISA is a strategic tool here and a step in the right direction that can pave the way for standardization of data and improve interoperability of the highly fragmented health system of Argentina. But a lot still needs to be done to enhance the integration of all stakeholders with the health information system in Argentina and enable the real-time flow of healthcare data in a safe and efficient manner with the help of the latest technologies.
VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.
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