5. Screening and early detection of diseases

In both LAC-7 and other OECD countries, three chronic non-communicable diseases (NCDs) are the leading causes of death: cardiovascular diseases, cancer and diabetes. Cardiovascular diseases and cancer represented 46% of all deaths in LAC-7 countries and 58% in other OECD countries in 2019. Diabetes stands as the fifth cause of mortality in LAC-7, representing 4% of all deaths, higher than the 2% across other OECD countries (Figure 5.1). The LAC-7 region is confronted to an increasing prevalence of long-term, chronic non-communicable disease, due mainly to evolutions in their population structures and demographic profiles and rising prevalence of risk factors for health. The performance of the health system to provide timely diagnosis and treatment also play a key role to explain the leading causes of death.

Diagnosing disease at an early stage improves health outcomes (both morbidity and mortality) by providing care at the earliest possible stage (WHO, 2022[2]). Aiming at improving the performance and capacity of their PHC systems, LAC-7 countries have built mechanisms to screen for some of the most epidemiologically relevant diseases (OECD, 2021[3]). Cervical, breast and colon-rectum cancers represent 31% of all cancer related deaths in LAC-7 in 2019 and similar percentages are seen in other OECD countries (Figure 5.2). It is estimated that around 30% of cancer cases can be cured if they are detected and treated early (PAHO/WHO, 2022[4]). Similarly, screening of hypertension and diabetes leads to early diagnosis and treatment, and can have important positive effects in patients’ health outcomes (US Preventive Services Task Force, 2021[5]; WHO, n.d.[6]; Jin, 2021[7]).

Early detection of disease include both the screening of healthy patients at risk and providing diagnosis for symptomatic patients as early as possible. Early detection is a determinant not only on the expected health outcome of the patient, but also in the expected financial cost and future utilisation of health care resources (Sroczynski et al., 2020[8]; Ratushnyak, Hoogendoorn and van Baal, 2019[9]; Rubin, Vedsted and Emery, 2011[10]). Primary health care (PHC) is an important actor on early detection (OECD, 2020[11]), usually performing routine clinical examinations and recommending tests, and nudging towards and implementing screening programmes to the population.

The chapter explores the performance of LAC-7 countries in the second function of PHC, screening and early detection of diseases. The second section explores the range of diseases included in the countries’ screening and early detection strategy, followed by an examination of the structural capacities in place, and the coverage of the screening efforts in LAC-7 countries. The third section explores the capacities built and the performance of the LAC-7 countries for early detection of COVID-19. The fourth section assesses the COVID-19 impact on screening and early detection of non-COVID-19.

All LAC-7 National Health Plans describe high-level aims and goals regarding early detection and screening. Different stakeholders transform the high-level goals into practical guidelines, and create the plans for early detection of specific diseases. The range of diseases included in early detection programmes varies across countries, but cancers (breast, cervical, colorectal), diabetes and hypertension, and antenatal and childcare are common across LAC-7. A selected list of screening and early detection programmes in LAC-7 are presented in Table 5.1.

In Mexico, PHC services are well-positioned to deliver screening services and reduce delays in diagnosing NCDs; however, these services face critical challenges that reduce the effectiveness of screening programmes. While early detection programmes in the country describe care pathways and performance indicators, there is no assignment for or accountability framework to the system stakeholder. Screening and early detection programmes in Mexico have changed towards population-based programmes in recent years, while before it was opportunistic (OECD, 2021[3]). However, several challenges have been highlighted by previous studies including limited access to treatment and follow-up after diagnosis due to scarce resources and poor-quality control (Chávarri-Guerra et al., 2012[12]). This has been associated with high rates of cancer mortality in Mexico (Chávarri-Guerra et al., 2012[12]). At the same time, the Mexican programme for antenatal care (Table 5.1) has been very successful due to a proactive engagement campaign (Serván-Mori et al., 2020[13]). The programme co-ordinates, and assigns responsibilities of outcomes to the health service providers. It also considers the active recruitment of target population (from a pregnant woman census) and fosters link with a social network to create additional support for the patients (Mexico Ministry of Health, 2013[14]).

Colombian screening and early detection programmes (Table 5.1) describe goals and outcome indicators, together with evaluation systems and pathways, protocols and responsibilities of stakeholders. However, the programmes are restricted to guidelines and there is no accountability framework to monitor outcomes and performance of providers. This results in a low adherence to guidelines (Colombian National Cancer Institute, 2019[15]), and as a result cancer care quality measures related with staging and early diagnosis suggest low performance at national level (CAC, 2021[16]). Early detection can happen through both opportunistic and population based initiatives, but there is no strategy to actively reaching out to target population.

Chile has a national programme for screening and early detection that includes several screening tests along the lifecycle of the population (Box 5.1). The specific programme in place for antenatal and childcare “Chile crece contigo” (“Growing together”) includes a comprehensive set of screening exams from the moment of the first antenatal check-up until the start of primary school. The programmes have a population-based approach for people enrolled in the public scheme, linked to the mandatory registration with PHC. Further, there is accountability for performance measures (such as coverage rates) based on a pay for performance incentive scheme for PHC: At least 25% of the adult population and 55% of the older adult population covered by the public health system should be included in screening and early detection life cycle programme. Patient level incentives, such as eligibility for subsides, are in place to actively involve families and target population into the early detection programme.

In Brazil, prevention and screening of cancer, diabetes and hypertension are of high importance and included in PHC sector guidelines (OECD, 2021[3]). There are national programmes for breast and cervical cancer screening, adding recently a programme for colorectal screening. Cancer screening programmes in the country are carried-out at the discretion of health professionals during health visits and routine care, on an opportunistic basis. The Brazilian national screening and early detection programmes include a detailed action plan assigning responsibilities, accountability and a pay for performance incentive scheme to PHC (15% of total funding). With the implementation of the new payment system for primary health in 2019-20 (the “Previne Brazil” programme, see Chapter 3), primary health care teams have financial incentives toward screening. Health care teams (especially the community health agents) are responsible for the identification, search and invitation of the target population for screening. Brazil should keep moving towards population-based screening programmes for breast and cervical cancer, where every person in the target population is systematically invited to participate, with a personalised approach and communication strategies (OECD, 2021[3]). At the same time, diabetes and hypertension screening are usually checked by blood pressure and blood glucose during PHC basic check-ups for chronic diseases, alongside other health measurements. However, there are significant challenges in care continuity for these diseases which call for the development of disease management pathways, stronger data infrastructure and better capacity at PHC level (OECD, 2021[3]).

Costa Rica has a detailed protocol to actively engage patients in the cancer detection, prenatal control, child growth programme and more generally into the development of screening and early detection programmes. At the first contact with PHC, the physician, nursing or dentistry staff apply a cancer prevention questionnaire to the people who consult the services. The questionnaire is registered in a centralised information system on-line. The questionnaire allows for the estimation of the risk of developing some types of cancer and, if deemed target population, there is a referral to more specialised care if necessary. Furthermore, early detection programmes describe the processes and mechanisms for the active invitation of target population.

By contrast, the Peruvian programme for cancer screening (Table 5.1) has been found limited in its ability to improve population coverage (Flores-Flores et al., 2018[32]). From 2014 to 2018, there have been little to no improvement in coverage of breast cancer screening, even though the country adopted a population-based approach (PAHO/WHO, 2015[33]). At the same time, the National programme for cervical cancer screening (Table 5.1), the HPV vaccination strategy and the prenatal early detection and control strategies have seen moderate success. The differences in effective implementation might have several causes, but success factors of functioning programmes are related to the new national health plan. Under the new model of care, primary care teams are in charge of providing care, not only focusing in diseases, but attending all the health needs in the community. This includes the responsibilities of PHC teams to send reminders for preventive visits, look for risks in individuals and families, and develop an integral health plan (Peru Ministry of Health, 2020[34]). However, due to a lack of equipment and capacities, some programmes are still unsuccessful. Further, early detection programmes don’t describe a pay for performance incentive scheme or other methods for holding stakeholders accountable for health or care quality outcomes. Across other OECD countries, Finland and Lithuania are good examples of successful programmes to increase coverage of cancer screening (see Box 5.2, Box 5.3,and Box 5.4).

Breast cancer screening recommendations by the WHO differ according to the strength and available resources of the health system. In well-resourced settings, organised population-based mammography screening programmes are recommended for women aged 50-69 years, every 2 years. Screening programmes for women 40-49 years of age and 70-75 years of age (without risk factors) is suggested only if it is conducted in the context of rigorous research, monitoring and evaluation. For limited resource settings with relatively strong health systems, organised population-based mammography screening programmes are suggested for women aged 50-69 years, every 2 years only if the conditions for implementing a screening programme are met. Further, recommendations are against screening for women outside of this age range as the method might not be the most cost-effective policy available with limited resources (WHO, 2015[45]). LAC-7 countries can be positioned in between these two recommendations, and this is noticeable in the main guidelines described by every country (Table 5.3). Most countries follow the target age recommended by WHO, though Chile has a slightly narrower age range and Mexico and Costa Rica have a slightly wider age range. The method (mammography) and periodicity (every two years) follow WHO recommendations. Most of LAC-7 countries have a population-based approach for their screening programmes. Mexico moved in this direction between 2015 and 2019, while Brazil is implementing several programmes towards incentivising population-based screenings (OECD, 2021[3]; PAHO/WHO, 2015[33]).

Regarding cervical cancer, WHO has recently updated recommendations regarding type of screening test (World Health Organization, 2021[49]) and most LAC-7 countries still need to adapt. The method for cervical cancer screening in all but Argentina follow old recommendations, with countries mostly using cytology (commonly known as a “Pap smear”) exams every 3 years (Table 5.4). A shorter periodicity is observed in the guidelines of Mexico and Peru (yearly). The new guidelines recommend using a HPV DNA based test, rather than visual inspection with acetic acid or cytology, for women over 30 years old every 5 to 10 years. The reasons for the change in guidelines relate to HPV-DNA testing detecting the high-risk strains of HPV that cause most cervical cancers. Together with HPV-DNA testing being an objective test where there is no space for interpretation and the fact HPV DNA testing is simpler to apply and has higher prevention rate, it results in a better cost-effectiveness ratio (World Health Organization, 2021[49]).

Recommendations for diabetes mellitus screening differ considerable between countries and health authorities. The World Health Organization considers countries different capacities to provide ad-hoc recommendations. There are several considerations to take into account when creating a diabetes screening plan and alternatives for testing strategies are given accordingly. Considerations might be epidemiological, concerning health system capacities, economic, ethical, and political and of competing priorities. The alternatives include questionnaires, urine glucose, blood glucose, Glycated haemoglobin or a combination of tests (Pippitt, Li and Gurgle, 2016[52]). In the United States, the U.S. Preventive Services Task recommends screening for abnormal blood glucose and type two diabetes in adults 35 to 70 years who are overweight or obese every three years (US Preventive Services Task Force, 2021[5]), or anyone that has high risk factors. Peru takes the same approach, shortening the age range to 40 to 70 years old (Ministerio de Salud, 2016[53]). Costa Rica takes a similar approach: Adults (18 years old or older) with any of a specified set of risk factors, prediabetes or woman with dimethylglycine will be screened every year. In the absence of these criteria, screening in Costa Rica should be made every three years starting from 45 years old (Caja Costarricense de Seguro Social, 2020[54]).

Argentina (Instituto Nacional de Estadística y Censos - I.N.D.E.C, 2019[55]) and Colombia (Sistema General de Seguridad Social en Salud, 2016[56]) take a two steps approach. First a questionnaire is used to evaluate the risk of having diabetes, and if the risk is larger than the threshold they perform a fingertip prick test (plasma glucose level) or schedule a blood test. Their guidelines recommend the FINDRISC questionnaire (Rodríguez et al., 2019[57]) applied to adults (18 year or order), with a threshold of 12 points.

Chile applies the fasting blood glucose test to 15 years old and older as part of their comprehensive plan according to life cycle. In Brazil, diabetes screening is recommended for asymptomatic individuals aged 45 years or over. In individuals under 45 years of age, diabetes screening should occur in overweight individuals with additional risk factors. Similarly, screenings for cardiovascular disease are based on age, family history and risk factors such as body mass index (OECD, 2021[3]).

Diabetes screening in Mexico is not found to be very effective, situation that resonates with the high burden of diabetes in the country and with the first cause of death in the country (Comité Consultivo Nacional de Normalización de Prevención y Control de Enfermedades, 2009[58]). In 2021,almost 17% of the population aged 20 years and over has diabetes, well above the global prevalence of around 10% (World Bank, 2021[59]). In theory, diabetes and prediabetes in Mexico should be screened every three years starting at age 20 onwards, and earlier if the patient presents risk factors. The screening consists in capillary glucose testing with an automatised glucose test (Comité Consultivo Nacional de Normalización de Prevención y Control de Enfermedades, 2009[58]). It is recommended that the screening is done together with hypertension, as it represents an important risk factor for the disease.

WHO recommendations about hypertension screening are going through a reform due to the latest evidence from Europe, moving away from population-based screening (Christian Ulrich Eriksen et al., 2021[60]). It is highlighted that policy makers should not discount the potential value of case-finding – which involves assessing patients who may be at risk of cardio-vascular disease when they use the health care system. In this sense, having robust opportunistic screening guidelines and protocol are essentials. The early detection programme for diabetes and hypertension in Mexico follows the Global Hearts Initiative by WHO and the Centre for Disease Control of the United States (Secretaría de Salud, 2013[21]), which is based on questionnaires to asses risk factors and blood pressure testing in population over 20 years old. Peru uses a similar approach (Ministerio de Salud, 2011[61]). Hypertension control and screening in Argentina doesn’t function in a national population-based campaign, and relies on locally driven campaigns with limited scope. The main campaign in the country is associated with the May Measurement Month, implemented yearly since 2017. The campaign consists of measuring blood pressure to all the population together with a questionnaire and recommendations for abnormal results. On 2019, it covered 94 523 individuals (Salazar et al., 2021[62]). Chile applies risk factor measures and blood pressure measurement to 15 years old and older (Box 5.1). Costa Rica guidelines indicate to measure blood pressure to any 20-year-old or older who consulted in any health centre, or received visit from a family health team at home or at work (Caja Costarricense de Seguro Social, 2002[63]). Colombia follows a similar approach for people aged 35 years or older, or people that present any risk factors (Sistema General de Seguridad Social en Salud, 2017[64]).

With regards to antenatal care, LAC-7 countries have a well developed approach, which is the result of sustained commitment to reduce infant and maternal mortality. Timely, skilled, and regular antenatal care is the primary mechanism for prevention and early detection of maternal and foetus complications during pregnancy, thus reducing the burden of maternal, neonatal, and infant mortality. (WHO, 2016[65]) LAC-7 countries approach to antenatal screening is population-based, as it is administered by protocol to all pregnant woman, and mostly occurs starting from the first visit of a health professional (Mexico Ministry of Health, 2013[14]; Ministerio de Desarrollo y Familia, 2022[28]; Ministry of Health, 2013[66]). A good example for the range of services provided during antenatal care is described for Chile in (Box 5.1)

Breast cancer screening in most LAC-7 countries has not reached the levels set out in the countries screening programmes. However, important improvements have been made in the last decade (OECD, 2021[3]; PAHO/WHO, 2015[33]). In 2019, Brazil had the lower coverage rate for breast cancer screening among the LAC-5 countries with comparable administrative data, covering 24% of all females aged 50 to 69 years old (Figure 5.3). However, the national health survey of 2019, a self-reported survey of 108 525 households, shows that 58% of women self-reported participation to breast cancer screening in Brazil (IBGE, 2019[67]). Mexico and Chile present the highest breast screening coverage rates in the region, at 45.4% and 40.1% respectively (Figure 5.3). These coverage rates are still well below the average across other OECD countries (59%).

In Mexico, breast screening coverage increased by 20 percentage points since 2015, suggesting the success of moving from opportunistic screening programmes toward population-based screening programme between 2015 and 2019 (PAHO/WHO, 2015[33]; OECD, 2021[3]). Important challenges remain in Mexico, including a limited capacity to manage care pathway effectively and problem in access to treatment (Ángeles-Llerenas et al., 2016[68]; Ortega–Olvera et al., 2016[69]).

Data for Argentina is available from the national survey for risk factors (Instituto Nacional de Estadística y Censos - I.N.D.E.C, 2019[55]). Results show that among 30 000 self-reporting households, 66% of the surveyed females aged 50 to 70 in 2018 reported to have a mammography in the last two years. This is above the average among LAC-6 and other OECD countries, although cross country comparisons is limited due to different methodology.

Among the five countries present in Figure 5.4, cervical cancer screening has better coverage rates when compared to breast cancer screening coverage. The reasons can be multiple, but some evidence shows a positive association between cervical cancer screening rates and use of family planning and contraceptive methods (Martínez-Donate et al., 2013[72]). Higher coverage rate can also be explained by the simplicity to carry-out cervical cancer screening collection method that generally occurs at the primary health care level. Among females aged 20-69, 58% was screened in the previous three years on average across other OECD countries (Figure 5.4). The cervical cancer screening coverage rate among LAC-5 countries is 42%, well below the average across OECD countries. Among the countries with comparable data, Chile reports the highest coverage rate (at 52% of the target population), while Costa Rica has the lowest coverage rates in the graph (at 25% of the target population).

Peru uses a different definition, limiting cross country comparisons (coverage rates are calculated among females aged 30 to 49 screened in the previous five years). Using this definition, the cervical screening coverage rate of Peru was 70% in 2019 (WHO, 2020[73]). However, according to the WHO Global Health Observatory (WHO, 2019[1]), Peru’s coverage rate (as defined by the country’s national programme) ranged between 10% and 50% in 2019, while in Colombia the same coverage rate (as defined by the country’s national programme) ranged between 50% and 70% the same year. As with breast cancer coverage rates, the national risk factor survey in Argentina (Instituto Nacional de Estadística y Censos - I.N.D.E.C, 2019[55]) indicates that 70.3% of surveyed women aged 20 to 65 self-reported to have participated to cervical cancer screening either with cytology or HPV test in the last three years. In the same line, the national health survey in Brazil indicated that 81.3% of women reported to have participated to cervical cancer screening (IBGE, 2019[67]). However, this information is not comparable with administrative data.

Screening and early diagnose of disease are key elements of effective antenatal and childcare (Tunçalp et al., 2017[74]). Having the minimal recommended doctor consultations during pregnancy is a good indicator for assessing the quality of antenatal care. Figure 5.5 shows that all 5 countries included in the graph have high coverage rates (over 90%) of at least four antenatal care consultations for pregnant women aged 15 to 49.

In Chile, the programme in place for antenatal and child screening and early detection (“Chile crece contigo”) (Table 5.1) covers around 75 to 80% of all born children in the country (Damian Clarke, Gustavo Cortés Méndez and Diego Vergara Sepúlveda, 2018[75]). Available evidence shows a slight improvement in coverage of pregnant women receiving care from a qualified professional, from 97% in 2015 to 98% in 2020 (ENDES-ENEI, 2020[76]). This is most likely linked to an increased number of consultations performed by obstetricians and nurses (ENDES-ENEI, 2020[76]).

Looking at coverage rates disaggregated by socio-economic characteristics provide evidence of inequalities in antenatal care in most LAC countries. Coverage rates varied widely across income quintiles in Colombia, with a difference of 15 percentage points between the poorest people (coverage rates at 81%) and the richest people (with a coverage rate at 96%) in 2015. Similar disparities have been found in Peru, Costa Rica, Argentina and Brazil (ICF, 2018[77]).

Diabetes and hypertension are routinely checked in LAC-7 countries, and embedded in PHC practice. However, while data for screening coverage rates is rather limited, available evidence shows that there is scope for improvement in all countries.

In Mexico, the low diabetes and hypertension screening rates is contrasted with the high prevalence of these diseases in the Mexican population. Based on survey data of 1 500 respondents over 18 years old in 2013, 72% of the respondents were screened for hypertension and serum cholesterol in the last year, and 61% answered that they had a preventive check-up in the last two years (Guanais and et al., 2018[79]). However, these levels of coverage differ from the population level statistics that the national health and nutrition survey shows, where in 2018 screening coverage for diabetes (12.9%), hypertension (12.9%) and serum cholesterol (10%) were far from the national goals (Shamah Levy, Rivera-Dommarco and Bertozzi, 2020[80]). Evidence suggest that women, people aged over 50, higher socio-economic status, having a health insurance, obesity and suffering from other comorbidities (like cardiovascular diseases) and family history of diabetes or hypertension are associated with higher use of diabetes and hypertension screening (Villalobos et al., 2020[81]). Further, the 2018 national health and nutrition survey found that 4.6% and 14.8% of the Mexican adult population had undiagnosed diabetes and hypertension, respectively (Shamah Levy, Rivera-Dommarco and Bertozzi, 2020[80]).

In Colombia, 60% of the respondents had a hypertension screening, 54% had serum cholesterol check in the previous year and 69% had a preventive health visit in the last two years (Guanais and et al., 2018[79]).

Brazil shows a lower performance with 58% of people reported they had been screened for hypertension, 80% for serum cholesterol and 42% reported they had a preventive check-up (Guanais and et al., 2018[79]).

In Argentina, a 2018 survey of around 30 000 households shows that 71.1% of the respondents over 18 years old had been tested for diabetes at least once in their lives. Similarly, 84.3% of respondents over 18 years old was checked for hypertension in the last two years and 82% of males over 35 and females over 45 had a serum cholesterol check. The same survey shows that 31.6% of the population aged between 50 and 75 had at least one colon cancer test in their lives (Instituto Nacional de Estadística y Censos - I.N.D.E.C, 2019[55]). In Peru, a study shows that 34.1% of a sample of low income population never had had a blood pressure assessment; 65.2% never had a serum cholesterol assessment; and 75.6% never had a diabetes screening (Flores-Flores et al., 2018[32]). These data clearly suggest that screening for hypertension and diabetes can be further strengthened at the PHC level, with a greater focus on disadvantaged population.

The success of screening and early detection programmes has several determining factors. As a start, the structural capacities of the country need to be sufficient to support the screening and early detection efforts of PHC. In fact, the lack of medical technology or human resources is an active restriction for the programme’s successful implementation. In LAC-7 countries, the lack of availability of medical technologies is a major problem limiting early detection of diseases and contributing to late diagnosis.

All LAC-7 countries define mammography as the main method for breast cancer screening (Table 5.3). However, mammography units per million females aged 50-69 are considerably lower than across other OECD countries. Costa Rica is close to the OECD average, having 150 mammography units per million females aged 50-69. At the lower end of the scale, Colombia and Chile have respectively 12 and 32 units per million females aged 50-69, well below the LAC-7 average of 76 mammography units (Figure 5.6).

The under-provision of mammography units is not the only challenge for breast cancer screening in the LAC region. Quality check-ups and qualified personnel are two other key elements. Argentina has a national mammography quality plan for accreditation and quality assurance of mammography services that supervises the quality of mammograms and the competencies of the workforce to ensure the units are usable. While quality governance is warranted, studies have shown a lack of proper quality control and human resource to operate the equipment at full capacity (Viniegra M, Paolino M and Arrossi S, 2010[86]). Similarly, in Mexico the lack of consistency in national cancer control plans, fuelled by the system fragmentation, creates discrepancies regarding infrastructure and training of personnel (Lopez et al., 2017[87]).

Care continuity after positive screening is also an area of concern. Even though care pathways are described in national guidelines, deficiencies in effective capacity and the lack of systems for accountability results in important delays to start treatment. Previous evidence shows that treatment in Argentina can start up to 150 days after screening, eliminating the advantages of an early detection (Viniegra M, Paolino M and Arrossi S, 2010[86]). Similarly, overall waiting times between diagnosis and initiation of treatment for all cancers in Colombia have been decreasing, yet remain above the reference time used as a benchmark, which is four weeks. Paradoxically, breast, cervical and prostate cancers have the longest waiting times amongst all cancers (Fondo Colombiano de Enfermedades de Alto Costo, 2021[88]). In Mexico, suboptimal knowledge on screening guidelines among medical students or residents and low awareness of current cancer screening standards among Mexican PHC physicians adversely impact the effective implementation of screening programmes (Ortega–Olvera et al., 2016[69]). Limited training in guidelines and care standards partly explain why screening targets are not reached as expected in all LAC-7, causing delays in diagnosis and treatment and shortening survival rates (Ángeles-Llerenas et al., 2016[68]).

The availability of Computed Tomography scanners per million population in LAC-7 countries is also significantly lower than across other OECD countries. Brazil reports the highest availability among the LAC-7 countries with 28 units per million population, similar to the OECD average of 29 units per million population. At the lower end of the scale, Colombia and Mexico report both 6 and 7 units per million population, almost 80% lower than the OECD average (Figure 5.7).

Magnetic resonance imaging (MRI) is a cost effective tool for supporting the early diagnosis of several diseases, including cancer (Giganti and Moore, 2019[90]) and others diseases such as Alzheimer (Teipel et al., 2013[91]) and rheumatoid arthritis (Tehranzadeh, Ashikyan and Dascalos, 2003[92]). Appropriate availability of MRI will secure early detection of disease, while under-provision will directly affect the country’s ability to promptly detect several diseases. LAC-5 countries (at 6.3 units per million population) show significantly lower supply of MRI units than across other OECD countries (average of 19 per million population). Among LAC-7 countries, Brazil reports the highest number (at 14.5 units per million population) while Colombia reports the lowest number of MRI (at 0.2 units per million population).

During health emergencies, primary health care teams can play a pivotal role to carry out early and precise case detection in the community they operate – through passive or proactive testing – which is key to minimise virus circulation. However, as earlier mentioned in Chapter 3, health care systems in LAC-7 countries not only have lower capacity than the OECD average in terms of health expenditures and number of health professionals but also in terms of testing capacity. The 2021 OECD policy survey suggests that the availability of COVID-19 testing was rather limited at the start of the pandemic. Some countries relied on foreign supply chain to achieve testing kits. Brazil and Mexico for example relied on 135 000 testing kits received from China (OECD, 2020[93]). Other LAC-7 countries (Argentina, Costa Rica, Colombia and Peru) also developed specific strategies to expand national capacity (Figure 5.9).

  • In Argentina, some provinces and municipalities build their testing strategies by increasing the availability of Antigen testing to be performed by primary health care workers. Argentina also developed its own testing kits with government-financed research from top national universities along with technology companied producing up to 100 000 testing kits per month (OECD, 2020[93]).

  • In Costa Rica, as there were not enough tests and laboratories in the CCSS service network to cover the high demand for COVID-19 testing, several measures were introduced to increase testing capacity. These included the regionalisation of molecular testing, the creation of six new laboratories to carry-out RT-PCR testing, and acquisition of materials (such as swabs and reagents). From September 2020 Costa Rica also relied on antigen testing to increase the testing capacity in primary health care setting. Together, these strategies helped to triple the number of tests carried out in 2021 as compared to 2020.

  • Colombia expanded its testing capacity in a period of five months after the start of the pandemic, reaching a total of 43 529 tests daily, out of which 13 248 were carried out by public laboratory, 28 281 by private laboratory and 2000 by the INS. To increase capacity there have been efforts to ensure different public and private laboratories allocate resources, acquire materials and carry out infrastructure investments (INS, 2020[94]). As of January 2021, the country had 162 authorised laboratories for the diagnosis of COVID-19 through the use of RT-PCR testing (Ministry of Health, 2021[95]).

  • In Peru, only the INS laboratory was able to perform PCR testing, resulting in large diagnosis delays. Over the course of 2020 and 2021, more than 110 molecular biology laboratories processing PCR samples for COVID-19 diagnosis were developed in the public and private sectors. All regions have now molecular testing, allowing to expand access to testing and reduce diagnosis delays for a more timely and effective responses. More than half of these laboratories are managed by public institutions which perform the tests free of charge. This has been communicated on the INS website and through a massive media campaign.

Guidelines and protocols on diagnostic testing for primary health care workers is also a key element to increase the effectiveness of primary health care response. Guidelines from National public authorities provides recommendations for the implementation of analytical tests for detecting COVID-19 and infection prevention measures, with evidence-based information on technical specification, procedures, materials or safety protocols (see good practice in Germany and New Zealand in Box 5.5). Guidelines help primary health care professionals to carry-out accurate and safe diagnosis to control the spread of the pandemic. In some LAC-7 countries, Ministry of Health made general recommendations for COVID-19 diagnosis, but sometimes at a late stage, requiring some local or subnational actions. In Brazil, while training videos were available in 2020 through YouTube, guidelines for primary health care workers on COVID-19 diagnosis was published in March 2021, almost one year after the start of the pandemic (Ministério da Saúde, 2021[97]). In Chile, guidelines from the Ministry of Health were established in June 2020 (Ministry of Health, 2020[98]), three months after the first case in the country. The primary health care network in each municipalities had to implement their own testing strategy before the national recommendations, leading to a great variability of the response across municipalities. In Argentina, the Ministry of Health published general recommendations on performing diagnostic tests, which were then developed by each primary health care facilities. In Colombia, Costa Rica and Peru, national guidelines were also published by the Ministry of Health but they did not specifically target primary health care workers (unlike other OECD countries such as New Zealand, see Box 5.5).

To improve response during health emergencies, there is a need for stronger stewardship from the central level to take key decisions and issue evidence-based guidelines. Involving stakeholders such as health workers, public health experts and the civil society, is a core element in developing evidence-based guidelines.

According to the 2021 OECD policy survey, COVID-19 testing has been carried-out to some extent in primary health care settings. All LAC-7 countries developed some forms of COVID-19 testing in primary health care settings, but with some level of heterogeneity within and across countries. In some provinces of Argentina, community health workers have played a leading role in detecting cases of COVID-19. Itinerant testing operations were also carried out by health workers from the PHC network (“Centros de atención primaria”). At national level, the DETECTAR Programme, launched by the MOH and implemented in co-ordination with the provinces in disadvantaged neighbourhoods or in defined areas, relied on the network of primary health care. As mentioned in Chapter 4, the DETECTAR programme is based on door to door visits to carry-out COVID-19 testing, but also health monitoring. The primary health care team is composed of between 15 and 45 people, including social workers, nurses, health promoters and doctors. The DETECTAR programme involved a mobile health facility, situated in the defined areas, to carry-out COVID-19 testing. The programme has been progressively extended to several areas and provinces, including the greater Buenos Aires area, in urban areas of Buenos Aires, in the Provinces of Chaco, Entre Rios, La Rioja, Santa Cruz and Santa Fe (PAHO, 2020[99]). The programme is now available to all jurisdiction. The DETECTAR programme is a best practice example of good co-ordination between national government and community level. All positive cases are reported daily through the MOH’s National Epidemiological Surveillance System (SNVS). The core element of success for the SNVS was the training of health workers, the increase in IT equipment and the economic incentives defined as part of the Sumar Programme (Chapter 4).

In Chile, after confirmation of the first case of COVID-19, testing, tracking and tracing (TTT) was responsibility of the regional administration. However, with insufficient capabilities, traceability was lost rapidly and in June 2020 TTT was assigned to PHC. The primary health care network in each municipalities started to implement the testing strategy by July 2020. Nevertheless, the funding for testing activities was late and insufficient to support primary health care to carry out the strategy successfully. It is only from 2021 that primary health care had a bigger role in COVID-19 testing, with positive results (Facultad de Medicina Universidad de Chile, 2021[100]). An important success factor of the testing strategy was the use of mobile testing and mobile labs. The Centinela strategy, developed in the Renca municipality (Box 5.6. The Centinela strategy in the Renca municipality (Chile), has been a very good local initiative to start reporting and monitoring the COVID-19 pandemic.

In Costa Rica, all EBAIS were responsible for the detection, notification and investigation of cases, which in turn notify the Local Epidemiological Surveillance Commission (COLOVE) of its Health Area. Primary health care also implemented sampling campaigns in places with an epidemiological outbreak, and screened for COVID-19 at vulnerable sites or disadvantaged populations. COLOVE provides the necessary support to consolidate data of all the EBAIS to carry-out epidemiological surveillance, case studies and implement specific health actions. The registration of COVID-19 cases is carried out through the Digital Health Record (EDUS), which links the health centres network of the CCSS (see Chapter 4). All COVID-19 laboratory results, regardless of the place or technique with which they are processed, are available in real time. Results are also available in the digital file of patients.

In Mexico, the Ministry of Health prioritised hospital care to deal with COVID-19. Primary health care only had the responsibilities to identify patients suspected to have COVID-19 to direct them in respiratory triage areas for laboratory tests (see Chapter 5). In Peru, during the second semester of 2021, the National Institute of Health implemented 924 COVID-19 testing points, many of these being located in primary care facilities and undertaken by health care workers specifically hired for this purpose. In addition, mandatory notification of COVID-19 cases was established in all IPRESS (Health Service Provider Institutions), whether public or private. This contributed to the improvement in the registry of the follow-up and evaluation of suspected, confirmed patients and deaths from COVID-19. The Ministry of Health developed a national surveillance system of COVID-19, with the Integrated System for COVID-19 (SISCOVID). In Brazil, Community References Centres were responsible for screening suspected COVID-19 cases and testing high risk patient groups, and provided greater assistance resolution to people with mild symptoms related to COVID-19. These centres acted as the first point of contact in PHC regarding patients with mild symptoms, and made it possible to maintain care continuity for other health care services (Chapter 6). The focus group of Community References Centres were underprivileged communities, and favelas. Around 130 centres were established and BRL 8.2 million (~EUR 1.3 million) spent each month (OECD, 2021[3]).

Responsibilities for COVID-19 testing have also been carried-out by PHC across other OECD countries included in Italy’s Veneto Region (Box 5.7). In Austria also, multi-disciplinary PHC teams were tasked with the triage and registration of suspected COVID-19 cases and to organise COVID-19 testing (Pichler, Frühwald and Burgmann, 2020[101]). Overall, new responsibilities and new form of co-ordination between national level and local level should be maintained to manage both short and long term challenge.

The efforts made to deal with COVID-19 pandemic had a profound effect in the normal functioning of LAC health systems. On the one hand, health care system resources, infrastructure and workforce shifted their attention to provide care to COVID-19 patients, mainly in hospital settings. On the other hand, people minimised their routine visits to health care professionals fearing getting infected in the process (WHO, 2022[104]). The result has been a worldwide disruption of health care services, where countries have reported disruptions across services (WHO, 2022[104]). Early detection services in LAC-7 countries have been severely affected, with important reduction in the coverage of screenings and early detections occurring during routine care. Postponed screenings will have a direct effect on population health in the long term, as patients with diseases that normally would have been detected early will have considerably worst prognosis and poorer health conditions (Vrdoljak et al., 2021[105]). Maintaining essential health services during health crises, including routine screening, is a critical attribute of resilient health systems. Yet, many LAC-7 countries, as many other OECD countries, were not resilient enough to minimise delays and disruptions in early detection of diseases.

Among the LAC-7 countries, growing evidence suggests that COVID-19 has dramatically impacted cancer screening or early detection of diseases (Figure 5.10). In Mexico, from April to December 2020, breast cancer screening dropped by 79%, cervical cancer screening declined by 68%, and antenatal care visits decreased by 27% compared to the previous year (Doubova et al., 2021[106]). In addition, INSABI reported a drop of 68.5% in out-patient consultations to people without social security between 2019 and 2020, a reduction which continued in 2021 (Vitela, 2022[107]). At the same time, available evidence shows that antenatal care visits decreased by 37.2% in 2020 (Alejandra Llanos-Guerrero and Judith S. Méndez Méndez, 2021[108]).

In Chile, for the population aged 20 to 64 years old enrolled in the public insurance scheme, screening coverage rates dropped from 16.5% to 3.6% between 2019 and 2020 (which represents a 78% reduction) and reached 2.4% in 2021 (which represents a 85% reduction). A similar situation occurred for population aged 64 and over, where it decreased from 47.9% in 2019 to 10.8% in 2020 and 10.5% in 2021 (DEIS - Ministerio de Salud Chile, 2022[109]). Similarly, cervical cancer screening for females aged 20-69 screened in the past three years dropped from 52% in 2019 to 47.1% in 2020 (which represents a 9.4% decrease) (OECD, 2022[36]). Breast cancer screening saw a drop from 40.1% in 2019 to 36.3% in 2020, representing a 10% decrease in the coverage of females 50-69 screened in the past two years. Early detection for people with diabetes, measured with normal Hb tests, dropped from 29.5% in 2019 to 20.1% in 2020 and 12.2% in 2021. Early detection for people with hypertension, measured with tests of normal blood pressure levels decreased from 48.5% in 2019, to 37.4% in 2020 and 18.6% in 2021 (DEIS - Ministerio de Salud Chile, 2022[109]).

In addition, the problem of access to routine care during the pandemic in Chile has been captured by the national monitoring system created for managing COVID-19. In 2021, only 71.3% of respondents declared being able to access a medical check-up, compared to 93.7% before the pandemic, an issue more prevalent among publicly insured population (Ismael Puga R et al., 2021[110]). Further, access to general care was drastically affected in diseases such as cancer, heart attacks, or strokes (Pacheco et al., 2021[111]). Childcare was also affected, in part because the authority limited the age of children who could attend routine care in PHC due to the pandemic efforts. A drop of 67% in the number of children with PHC consultations was observed from 2019 to 2020 (Ministry of Health, 2020[112]).

In Peru, the disruption of early detection services for cancer is of particular concern, as already before the pandemic evidence shows that the country had a large percentage of cancers diagnosed at advanced stages (Astigueta-Pérez et al., 2020[116]). The deficiencies are rooted in the fragmentation of the system and the dependence of the programme on the yearly budget assigned by different institutions. Because the pandemic absorbed most of the budget, the programmes reduced the target in terms of population coverage and diminished the proactive actions towards population screening. In 2021, 146 498 persons were screened for cervical cancer, against 256 967 in 2019. Because of the changes in target population, the coverage percentages are not comparable in time or against other countries. However, they do provide an approximation towards the disruption in the active search for patients. In 2019 the coverage was 81%, dropping to 41% in 2020 and partially recovering in 2021 (59%) (BPT, GOPBM –MINSA, 2021[113]). At the same time, according to the minister of health, pap smear tests decreased in 2020 (528 840) and 2021 (974 410) compared with 2019 (1 418 894) (62% and 31% reduction respectively). For breast cancer, screenings were made to 83% of the target population in 2019, dropping to 41% in 2020 and recovering to 66% in 2021. For colorectal cancer, in 2021 the first semester goal was 80 567 people screened, but only 10 565 (13.1%) were actually screened. In 2020 the coverage was 23.4% (66 653 screened people) (BPT, GOPBM –MINSA, 2021[113]).

Pregnant woman had difficulties to access routine care in Peru, where 35.5% of the pregnant woman who died in 2020 had no antenatal check-up, while 67.3% had between one and five check-up (Maternal Health - Roundtable for Concertation and Fight against Poverty, 2021[114]). There were 9 367 197 early childcare and development controls made in 2019, most of them by the primary care facilities; this number decreased by 56% in 2020 (4 122 275) and recovered to 60% of the initial level in 2021 (5 620 087) (MINSA, 2022[117]). In addition, the Ministry of Health reports a 62% decrease in hypertension screenings between 2019 and 2020, but with a positive recovery in 2021.

According to the WHO Pulse survey (WHO, 2022[118]), 50% of cancer screening services were disrupted in Argentina in 2021 and in Brazil in 2020 (until March 2021), while only 5% was disrupted in Costa Rica (Figure 5.11). During 2021, ordinance GM/MS nº 3 712 in Brazil allocated BRL 150 million (~23, EUR 5 million) from the central government to the states and Federal District to secure the continuity of screening and early diagnosis actions for breast and cervical cancer during the COVID-19 pandemic (Ministro de Estado da Saúde, 2020[119]). In addition, the Brazilian National Cancer institute published a technical note in March 2020 explaining what early detection actions could be postponed, followed by a note in June of the same year with guidance on the conditions and requirement to resume screening services. By 2021, given the growing concern of the oncologic morbidity and mortality, priority was given to assist health care centres to resume early detection of cancer (Migowski and Corrêa, 2020[120]).

Other OECD countries have seen large drop in cervical, breast and colorectal cancer screenings between 2019 and 2020 (Box 5.8).

As the first and main point of contact with the health care system, primary health care is best placed to detect disease at the early stage. However, the technical capacities for this purpose in LAC-7 countries are lower than in other OECD countries, especially in terms of the availability of medical technologies including mammography units, CT scanners and MRI. National recommendations for screening follow the World Health Organization guidelines in terms of the population-based approach, the testing methods for screening, and periodicity. However, in all LAC-7 countries there is scope to expand the coverage of screening for breast and cervical cancer, and for hypertension and diabetes. Key elements of successful PHC programme include explicit implementation details, alongside clear responsibilities, appropriate trainings and accountability system. In Chile for example, PHC centres are responsible for implementing preventive tests according to life cycle, including mammography at the PHC centre or in co-ordination with another provider. One key success factor for the Chilean programme is to hold PHC centres accountable for the screening process. In Peru, antenatal consultations, which can occur entirely in PHC, fully benefit from the new community-based care plan that includes explicit roles and responsibilities of PHC workers for the active identification and invitation of target population. Centralised and integrated information systems will be critical to help assess the effectiveness of the programme and assess practices at provider level.

During the COVID-19 pandemic, the availability of COVID-19 testing was rather limited, and recommendations from the Ministry of Health for primary health care workers to carry-out COVID-19 testing were most often late (as in Brazil, Chile or Argentina). To improve preparedness and response during health emergencies, there is a need for stronger stewardship from the central level to take key decisions and issue evidence-based guidelines. All LAC-7 countries developed some forms of COVID-19 testing in primary health care settings, but with high heterogeneity within and across LAC-7 countries. In Costa Rica for example, all EBAIS were responsible for COVID-19 testing, while in Mexico the role of primary health care in COVID-19 testing was rather limited. The variations that can be seen within the regions reflect differences in PHC systems across LAC countries. New responsibilities and new forms of co-ordination between national level and local level (as in Argentina with the Detectar programme) should be maintained to manage both short and long term health challenges.

As in other OECD countries, early detection of diseases was suspended during the first phase of the pandemic to increase capacity for patients with COVID-19 complications. The result is that early detection of non-COVID-19 disease was postponed, with large impact on cancer screening, detection of hypertension and of diabetes (as in Argentina, Brazil, Chile, Mexico and Peru). LAC-7 countries should urgently acknowledge the generated backlog of services and create plans accordingly, so that health and economic effects are minimised.


[108] Alejandra Llanos-Guerrero and Judith S. Méndez Méndez (2021), Interrupción de los servicios de salud por Covid-19: Implicaciones en el gasto de bolsillo[Disruption of health services due to COVID-19: Implications for COVID-19 out-of-pocket spending, health and public finances], Centro de Investigación Económica y Presupuestaria, A. C., https://ciep.mx/IX9Q (accessed on 7 June 2022).

[68] Ángeles-Llerenas, A. et al. (2016), “Effect of care-delivery delay on the survival of Mexican women with breast cancer”, Salud Pública de México, Vol. 58/2, pp. 237-250, https://doi.org/10.21149/spm.v58i2.7793.

[116] Astigueta-Pérez, J. et al. (2020), “Cancer disease progression and death during the COVID-19 pandemic: a multidisciplinary analysis for the Peruvian setting”, ecancermedicalscience, Vol. 14, https://doi.org/10.3332/ecancer.2020.1098.

[48] Blanco, S. et al. (2019), “Quality of mammography and breast cancer screening in Argentina [Qualidade da mamografia e prevenção do câncer de mama na Argentina]”, Revista panamericana de salud publica = Pan American journal of public health, Vol. 43, p. e63, https://doi.org/10.26633/RPSP.2019.63.

[113] BPT, GOPBM –MINSA (2021), Evaluation of health budget programs. I semester 2021, Budget Programs Team, General Office of Planning, Budget and Modernization - MINSA., http://www.minsa.gob.pe/presupuestales/?pg=6#contact.

[16] CAC (2021), Situación del cáncer en al población adulta atendida en el SGSSS de Colombia 2020.

[54] Caja Costarricense de Seguro Social (2020), Guía para la atención de la persona con diabetes mellitus tipo 2, EDNASSS-CCSS, San José, C. R.

[63] Caja Costarricense de Seguro Social (2002), Guias para la deteccion, diagnostico y tratamiento de la hipertension arterial en el primer nivel de atencion, gerencia de division medica direccion tecnica de servicios de salud departamento de medicina preventiva, https://www.binasss.sa.cr/hipertension.pdf (accessed on 10 June 2022).

[29] CCSS (2021), Institutional Memory, 2020, https://repositorio.binasss.sa.cr/repositorio/handle/20.500.11764/4033 (accessed on 24 June 2022).

[19] Centro Nacional de Equidad de Género y Salud Reproductiva (2015), El Programa de Prevención y Control de Cáncer de la Mujer, Centro Nacional de Equidad de Género y Salud Reproductiva. Subsecretaría de Prevención y Promoción de la Salud. México.

[12] Chávarri-Guerra, Y. et al. (2012), “Breast cancer in Mexico: a growing challenge to health and the health system”, The Lancet Oncology, Vol. 13/8, pp. e335-e343, https://doi.org/10.1016/s1470-2045(12)70246-2.

[38] Chen, A. et al. (2018), “Facilitating autonomous, confident and satisfying choices: a mixed-method study of women’s choice-making in prenatal screening for common aneuploidies”, BMC Pregnancy and Childbirth, Vol. 18/1, https://doi.org/10.1186/s12884-018-1752-y.

[60] Christian Ulrich Eriksen et al. (2021), What is the effectiveness of systematic population-level screening programmes for reducing the burden of cardiovascular diseases?, WHO Regional Office for Europe. Health Evidence Network synthesis report, No. 71.

[15] Colombian National Cancer Institute (2019), Boletin de Servicios Oncologicos, https://www.cancer.gov.co/conozca-sobre-cancer-1/publicaciones/boletin-servicios-oncologicos-2019.

[58] Comité Consultivo Nacional de Normalización de Prevención y Control de Enfermedades (2009), Norma oficial mexicana nom-015-ssa2-2010, para la prevencion, tratamiento y control de la diabetes mellitus, Diario Oficial de la Federación.

[30] Costa Rica Ministry of Health (2012), Plan Nacional para la Prevención y Control del Cáncer 2011-2017, http://www.cuidadospaliativosbelen.com/Downloads/2011-2017_PNPCC.pdf (accessed on 24 June 2022).

[75] Damian Clarke, Gustavo Cortés Méndez and Diego Vergara Sepúlveda (2018), “Growing Together: Assessing Equity and Efficiency in an Early-Life Health Program in Chile”, No. IZA DP No. 11847, The IZA Institute of Labor Economics, Bonn, Germany, https://docs.iza.org/dp11847.pdf (accessed on 9 June 2022).

[109] DEIS - Ministerio de Salud Chile (2022), Base de datos de establecimientos de la red asistencial., https://deis.minsal.cl/.

[106] Doubova, S. et al. (2021), “Disruption in essential health services in Mexico during COVID-19: an interrupted time series analysis of health information system data”, BMJ Global Health, Vol. 6/9, p. e006204, https://doi.org/10.1136/bmjgh-2021-006204.

[76] ENDES-ENEI (2020), Demographic and Family Health Survey-ENDES, Instituto Nacional de Estadística e Informática. Peru.

[100] Facultad de Medicina Universidad de Chile (2021), Monitorización de estrategia de Testeo-Trazabilidad-Aislamiento en la APS, http://www.medicina.uchile.cl/atencionprimaria/Otros/monitoreo-estrategia-tta/septimo-y-octavo-monitoreo-tta.

[32] Federici, S. (ed.) (2018), “Older adults with disability in extreme poverty in Peru: How is their access to health care?”, PLOS ONE, Vol. 13/12, p. e0208441, https://doi.org/10.1371/journal.pone.0208441.

[88] Fondo Colombiano de Enfermedades de Alto Costo (2021), Situación del cáncer en la población adulta atendida en el SGSSS de Colombia 2020.

[90] Giganti, F. and C. Moore (2019), “MRI in early detection of prostate cancer”, Current Opinion in Urology, Vol. 29/6, pp. 563-568, https://doi.org/10.1097/mou.0000000000000668.

[79] Guanais, F. and et al. (2018), From the Patient’s Perspective: Experiences with Primary Health Care in Latin America and the Caribbean, Inter-American Development Bank, https://doi.org/10.18235/0001255.

[71] Hernández-Vásquez, A. and H. Chacón-Torrico (2019), “Use of mammography in Peruvian women: An analysis of the 2018 Demographic and Health Survey”, Medwave, Vol. 19/09, pp. e7701-e7701, https://doi.org/10.5867/medwave.2019.09.7701.

[67] IBGE (2019), National Survey of Health (Pesquisa Nacional de Saúde), Instituto Brasileiro de Geografia e Estatística, https://www.ibge.gov.br/en/statistics/social/health/16840-national-survey-of-health.html?=&t=microdados.

[77] ICF (2018), The DHS Program Data Repository, Funded by USAID, https://dhsprogram.com/data/available-datasets.cfm (accessed on 9 June 2022).

[17] INCA (2020), Histórico das ações, INCA – Instituto Nacional de Câncer, https://www.inca.gov.br/controle-do-cancer-do-colo-do-utero/historico-das-acoes (accessed on 27 May 2022).

[94] INS (2020), Colombia tiene la mejor capacidad diagnóstica en América Latina, https://www.ins.gov.co/Noticias/Paginas/Colombia-tiene-la-mejor-capacidad-diagn%C3%B3stica-en-Am%C3%A9rica-Latina.aspx (accessed on 8 July 2022).

[37] Institute of Health and Welfare (2014), The development of cancer prevention, early detection and rehabilitation assistance for the period 2014-2025, https://www.iccp-portal.org/system/files/plans/URN_ISBN_978-952-302-185-3.fi_.en_.pdf (accessed on 4 July 2022).

[70] Instituto Nacional de Cancerologia (2019), Boletin de Servicios Oncologicos, Instituto Nacional de Cancerologia, Bogota.

[26] Instituto Nacional de Cancerología (2012), Ten year plan for cancer care in Colombia (Plan Decenal para el Control del Cáncer en Colombia), Ministerio de Salud y Protección Social - Instituto Nacional de Cancerología.

[55] Instituto Nacional de Estadística y Censos - I.N.D.E.C (2019), 4° Encuesta Nacional de Factores de Riesgo. Resultados definitivos. - 1a ed. -, Secretaría de Gobierno de Salud de la Nación, Ciudad Autónoma de Buenos Aires.

[51] Instituto Nacional del Cáncer (2008), Programa Nacional de Prevención de Cáncer Cervicouterino, Ministerio de Salud, https://www.argentina.gob.ar/salud/instituto-nacional-del-cancer/institucional/pnpcc#:~:text=El%20PNPCC%20forma%20parte%20de,PAP%20o%20test%20de%20VPH). (accessed on 7 June 2022).

[110] Ismael Puga R et al. (2021), “What factors explain COVID-19 vaccination in Chile? An analysis in a sample of individuals from priority groups”, Medwave 2021;21(S2): eSP26, https://doi.org/10.5867/Medwave.2021.S2.SP26.

[7] Jin, J. (2021), “Screening for Hypertension in Adults”, JAMA, Vol. 325/16, p. 1688, https://doi.org/10.1001/jama.2021.5288.

[82] Laura Limardo; Marta Donia; Patricia Provenzano (2018), Resultados del Censo Nacional de Mamógrafos, Instituto Nacional del Cáncer, Ciudad Autónoma de Buenos Aires.

[87] Lopez, M. et al. (2017), “Cervical cancer prevention and treatment in Latin America”, Journal of Surgical Oncology, Vol. 115/5, pp. 615-618, https://doi.org/10.1002/jso.24544.

[72] Martínez-Donate, A. et al. (2013), “Prevalence and Correlates of Breast and Cervical Cancer Screening Among a Midwest Community Sample of Low-Acculturated Latinas”, Journal of Health Care for the Poor and Underserved, Vol. 24/4, pp. 1717-1738, https://doi.org/10.1353/hpu.2013.0165.

[114] Maternal Health - Roundtable for Concertation and Fight against Poverty (2021), Concerted follow-up between the state and civil society of health policies, Work Subgroup on “Maternal and Neonatal Health”, Maternal mortality continues to increase in the context of COVID-19, a call to action. Alert N ° 1-2021-SC / GT Salud-MCLCP, https://www.mesadeconcertacion.org.pe/storage/documentos/2021-05-07/mclcp-alerta-sobre-muertes-maternas-abril-2021-vp4.pdf (accessed on 7 June 2022).

[103] Mauro, M. and M. Giancotti (2021), “Italian responses to the COVID-19 emergency: Overthrowing 30 years of health reforms?”, Health Policy, Vol. 125/4, https://doi.org/10.1016/j.healthpol.2020.12.015.

[14] Mexico Ministry of Health (2013), National Program of Maternal and Antenatal Care (Programa de Salud Materna y Perinatal), Centro Nacional de Equidad de Género y Salud Reproductiva, https://www.gob.mx/salud/acciones-y-programas/programa-de-salud-materna-y-perinatal-cnegsr-12031 (accessed on 2 June 2022).

[120] Migowski, A. and F. Corrêa (2020), “Recommendations for early detection of cancer during covid-19 pandemic in 2021”, Rev. APS, Vol. jan./mar.; 23(1)/Monitoramento das ações de controle do câncer, https://periodicos.ufjf.br/index.php/aps/article/view/33510/22830.

[97] Ministério da Saúde (2021), Atenção Primária à Saúde contra a covid-19: 7 passos para uma assistência resolutiva, https://egestorab.saude.gov.br/image/?file=20210330_N_7passosweb_5134105108623129303.pdf (accessed on 25 May 2022).

[18] Ministério da Saúde (2010), Rastreamento (Tracking), Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Ministério da Saúde. http://www.saude.gov.br/dab (accessed on 27 January 2021).

[28] Ministerio de Desarrollo y Familia (2022), Presentation of “Chile grows with you system” (Presentación del Sistema “Chile Crece Contigo”), https://www.crececontigo.gob.cl/acerca-de-chcc/ (accessed on 3 June 2022).

[53] Ministerio de Salud (2016), Guía de práctica clínica para el diagnóstico, tratamiento y control de la diabetes mellitus tipo 2 en el primer nivel de atención, Dirección General de Intervenciones Estratégicas en Salud Pública. Dirección de Prevención de Enfermedades No Transmisibles y Oncológicas. Estrategia Sanitaria Nacional de Prevención y Control de ENT, Lima, Peru.

[61] Ministerio de Salud (2011), Guía de práctica clínica para la prevención seguimiento y control de la enfermedad hipertensica en el primer nivel de atención., Dirección General de Salud de las Personas. Estrategia Sanitaria Nacional de Prevención y Control de Danos no Transmisibles. Ministerio de Salud, Lima, Peru, http://bvs.minsa.gob.pe/local/MINSA/2826.pdf (accessed on 10 June 2022).

[24] Ministerio de Salud – Dirección General de Intervenciones Estratégicas en Salud Pública – Dirección de Prevención y Control de Cáncer (2017), “Plan nacional de prevención y control de cáncer de mama en el perú 2017-2021”, http://bvs.minsa.gob.pe/local/MINSA/4234.pdf (accessed on 1 June 2022).

[23] Ministerio de Salud Peru (2012), Programa presupuestal Prevención y control del cáncer (national budget program for cancer ).

[119] Ministro de Estado da Saúde (2020), ORDINANCE GM/MS No. 3,712, DECEMBER 22, Ministério da Saúde, https://www.in.gov.br/web/dou/-/portaria-gm/ms-n-3.712-de-22-de-dezembro-de-2020-295788198.

[95] Ministry of Health (2021), Laboratorios que están avalados para realizar Diagnóstico de SARS-COV2, https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/laboratorios-pruebas-covid-19.pdf (accessed on 8 July 2022).

[112] Ministry of Health (2020), Continuidad de atención a niños y niñas en Atención Primaria de Salud en el contexto de alerta sanitaria COVID-19., Subsecretaría de Salud Pública - Subsecretaría de Redes Asistenciales. Ministerio de Salud. Chile., https://diprece.minsal.cl/wp-content/uploads/2020/04/Continuidad-de-Atencion-de-NN-en-APS-version-II.pdf (accessed on 7 June 2022).

[98] Ministry of Health (2020), Diario Oficial de la República de Chile, https://www.diariooficial.interior.gob.cl/publicaciones/2020/06/06/42674/01/1770543.pdf.

[47] Ministry of Health (2014), Norma para la atención integral de personas con cáncer de mama, Presidencia de la República, Dirección garantía acceso servicios de salud, Unidad de atención directa a las personas.

[66] Ministry of Health (2013), Orientaciones para la implementación del modelo de atención integral de Salud Familiar y comunitaria dirigido a equipos de salud. [Guidelines for the implementation of the comprehensive family and community health care model aimed at health teams.], Ministry of Health, Subsecretaría de Redes Asistenciales, División de Atención Primaria, Chile., https://www.minsal.cl/portal/url/item/e7b24eef3e5cb5d1e0400101650128e9.pdf.

[31] Ministry of Health - Chile (2012), LEY 19966 Establece un Régimen de Garantías en Salud, Biblioteca del Congreso Nacional, http://www.leychile.cl/N?i=229834&f=2004-09-03&p= (accessed on 28 June 2022).

[25] Ministry of Health (Ministerio de Salud) (2020), Ministerial Resolution No. 030-2020, Technical Document "Model of Comprehensive Health Care for the Life Course for the Person, Family and Community (MCI)".

[39] Ministry of Social Affairs and Health (2022), Prenatal screening, https://stm.fi/en/prenatal-screening (accessed on 4 July 2022).

[117] MINSA (2022), Hard data in requet for access to inforamtion No 21-015195.

[102] Mugnai, G. and C. Bilato (2020), “Covid-19 in Italy: Lesson from the Veneto Region”, Eur J Intern Med, https://doi.org/10.1016/j.ejim.2020.05.039.

[22] National Cancer Institute (Instituto Nacional del Cáncer) (n.d.), Program (Líneas prográmaticas), Ministry of Health (Ministerio de Salud), https://www.argentina.gob.ar/salud/instituto-nacional-del-cancer/institucional/pnpcc (accessed on 2 June 2022).

[85] Nogueira, M. et al. (2019), “Inequities in access to mammographic screening in Brazil”, Cadernos de Saúde Pública, Vol. 35/6, https://doi.org/10.1590/0102-311x00099817.

[36] OECD (2022), OECD Health Statistics 2022, http://dotstat.oecd.org/?lang=en.

[96] OECD (2021), Policy survey on the role of primary health care during the COVID-19 Pandemic.

[3] OECD (2021), Primary Health Care in Brazil, OECD Reviews of Health Systems, OECD Publishing, Paris, https://doi.org/10.1787/120e170e-en.

[93] OECD (2020), “COVID-19 in Latin America and the Caribbean: An overview of government responses to the crisis”, OECD Policy Responses to Coronavirus (COVID-19), OECD Publishing, Paris, https://doi.org/10.1787/0a2dee41-en.

[11] OECD (2020), Realising the Potential of Primary Health Care, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/a92adee4-en.

[89] OECD/The World Bank (2020), Health at a Glance: Latin America and the Caribbean 2020, OECD Publishing, https://doi.org/10.1787/6089164f-en.

[69] Ortega–Olvera, C. et al. (2016), “Knowledge and recommendations regarding breast cancer early screening in an upper middle income country: Primary and secondary health care professionals”, Preventive Medicine, Vol. 86, pp. 147-152, https://doi.org/10.1016/j.ypmed.2016.02.041.

[111] Pacheco, J. et al. (2021), “Gender disparities in access to care for time-sensitive conditions during COVID-19 pandemic in Chile”, BMC Public Health, Vol. 21/1, https://doi.org/10.1186/s12889-021-11838-x.

[99] PAHO (2020), Detecting: Argentina’s testing and contact tracing strategy to break the COVID-19 transmission chain, https://www.paho.org/en/stories/detecting-argentinas-testing-and-contact-tracing-strategy-break-covid-19-transmission-chain.

[4] PAHO/WHO (2022), Cancer, https://www.paho.org/es/temas/cancer (accessed on 12 June 2022).

[33] PAHO/WHO (2015), Country Capacity Survey Results, Pan American Health Organization & World Health Organization, https://ais.paho.org/phip/viz/nmh_ccs_resultstool.asp (accessed on 8 June 2022).

[35] Paulauskiene, J. et al. (2019), “Organised Versus Opportunistic Cervical Cancer Screening in Urban and Rural Regions of Lithuania”, Medicina, Vol. 55/9, p. 570, https://doi.org/10.3390/medicina55090570.

[42] Peisl, S. et al. (2019), “Comparison between opportunistic and organised breast cancer mammography screening in the Swiss canton of Fribourg”, BMC Cancer, Vol. 19/1, https://doi.org/10.1186/s12885-019-5706-1.

[34] Peru Ministry of Health (2020), Technical Document “Model of Comprehensive Health Care for the Life Course for the Person, Family and Community (MCI), https://cdn.www.gob.pe/uploads/document/file/496394/resolucion-ministerial-030-2020-MINSA.pdf (accessed on 10 February 2022).

[101] Pichler, R., C. Frühwald and S. Burgmann (2020), New routine in primary care: Experiences from an Austrian PHC center during the COVID-19 crisis, https://improvingphc.org/blog/2020/06/11/new-routine-primary-care-experiences-austrian-phc-center-during-covid-19-crisis (accessed on 11 May 2022).

[52] Pippitt, K., M. Li and H. Gurgle (2016), “Diabetes Mellitus: Screening and Diagnosis.”, American family physician, Vol. 93/2, pp. 103-9.

[83] Ramos Muñoz, W. and N. Guerrero Ramírez (2021), Análisis de la situación del cáncer en el Perú, 2018, Centro Nacional de Epidemiología, Prevención y Control de Enfermedades Ministerio de Salud Perú.

[9] Ratushnyak, S., M. Hoogendoorn and P. van Baal (2019), “Cost-Effectiveness of Cancer Screening: Health and Costs in Life Years Gained”, American Journal of Preventive Medicine, Vol. 57/6, pp. 792-799, https://doi.org/10.1016/j.amepre.2019.07.027.

[115] Ribeiro, C., F. Correa and A. Migowski (2022), “Efeitos de curto prazo da pandemia de COVID-19 na realização de procedimentos de rastreamento, investigação diagnóstica e tratamento do câncer no Brasil: estudo descritivo, 2019-2020”, Epidemiol. Serv. Saúde, https://doi.org/10.1590/S1679-49742022000100010.

[57] Rodríguez, M. et al. (2019), “The FINDRISC questionnaire capacity to predict diabetes mellitus II, arterial hypertension and comorbidity in women from low-and-middle-income countries”, Health Care for Women International, Vol. 41/2, pp. 205-226, https://doi.org/10.1080/07399332.2019.1680678.

[10] Rubin, G., P. Vedsted and J. Emery (2011), “Improving cancer outcomes: better access to diagnostics in primary care could be critical”, British Journal of General Practice, Vol. 61/586, pp. 317-318, https://doi.org/10.3399/bjgp11x572283.

[40] Saaristo, T. et al. (2007), “National type 2 diabetes prevention programme in Finland: FIN-D2D”, International Journal of Circumpolar Health, Vol. 66/2, pp. 101-112, https://doi.org/10.3402/ijch.v66i2.18239.

[62] Salazar, M. et al. (2021), “May Measurement Month 2019: an analysis of blood pressure screening results from Argentina”, European Heart Journal Supplements, Vol. 23/Supplement_B, pp. B12-B14, https://doi.org/10.1093/eurheartj/suab055.

[41] Santalahti, P. and E. Hemminki (1998), Use of prenatal screening tests in Finland.

[50] Santamaría-Ulloa, C. et al. (2021), “Inequidades en la detección temprana del cáncer de cérvix: una realidad en la población costarricense”, Población y Salud en Mesoamérica, https://doi.org/10.15517/psm.v19i2.48122.

[46] Secretaria de Salud (2017), Prevención tamizaje y referencia oportuna de casos sospechosos de cáncer de mama en el primer nivel de atención, Guía de evidencias y recomendaciones: Guía de práctica clínica., CENTEC, Mexico, http://www.cenetec-difusion.com/CMGPC/S-001-08/ER.pdf (accessed on 8 June 2022).

[20] Secretaría de Salud (2013), Programa de Acción Específico; Prevención y Control de la Diabetes Mellitus 2013-2018, Sectorial de Salud, México.

[21] Secretaría de Salud (2013), Programa de Acción Específico; Prevención y Control de la Obesidad y Riesgo Cardiovascular 2013-2018, Secretaria de Salud, México, https://www.gob.mx/cms/uploads/attachment/file/278072/PAE_PrevencionControlObesidadRiesgoCardiovascular2013_2018.pdf (accessed on 1 June 2022).

[13] Serván-Mori, E. et al. (2020), “Assessing the continuum of care for maternal health in Mexico, 1994–2018”, Bulletin of the World Health Organization, Vol. 99/3, pp. 190-200, https://doi.org/10.2471/blt.20.252544.

[80] Shamah Levy, T., J. Rivera-Dommarco and S. Bertozzi (2020), “Encuesta Nacional de Salud y Nutrición 2018-19: análisis de sus principales resultados”, Salud Pública de México, Vol. 62/6, Nov-Dic, pp. 614-617, https://doi.org/10.21149/12280.

[64] Sistema General de Seguridad Social en Salud (2017), Guía de Práctica Clínica para el manejo de la hipertensión arterial primaria, Ministerio de Salud y Protección Social Instituto de Evaluación Tecnológica en Salud Fundación Cardioinfantil -Instituto de Cardiología, Colombia.

[56] Sistema General de Seguridad Social en Salud (2016), Guía de práctica clínica para el diagnóstico, tratamiento y seguimiento de la diabetes mellitus tipo 2 en la población mayor de 18 años, Ministerio de Salud y Protección Social, Bogotá, Colombia.

[8] Sroczynski, G. et al. (2020), “A Systematic Review on Cost-effectiveness Studies Evaluating Ovarian Cancer Early Detection and Prevention Strategies”, Cancer Prevention Research, Vol. 13/5, pp. 429-442, https://doi.org/10.1158/1940-6207.capr-19-0506.

[27] Subsecretaria de Salud Pública. (2013), Preventive Medicine Examination Clinical Guide (Guía clínica examen de medicina preventiva), Ministerio de Salud.

[92] Tehranzadeh, J., O. Ashikyan and J. Dascalos (2003), “Magnetic Resonance Imaging in Early Detection of Rheumatoid Arthritis”, Seminars in Musculoskeletal Radiology, Vol. 07/2, pp. 079-094, https://doi.org/10.1055/s-2003-41342.

[91] Teipel, S. et al. (2013), “Relevance of Magnetic Resonance Imaging for Early Detection and Diagnosis of Alzheimer Disease”, Medical Clinics of North America, Vol. 97/3, pp. 399-424, https://doi.org/10.1016/j.mcna.2012.12.013.

[74] Tunçalp, Ӧ. et al. (2017), “WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival”, BJOG: An International Journal of Obstetrics & Gynaecology, Vol. 124/6, pp. 860-862, https://doi.org/10.1111/1471-0528.14599.

[78] UNICEF (2021), Global databases of antenatal care, https://data.unicef.org/.

[84] United Nations and Department of Economic and Social Affairs - Population Division (2019), World Population Prospects: The 2019 Revision.

[5] US Preventive Services Task Force (2021), “Screening for Prediabetes and Type 2 Diabetes”, JAMA, Vol. 326/8, p. 736, https://doi.org/10.1001/jama.2021.12531.

[81] Villalobos, A. et al. (2020), “Perfiles poblacionales asociados con la asistencia a servicios preventivos para tamizaje de diabetes e hipertensión. Ensanut 2018-19”, Salud Pública de México, Vol. 62/6, Nov-Dic, pp. 754-766, https://doi.org/10.21149/11556.

[86] Viniegra M, Paolino M and Arrossi S (2010), Cancer de mama en Argentina: organización, cobertura y calidad de las acciones de prevención y control, Pan American Health Organization, https://iris.paho.org/handle/10665.2/5527 (accessed on 8 June 2022).

[107] Vitela, N. (2022), Caen por pandemia consultas con INSABI [INSABI consultations fall due to the pandemic], Reforma, Mexico, https://www.reforma.com/ (accessed on 7 June 2022).

[105] Vrdoljak, E. et al. (2021), “COVID-19 Pandemic Effects on Breast Cancer Diagnosis in Croatia: A Population- and Registry-Based Study”, The Oncologist, Vol. 26/7, pp. e1156-e1160, https://doi.org/10.1002/onco.13791.

[2] WHO (2022), Promoting cancer early diagnosis, World Health Organization, https://www.who.int/activities/promoting-cancer-early-diagnosis.

[118] WHO (2022), Pulse survey on continuity of essential health services during the COVID-19 pandemic, World Health Organization, https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2022.1.

[104] WHO (2022), Third round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic: November–December 2021, World Health Organization, Interim Report, http://WHO/2019-nCoV/EHS_continuity/survey/2022.1.

[44] WHO (2021), CanScreen5 - Key definitions, World Health Organization International Agency for Research on Cancer, https://canscreen5.iarc.fr/?page=help.

[73] WHO (2020), Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey, Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey, Geneva. License: CC BY-NC-SA 3.0 IGO.

[1] WHO (2019), The Global Health Observatory, World Health Organization, Geneva, https://www.who.int/data/gho/data/indicators (accessed on 8 June 2022).

[65] WHO (2016), WHO recommendations on antenatal care for a positive pregnancy experience, World Health Organization, Geneva, https://www.who.int/publications/i/item/9789241549912.

[45] WHO (2015), WHO Position Paper on Mammography Screening, World Health Organization, Pan American Health Organization, https://paho.org/hq/dmdocuments/2015/WHO-ENG-Mammography-Factsheet.pdf (accessed on 8 June 2022).

[6] WHO (n.d.), Diabetes, World Health Organization, https://www.who.int/health-topics/diabetes#tab=tab_1 (accessed on 28 June 2022).

[59] World Bank (2021), World Bank Open Data - World Development Indicators, https://data.worldbank.org/ (accessed on 14 December 2021).

[49] World Health Organization (2021), WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition, Licence: CC BY-NC-SA 3.0 IGO, Geneva.

[43] Zhang, L. et al. (2022), “An international consensus on the essential and desirable criteria for an ‘organized’ cancer screening programme”, BMC Medicine, Vol. 20/1, https://doi.org/10.1186/s12916-022-02291-7.

Metadata, Legal and Rights

This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area. Extracts from publications may be subject to additional disclaimers, which are set out in the complete version of the publication, available at the link provided.

© OECD 2022

The use of this work, whether digital or print, is governed by the Terms and Conditions to be found at https://www.oecd.org/termsandconditions.