ecuador haiti nicaragua and paraguay for instance have public health spending below high outofpocket spending and a very low proportion of older persons given that the pace of population ageing in these countries will be very rapid and that they must also face the epidemiological backlog amidst widespread poverty the lack of health protection will definitely worsen unless measures are introduced to strengthen the public system inequity on the other hand stems from having to make outofpocket payments to access health services or buy medications titelman