11/1/2010

1

EXPANDING ACCESS TO

SPECIALIZED HEALTH CARE

FOR POOR AND EXCLUDED

POPULATIONS IN THE

ANCASH REGION – PERU

Authors:

Inga Salazar, Richard

Nino Guerrero, Alfonso

Vigo Obando, Ina

CONTENTS

I. General Information

II. Problem

III. Objectives

IV. Scope of Intervention

V. Methods

VI. Results

VII.Conclusions

I. GENERAL INFORMATION

� Peru: Total population28,220,764 inhabitants

� Urban population75.9 %

� Poverty rate:2005:54.%2010: 39.3%

� Mortality rate per 1000 live births: 6

I. GENERAL INFORMATION

Peruvian Health System Information

� 73% of the population seeks medical attention in publicservices provided by the Ministry of Health, which are not fr ee.The rest of the population seeks attention in: Social Securi ty:17.9%, Armed Forces: 3%, Private: 5.9%.

� In 2001 the Peruvian government created Public Insurance,called the “Integral Health Insurance” (SIS) to provide fre ehealthcare for the extremely poor and excluded population.

� Currently SIS coverage reaches 18.5% at a national level.

� Health establishments: First level centers: 8,486Hospitals: 469

94%

6%

POPULATION OF THE PROJECT : 427,141 PEOPLE.

No reciben atención especializada

NEED SPECIALIZED CARE: 86,429

� In the Ancash Region, thepoor and excludedpopulation:

� 86,429 people requirespecialized healthcare

� Only 6% receive it

� Excluded and Disperse Population: area with the greatest population dispersement at aregional level, located more than four (4) hours on a track and by river, or the means oftransport most frequently used by the healthcare center. R.M. 478-2009/MINSA.Technical Regulation for Integral Healthcare for Excluded and DispersePopulations.

II. THE PROBLEM: INEQUITY AND

EXCLUSION

Not received

specialized

care

5,186 people receive

specialized care

II. PROBLEM: INEQUITY AND EXCLUSION

BARRIERS ACTIONS CARRIED OUT BY THE GOVERMENT

LIMITATIONS

ECONOMIC Integral Health Insurence(SIS) for the poor and excluded population.

Benefits plan includes little specializedhealthcare.

GEOGRAPHIC Basic attention brigades for excluded and disperse populations (AISPED)

Insufficient regarding numbers.

FUNCTIONAL The offer is insufficient andconcentrated in the big cities.

Specialized doctors in Ancash: 0.13surgeons per 10,000 residents, 0.4pediatricians per 10,000 children.

CULTURAL Vertical births, waiting homes for pregnant women

Partially implemented.

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III. OBJECTIVE

Expand access to specialized healthcare for thepoor and excluded population through thedevelopment of new mobile healthcarestrategies, linking the attention levels andinvolving local actors in the Ancash Region,Peru.

IV. SCOPE OF INTERVENTION

� 407 Km. Northeast of Lima

� 427,141 (37% of regional total: 1’154,523 residents)

� 390 disperse and excluded communities

� 44 first level centers

� 10 hospitals

ANCASH REGION

V. METHODS

Component 1: Development of a mobile specialized healthcare model.

Selection of cases on the

first level

Specialized healthcare

campaigns in local hospitals

Specialized healthcare

campaigns in schools

1.1 1.2 1.3

COMPONENT 1

1.11.11.11.1

C C C

cc

c

Educational

Institutions

Specialized healthcare campaignsin local hospitals

AISPED: Basic Attentionand selection of cases that need

specialized healthcare

Specialized

healthcare

campaigns in

schools

Referrals to level II hospitals, National Hospitals and Institutes via SIS

EE.SS.

First level

Selection of Cases that need specialized

healthcare

1.31.31.31.3

1.21.21.21.2

� Training for the selection of cases based on prevalent pathologies by specialty to personnel from the AISPED brigades and first level centers.

� Standardization of instruments by specialty for the selection of cases.

� Improvement of the brigades’ equipment for the selection of cases: Snellen card, occlusometer, speculum, glucotest, PRAT equipment.

SELECTION OF CASES ON THE FIRST LEVEL1.11.11.11.1

Ophthamology Gynecology Internal Medicine Surgery

SPECIALIZED HEALTHCARE CAMPAIGNS

IN LOCAL HOSPITALSB

E

F

O

R

E

D

U

R

I

N

G

A

F

T

E

R

Analysis of the volume

and type demanded in

order to program

specialties

Adaption of the

installations and

processes

Coordination with

the main hospital

and local actors

Admission and

registration of

patients, based

on programming

External

consultation,

diagnostic aid

exams, medicine

Monitoring the

perceived quality,

satisfaction

surveys

Surgery: RxQx,Informed consent,

security checklist, hospitalization

Clinical Records

Archive in the

Main Hospital

Referrals via

Public Insurance

(SIS)

Report to

Regional Health

Board

Post op follow up

and delivery of

glasses

1.21.21.21.2

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� Odontology: Classrooms free from active cavities

� Ophtamology and delivery of glasses.

� Pediatric care

SPECIALIZED HEALTHCARE IN EDUCATIONAL

INSTITUTIONS1.31.31.31.3

Strengthening skills for

specialized healthcare

Improving the quality of

healthcare in hospitals

Strengthening the reference and

counter-reference system

V. METHODS

Component 2 : Strengthening the public healthcare sector for specialized healthcare in order to genera te sustainability.

2.1 2.2 2.3

STRENGTHENING SKILLS FOR SPECIALIZED

HEALTHCARE

280 healthcare workers involved in specialized healthcare, trained inservice

35 training odontologists to manage PRAT (Atraumatic RestorationPractice) and in surgical techniques

65 updating doctors in level I hospitals in managing transmitablediseases, chronic illness and diagnostics through images.

30 Masters in Hospital Management15 Masters in Medical Audit

2.12.12.12.1

IMPROVING QUALITY OF HEALTHCARE IN

HOSPITALS

Standardization of healthcare processes for external consultationsand surgery: clinical history by specialty, pre-op evaluation andsurgical risks, informed consents, surgical safety checklist in 100%of the patients attended.

Implementation of medical audit system in hospitals and auto-evaluation of quality standards.

Satisfaction surveys carried out by external users to evaluatequality. 84% of the attended users satisfied with the attentionreceived.

Improved use of information (indicators)

2.22.22.22.2STRENGTHENING OF REFERENCE AND

COUNTER-REFERENCE SYSTEM

Implementation of 45 first level centers with radiocommunication equipments.

Tele-medicine pilot: tele-electrocardiography and tele-spirometry in level I hospitals, placing priority on the mostdistance areas.

2.32.32.32.3

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INDICADOR DE PROPOSITO

73%

27%

POPULATION OF THE PROJECT : 427,141 PEOPLE..

No reciben atención especializada

Reciben algun tipo de atención especializada

Need Attention: 86,429

23,383 people receive

specialized care

VI. RESULTS

The population receiving specialized healthcare increased from 6% to 27%.

Not received specialty

care

Receives some kind of

specialized care

Q 128.54%

Q 255.64%

Q 315.77%

Q 40.04%

Q 50.01%

Chart 1: Consultations by poverty quintilePAAES. march to november 2008

8.75

%

5.26

%

4.89

%

4.66

%

4.35

%

4.03

%

3.54

%

2.22

%

1.94

%

1.90

%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

CA

RIE

S D

E L

A

DE

NT

INA

GA

ST

RIT

IS Y

D

UO

DE

NIT

IS

VU

LV

OV

AG

INIT

IS

DE

FE

CT

O

RE

FR

AC

TIV

O

PR

ES

BIC

IE

INF

EC

CIO

N

TR

AC

TO

UR

INA

RIO

PA

RA

SIT

OS

IS

INT

ES

TIN

AL

PT

ER

IGIO

N

MIO

PIA

AM

ET

RO

PIA

Chart 4: Ten leading causes of general morbidityPAAES: March - November 2008

%

ACUM

Internal medicine25.1%

Ophthalmology

22.0%

Pediatrics11.2%

Gynecology12.3%

Surgery2.7%

Other specialties

1.9%

Dentistry24.9%

Chart 2: Consultations by type of specialtyPAAES, march to November 2008

14.9% 11.7%

54.8%

18.6%

20.5

%

20.7

%

48.2

%

10.4

%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Childrens Teens Adults Seniors

Chart 3: Attended by age groupPAAES March a November. 2008

% ATD

% de pob 2008

CONCLUSIONES

� It is feasible to reduce barriers to access andto bring specialized attention to the poor anddisperse population by applying strategiesrelated to a mobile healthcare, linkingattention levels and involving local actors.

� Providing specialized healthcare applyingmobile strategies to disperse and excludedpopulations is more efficent than implementinga fixed offer.

VII. CONCLUSIONSVII. CONCLUSIONSVII. CONCLUSIONSVII. CONCLUSIONS CONCLUSIONES

� The applied methodology could beused by the current Public Insurance(SIS) in order to expand access todisperse populations.

� The project has contributed toimproving the quality of life of theattended population by reducingincapacity and mortality related topathologies that demand specializedhealthcare.

VII.CONCLUSIONS

Thanks for your attention

richard.inga@upch.pe