eduardo levcovitz, md, msc, ph.d chief. health policies and systems unit health systems...

Eduardo Levcovitz, MD, MSC, Ph.D

Chief. Health Policies and Systems Unit

Health Systems Strengthening Area

VII Regional Forum: Strengthening PHC-Based Health Systems

Quito, Ecuador - October 2007

PROCESSES OF CHANGE AND CHALLENGES FOR HEALTH

SYSTEMS BASED ON THE

RENEWED PHC STRATEGY

PROCESSES OF CHANGE AND CHALLENGES FOR HEALTH

SYSTEMS BASED ON THE

RENEWED PHC STRATEGY

SCRIPT:

1.Changes/Reforms in

health systems in LAC

2. Segmented and

fragmented systems

3.Challenges of PHC-based

health systems

PROCESSES OF CHANGE AND CHALLENGES

IN PHC-BASED HEALTH SYSTEMS

BRIEF HISTORY OF HEALTH SYSTEMS IN

THE 20TH CENTURY

• Before the ‘20s: Health Campaigns

• ‘20s-’40s: Social Security (Bismarck)

• ‘50s-’70s: “Welfare Sate” (Beveridge)

BRIEF HISTORY OF HEALTH SYSTEMS IN

THE 20TH CENTURY

•1970s-’80s: Intersectoral approach; Social Determinants; Expanded Coverage; Primary health care (Alma-Ata: WHO)

Physical environment

Health services

Biological influences

Social and Economic

Conditions

Cultural, Ethnic, and Gender-Age Factors

HEALTH

•‘80s-’90s: “Reforms”- Economic efficiency in management and reduction of public expenditure in health (International Financial Institutions)

NATIONAL

HEALTH SERVICES SOCIAL

SECURITY HEALTH SYSTEM

“BUSINESS MODEL”

HEALTH SYSTEMS IN LAC

www.lachealthsys.org

Sources of

Information

• Country Health Profiles

• The reforms have been linked to

the macroeconomic adjustment

processes, reduction in the size

and role of the State, and

market deregulation that

occurred in countries of the

Region in the ‘80s and ‘90s

HEALTH SYSTEM “REFORMS” IN

LAC IN THE ‘80s AND ‘90s HEALTH SYSTEM REFORMS

COUNTRY REFORMS

See, Doctor, my glucose jumped to 2,50, then it dropped to 0,85 and in the end reached 1,20.

It now seems that even diseases are being deregulated.

• The reforms did not respect each

country’s unique characteristics

(historical, political, and health

organization) and tended to

adopt the patterns in vogue and

the uniform prescriptions

imposed by the International

Financial Institutions

HEALTH SYSTEM ”REFORMS” IN

LAC IN THE ‘80s AND ‘90s

RESULTS PROBLEMS

Health systems were identified, and in many countries these functions were separated.

The private sector took on a greater role in insurance and service delivery.

The creation and deregulation of insurance and provider markets led to the multiplication of competing intermediaries.

The competition for clients who were

able to pay exacerbated the segmentation and inequity

These mechanisms inflated transaction

costs and undermined the steering role of the Ministry of Health



RESULTS PROBLEMS

The search for new

sources of financing commenced.

The introduction of user fees and other payment mechanisms at the point of care increased out-of-pocket expenditure and inequity.



RESULTS PROBLEMSFiscal responsibility was introduced in the public sector, with emphasis on financial sustainability.

Public expenditure was cut in the majority of countries.

The implementation of strict cost-

control mechanisms led to losses in public infrastructure and human resources



RESULTS PROBLEMS

Outsourcing improved services in some countries.

Efficiency and effectiveness became the criteria for service delivery.

The introduction of quasi-markets in the public sector led to a deterioration in public health.

The introduction of economic incentives in

the delivery of personal health care services gave curative services priority over preventive services and health promotion.

Little progress has been made in improving

the system’s performance, effectiveness,

and quality of care.



RESULTS PROBLEMS

Many countries created specific funds for people who could pay and people who could not pay

The creation of specific funds led to a loss of solidarity in the financing of the system, accentuating the segregation of the population and increasing inequity in access and health outcomes.



RESULTS PROBLEMS

Targeting mechanisms were set up and “basic packages” were created for poor and marginalized populations.

The “basic packages” with benefits for the different population strata that differed in quality and quantity intensified the segmentation

The coverage did not increase as expected, and the increased demand for health services could not be met due to the shortage of resources allocated to improving service delivery

HEALTH SYSTEM "REFORMS" IN


RESULTS PROBLEMS

In the majority of the countries the goal was to increase local participation in the administration of services through decentralization

Incomplete decentralization processes

intensified the lack of governance and the geographical inequity in health service delivery.

The fragmentation of the service network was intensified and today is one of the most typical features of health systems in the Region, where multiple agents operate without coordination, often competing against each other




LAC IN THE ‘80s AND ‘90s PROBLEMS

Few countries have faced

the challenge of developing

and training HUMAN

RESOURCES to adapt to

the new characteristics of

the public sector and cope

with the challenges created

by the reforms

• The reforms have focused

on managerial aspects such

as economic efficiency, decentralization,

privatization, separation of

the functions of financing/delivery, and

autonomy of service

providers



NATIONAL HEALTH

SERVICES

SOCIAL SECURITY HEALTH SYSTEM

“BUSINESS”

“REFORMED” HEALTH

SYSTEMS

HEALTH SYSTEM

REFORMS

• Chapter 2:

`Segmented and

fragmented

systems

End of Chapter

1 ….

Welcome to theHealth System

Enter here

PROCESSES OF CHANGE AND CHALLENGES

IN PHC-BASED HEALTH SYSTEMS

A GHOST HAUNTS THE HEALTH SYSTEMS OF

LAC….

Segm

enta

tion

base

d on

the

abili

ty to

pay

SEGMENTED/FRAGMENTED

SYSTEMS PREVAIL IN THE

AMERICAS

Ope

ratio

nal

frag

men

tatio

n

Coexistence of subsystems with different modalities of financing, affiliation, and service delivery, each of them “specialized” in different population strata according to their place in the workforce, income level, ability to pay, economic status, and social class.

SEGMENTATION

This kind of institutional organization consolidates and deepens inequity in health access across the different population groups. In organizational terms, the coexistence of one or more public entities, social security, and various financing/insurance and private suppliers occurs, depending on the degree of market mechanisms introduced.

The presence of multiple agents operating in an

unintegrated manner impedes the proper standardization

of the contents, quality, cost, and delivery of health

services, and leads to the existence of service networks

that do not work in a coordinated, coherent, or synergistic

manner and that tend to ignore or compete with other

providers, leading to higher transaction costs and

promoting inefficient resource allocation throughout the

system.

FRAGMENTATION

Presence of many units or entities not integrated into

the health services network.

PREMIUMS FROM FORMAL

EMPLOYMENT

INTERNATIONAL LOANS AND DONATIONS

GENERAL AND SPECIFIC TAXES

PRIVATE PREMIUMS

CONTRIBUTIONS FROM

HOUSEHOLDS TO COMMUNITY

FUNDS

Public

Private

External

LIMITATIONS OF SEGMENTED AND FRAGMENTED SYSTEMS

Segmentation of financial sources/risk pools

Sources

• Regressive and insufficient financing with predominantly out-of-pocket payments


Public and Private Expenditure as a Percentage of GDP:Latin America and the Caribbean, 2000-2004

0%

20%

40%

60%

80%

100%

GU

T

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N

SU

R

JAM

DO

R

ELS

HO

N

UR

U

EC

U

GU

Y

PE

R

TRT

SC

N

CH

I

ME

X

PA

R

GR

E

AN

T

AN

G

STL

BR

A

NIC

SV

T

CO

L

BLZ

PA

N

BO

L

DO

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CO

R

AR

G

US

A

BA

R

CA

N

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T

HA

I

Percentage of GDP Source: Basic Indicators 2005 (HP/HSS)Public Private

Inequities in access and

utilization • Major differences in insurance rights, levels of per capita expenditure and access to services, benefits and opportunities in health for different population strata


BIRTHS ATTENDED BY SPECIALIZED PERSONNEL, AROUND 2002

Source: World Bank. Socio-Economic Differences in Health, Nutrition, and Population. Wash, D.C.

• HIGH TRANSACTION COSTS

• Administration, advertising, sales, and intermediation

• Lack of integrated planning and programming

• Targeting and micro-insurance for lower-risk “pools”

• Patronage, corporatism, and corruption

• Insufficient capacity for drawing up contracts with providers and use of payment mechanisms that generate perverse incentives

• WEAK GOVERNANCE: inadequate regulatory

framework and oversight


NGO

Health

Center

Social Security

HospitalMunicipal outpatient

clinic

EFFICIENCY EQUITY

Overlapping networks, lack of complementarity among services and continuity of care, making comprehensive care impossible


End of Chapter 2 ….

Those of you who agree with Manolito,, raise your hand!!!!

• Chapter 3: Challenges for PHC-based health

systems

Whoever doesn’t understand, raise your hand…

What don’t you understand, Manolito?

Since March until now, NOTHING!!!

INTERINSTITUTIONAL CONVERGENCE

+OPERATIONAL

INTEGRATION

To avoid collective despair …

STRATEGIES TO

REDUCE SEGMENTATION AND

FRAGMENTATION

INTERINSTITUTIONAL

CONVERGENCE

OPERATIONAL

INTEGRATION

Strengthening of STEERING of Sectoral Policy

Alignment and Harmonization of International Cooperation

Integrated comprehensive service NETWORKS

PHC-based Health Systems

Incorporation of knowledge from the PROGRAMS into the

organization of SYSTEMS

POLITICAL/SOCIAL DIALOGUE between multiple stakeholders

Harmonization and integration of FINANCING

STRATEGIES TO

REDUCE SEGMENTATION AND

FRAGMENTATION

Capacity-building in Public Health/EPHF

HEALTH FOR ALL

Information and knowledgeInformation and knowledge

Human RightsHuman Rights

Primary Health Care

Primary Health Care

Social Protection

Social Protection

Health Promotion

Health Promotion

PUBLIC POLICY PRINCIPLES FOR STRENGTHENING PHC-BASED HEALTH

SYSTEMS

EVOLUTION OF THE GUIDING VALUES/PRINCIPLES FOR HEALTH

SYSTEMS

‘20s-’40s ‘80s-’90s‘50s-’70s 21st Century

Formal Social Security

for industrialworkers

Public Assistanceand Charity for the

poor and indigent

20th Century

WELFARESTATE

REFORMS:

Access based

on the abilit

y to

pay

UNIVERSAL SOCIAL

PROTECTION AS CIVIL RIGHT

WORLD HEALTH ASSEMBLY 2005

PANAMERICAN SANITARY CONFERENCE - 2002

Resolution WHA58.33

EXTENSION OF SOCIAL PROTECTION IN HEALTH

To guarantee all citizens UNIVERSAL SOCIAL PROTECTION in health, eliminating or reducing insofar as possible avoidable inequalities in coverage, access and utilization of services, and ensuring that all individuals receive care according to their needs and contribute to the financing of the system according to their ability to pay

THE KEY CHALLENGE FOR THE HEALTH SYSTEMS OF THE COUNTRIES OF THE

REGION IS ....

SOCIAL PROTECTION

IN HEALTH • GUARANTEE THAT, THROUGH

GOVERNMENT, SOCIETY

ENABLES an individual or group

of individuals to meet their

needs and demands in health,

obtain adequate access to health

services through one of the

existing health systems in the

country, without the ability to

pay constituting a constraint

CONDITIONS FOR THE EXTENSION OF SOCIAL PROTECTION IN HEALTH

• COLLECTIVE FINANCING:

intergenerational, across various

occupational categories, diverse

income groups, and population groups

exposed to different health risks

• HOUSEHOLD FINANCIAL SECURITY: the financing of health services should

not pose a threat to the financial

stability of families or to the

development of family members.

CONDITIONS FOR THE EXTENSION OF SOCIAL PROTECTION IN

HEALTH• ACCESS TO SERVICES:

availability of the necessary and

timely supply of service for the

delivery of care and the elimination

of physical, geographical, and

financial barriers.

• DIGNITY IN CARE: delivery of

timely, high-quality,

compassionate under conditions

that respect ethnicity, culture,

gender, age, and sexual

orientation.

Years in which LAC countries enacted legal provisions recognizing health as a universal

right

Country Year Law/ Resolution/ RegulationArgentina 1989 Law 23.661

Bolivia 1998 Presidential Decree 25.265

Brazil 1988/90 Federal Constitution; Laws 8.080 & 8142

Colombia 1993 Law No. 100

Costa Rica 1973 General Health Law 5395

Chile 1985 Law 18.469

Cuba 1976 Constitutional Charter

Dominican Republic 2001 Law 87

Ecuador 2002 Law 80 RO 670

El Salvador 1983 Constitutional Charter

Country Year Law/Resolution/RegulationGuatemala 2001 Social Dev. Law, Decree 42

Guyana 1980 Constitutional Charter

Haiti 1987 Constitutional Charter

Honduras 1982 Constitutional Charter

Mexico 2003 General Health Law

Nicaragua 1997 Constitutional Charter

Panama 1972 Constitutional Charter

Paraguay 1980 Law 836

Peru 2002 Law 27.812

Venezuela 1999 Constitutional Charter

Years in which LAC countries enacted legal provisions recognizing health as a universal

right

• Unified Health System - SUS (Brazil)

•Comprehensive Health Insurance -

SIS (Peru)

• People’s Health Insurance (Mexico)

• Universal free services (Mexico DF)

• Subsidized Regimen of the SGSSS

(Dominican Republic)

• Universal Health Insurance

(Ecuador)

• Community insurance of Cazaapa

(Paraguay)

COUNTRY INITIATIVES FOR THE EXTENSION OF SOCIAL PROTECTION

IN HEALTH

• Universal Maternal and Child

Insurance - SUMI (Bolivia)

• National Health Insurance (Bahamas, Trinidad & Tobago, Aruba)

• Explicit Guarantees in Health (Chile)

• State-subsidized enrollment in the Costa Rican Social Security Fund - CCSS (Costa Rica)

• Provincial Maternal and Child Health Insurances (Argentina)

• Opportunity Program (Mexico)

COUNTRY INITIATIVES FOR THE EXTENSION OF SOCIAL PROTECTION

IN HEALTH

• “Inside the Neighborhood” Mission (Venezuela)

• Legislative review of Law 100 (Colombia)

• Extension of social security benefits to dependent family members (El Salvador)

• Expansion of PHC Coverage in rural areas (Guatemala, Honduras)

• Universal Basic Insurance (Massachusetts and California, USA)

• Drug Insurance (Quebec, Canada)

COUNTRY INITIATIVES FOR THE EXTENSION OF SOCIAL PROTECTION IN HEALTH

Expansion of traditional social security plans,

including enrollment of workers from the informal sector

Promotion and development of innovative strategies for

coverage, including community-based initiatives

Expansion of mechanisms and projects to extend

coverage of health systems

Design of links between previous/other protection mechanisms and public

initiatives (overcome fragmentation, segmentation,

and improve equity)

SYNERGY AND

COHERENCE

INITIATIVES FOR THE EXTENSION OF SOCIAL PROTECTION IN HEALTH

• LEADERSHIP AND INSTITUTIONAL CAPACITY

• INFORMATION, KNOWLEDGE,

AND INNOVATION

• PLANNING AND

COORDINATION

• INTELLIGENCE, CREATIVITY,

DIALOGUE, COMMITMENT,

AND BOLDNESS

INTERVENTION OPPORTUNITIES

eduardo levcovitz, md, msc, ph.d chief. health policies and systems unit health systems...

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