1 regional meeting integrated health services networks and vertical programs: maximizing synergies...
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REGIONAL MEETING
Integrated Health Services Networks and Vertical Programs:
Maximizing Synergies for Collaborative Work
URUGUAY: Coordinating national health systems and priority programs
Cuzco - Peru
November 2009
Dr. Miguel Fernández GaleanoVice Minister of Public Health
URUGUAY
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NEW PARADIGM
Health as an essential human right, a public resource, and a social and responsibility of State
and government
“The goal we have defined is that all Uruguayans enjoy access to comprehensive health care – all Uruguayans – through an integrated, nonprofit National Health System with a public-private mix, funded by national health insurance.”
Dr. Tabaré Vázquez President of the Eastern Republic of Uruguay
25 September 2005
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COMMON CRITERIA
Universal access
User contributions scaled to income, and benefits received according to need
Budget increase to supplement development resources from social policy
Priority to households with greatest number of under-18 members
SOCIAL REFORM
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SOCIAL POLICY: CONCEPTUAL CATEGORIES
Function of social policy Type of policy – orientation and objectives
Social goals
Temporary protection of sectors in critical poverty.
Ensure minimum social conditions.Provide targeted assistance.
Critical needs
Permanent or semi-permanent protection: satisfaction of basic needs and legal protection of rights (children, young people, jobs, food, urban public facilities).
Ensure minimum conditions, and improve quality of life for specific groups – assistance accompanied by targeted social promotion.
Needs + capacities
Classic well-being and traditional social rights (education, health, social security, labor sectors).
Invest in human capital and address common risks; promote universal citizenship.
Risks + capacities + opportunities
Well-being in terms of inclusion, equity and modern citizenship (gender, ethnicity, human rights, community building).
Incorporate new demands and social participation – combine universal and local approaches.
Equal opportunity
Source: Raczynski, D. and C. Serrano (2005), “Las políticas y estrategias de desarrollo social. Aportes de los años 90 y desafíos futuros,” in La paradoja aparente: resolviendo el dilema. Patricio Meller (ed.), Santiago, Chile. Modified ICP-FCS team (Institute of Political Science, School of Social Sciences, University of the Republic), 2006.
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Passage of three laws, creating the National Health Fund (FONASA), the Integrated National Health System (SNIS), and making ASSE a decentralized entity independent of the Ministry of Public Health.
Development of a public health policy that guarantees the rights of the population and promotes healthy lifestyles (programs to reduce smoking, promote healthy eating, reduce traffic accidents, etc.)
Development of a policy to improve public services and generate complementarity between public and private providers of social services, with emphasis on the primary care level.
Implementation of regulations that guarantee quality service to users. For this purpose, social participation was called on to help design a National Health Board (JUNASA) to function as the administrative entity of the National Health Fund (FONASA).
Key elements of health system reform
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THE REFORM STRATEGY
Change in care model
Change in management model
Change in funding model
Integrated National Health System
National Health Fund
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National Health Fund
Contributions of the StateHouseholds
Firms
USERS
Payment as a function of
income and fam
ily coverage
P
er cap
ita p
aym
ent a
s a
funct
ion o
f
age,
sex
and s
ervi
ce g
oals
INSTITUTIONSIntegrated with national
public health system and private nonprofit system FREE CHOICE
COMPREHENSIVE CARE
Composition of National Health Fund (FONASA)
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RATES GOVERNING CONTRIBUTIONS TO FONASA
Contributions to FONASA Contributions as a percentage of income
Health care entitlements
Workers with incomes below 2.5 BPC units
3% Care provided to worker and worker’s children
through the provider selected by them.
On retirement, workers are still covered by the
insurance.
Workers with incomes above 2.5 BPC units
3% + 1.5%
Workers with dependent children and incomes above 2.5 BPC units
3% + 3%
Firms 5%
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STRUCTURE OF HEALTH CARE PREMIUMSBY AGE AND SEX
Man
Women
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Starting pointExpenditure per user in NUr$ 900/month (US$ 45.00)collective medical care institutions (CMCIs)(private nonprofit)
Spending per user in ASSE NUr$ 280/month (US$ 14.00)(State) 3:1 ratio
Current situation, including allocations that will be proposed in the accounting: The budget of the State provider (ASSE) rose from US$ 185 million to US$ 550 million, the highest ASSE budget in the country’s history. As a result:
Expenditure per user in CMCIs (private nonprofit) NUr$ 1,000/month (US$ 50.00)Expenditure per user in ASSE (State) NUr$ 820/month (US$ 41.00)1.2:1 ratio
SOCIAL JUSTICE IN THE DISTRIBUTION OF
EXPENDITURE
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Guaranteed access to a comprehensive provider within the SNIS for the entire population.
Current total users of: CMCIs – medical cooperatives Private insurance ASSE Military and police health
These users represent 100% of the population. Example: individuals under 18:
500,000 joined FONASA. 170,000 were in CMCIs and parents stopped paying out-of-pocket premium. 130,000 were in ASSE and moved to CMCIs. 200,000 did not have comprehensive coverage and acquired it within the SNIS.
ACCESS OF POPULATION TO HEALTH SYSTEM WITH COMPREHENSIVE PROGRAMMED COVERAGE
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Expansion of comprehensive care
ASSE
Dec. 2007 Dec. 2008
IAMC
Private insurance
Military and Policy Health
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Starting point: DISSE covered 588,000 workers (only private-sector, and with no benefits for children).
As of May 2009, FONASA covers 1,485,000 individuals, including 500,000 children of workers.
An example of accessibility: Between 1996 and 2007, 50,000 retirees had social security coverage. Between August 2007 and May 2009, 35,000 more entered the system, i.e., two years saw the entry of 70% of the number who had entered over the previous 11 years. Reason: The policy of reducing tickets and orders in the CMCI membership contract.
ADVANCES IN COVERAGE THROUGH FONASA
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Lower copayments.
40% reduction for drug vouchers Access without charge for diabetics Free pregnancy tests Free preventive tests for women: mammograms,
Pap smear. Price of drug vouchers for hypertensives lowered
to a maximum of NUr$ 50. Free set of vouchers for retirees entering through
FONASA. Totally free preventive care for people under 18.
GREATER ACCESS
FOR THE POPULATION
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STEERING FUNCTIONS and new institutional tools
CONDUCT/LEAD
REGULATION
ESSENTIAL PUBLIC HEALTH FUNCTIONS
GUARANTEE OF INSURANCE
ORIENTATION OF FINANCING
HARMONIZATION OF SERVICES DELIVERY
PolicyStrategy
GoalsParticipation and Consensus
Intersectoral advocacy
Qualification, accreditation, certification
and monitoring of professionals, services,
technology, and supplies
Epidemiological surveillancePromotion/participation
Human resources developmentEvaluation of quality of services
Implementation of comprehensive care plans
Evaluation of sufficiency and quality of services
Banco de Previsión Social (BPS) functions as FONASA administrative entity.
Integrated systemLevels of complexity
ComplementarityReferrals/counterreferrals
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ESSENTIAL PUBLIC HEALTH FUNCTIONS (2002)
Measurement Results
Essential Public Health Functions
EPHF 1 EPHF 2 EPHF 3 EPHF 4 EPHF 5 EPHF 6 EPHF 7 EPHF 8 EPHF 9 EPHF 10 EPHF 11
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GUARANTEE QUALITY CARE FOR USERS OF SNIS
OBJECTIVE IS TO EXERCISE THE LEADERSHIP NEEDED TO GUARANTEE QUALITY CARE FOR USERS OF SNIS.
Exercise proper regulation to guarantee quality care for users of SNIS.
The starting point was the exhaustive deregulation of the 1990s. This included a policy of fait accompli in which things were done and approval was requested ex post facto if at all.
Framework of sanctions imposed on providers by JUNASA according to the frequency with which they fail to meet contractual conditions.
Minor Greater Serious
First time Note in provider’s file Temporary suspension of up to 20%
Temporary suspension of up to 50%
Second time Temporary suspension of up to 35%
Temporary 100% suspension
Permanent suspension of up to 12%
Third time Permanent 4% suspension
Permanent suspension of up to 8%
Permanent suspension of up to 100%
Source: Decree 464/008, Article 10.
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National Health Board created. The Board will sign service contracts with all public- and private-sector care providers, and enforce requirements that guarantee quality care for users. The Board has the power to impose sanctions if agreed care model or management model goals are not met.
The current decree regarding maximum waiting period gives every user of the SNIS the right to see a general practitioner, pediatrician, or gynecologist within 24 hours, and other specialists within 30 days.
Providers receive a special payment for meeting service goals. In order to qualify, they must examine all pregnant women in their system and provide nine free exams during the first 14 months of life for children. Failing this, the institution does not receive its bonus from FONASA.
The Ministry of Public Health has 150 inspectors whose pay has been raised. They are subject to an accountability arrangement that requires a high degree of dedication, and prohibits them from carrying out any functions in the institutions that they inspect.
IMPROVED LEADERSHIP
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.
Within the framework of a changed care model and in addition to public health policy, budgetary improvements for primary care, and strengthening of human resources, the new care model implies a strategy to ensure:
the presence of public health programs, since the health of the population is not solely the result of the action of health service providers. People’s habits and the environment in which their activity takes place are also important determinants of health. (Thus, for example, the strategy addresses smoking, healthy living and eating habits).
STRENGTHENING PRIMARY CARE AND CREATING COMPLEMENTARITY BETWEEN THE PUBLIC SECTOR AND THE NONPROFIT PRIVATE
SECTOR
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PRIORITY PROGRAMS Population groups
National Women’s Health and Gender Program
National Child Health Program National Adolescent Health
Program National Adult Health Program National Elder Health Program
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NATIONAL WOMEN’S HEALTH AND GENDER PROGRAM
National Women’s Health
and Gender Program
GENDER VIOLENCE
MEN’S CONDITION
SEXUAL AND REPRODUCTIVE
HEALTH
ADVISORY SERVICES, RESEARCH AND MANAGEMENT
MENTAL HEALTH AND GENDER
CANCER IN WOMEN
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NATIONAL CANCER CONTROL PROGRAM
NATIONAL ONCOLOGICAL NETWORK (RED ONCOLÓGICA NACIONAL - RON)Ministry of Public Health – CHLCC
MODULE 3EPIDEMIOLOGY
National cancer registryEpidemiological surveillance
MODULE 1MANAGEMENT
Patient
MODULE 2EDUCATION
Oncologist
CareScreeningReferrals
COMPUTERIZED HISTORY
• Clinical• Laboratory• Surgery• Pathology• OM – Tumor Bank• RT – images
Information for timely and effective action
NETWORK OF HEALTH PROVIDERS
COMPUTARIZED SYSTEM
Basic clinical platform(Plataforma básica clínica-PBC)
Oncologist, pathologist, nurse
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PRIORITY PROGRAMS Prevalent health problems
Priority chronic noncommunicable diseases program:
- Cardiovascular health (CHLCV) - Kidney Health
- Diabetes
National Cancer Control Program (Comisión Honoraria de Lucha Contra el Cáncer, CHLCC)
National Smoking Control Program
National Mental Health Program
National Eye Health Program
National Oral Health Program
National STI-AIDS Health Program
National Nutrition Program
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INTERSECTORAL AND INTERGOVERNMENTAL COORDINATION MECHANISMS
Social cabinet: Ministry of Economy and Finance (MEF); Ministry of Development (MIDES); Ministry of Housing, Land management and Environment (MVOTMA), Ministry of Public Health (MSP), Ministry of Education and Culture (MEC), Ministry of Tourism and Sports (MTD), Ministry of Labor and Social Security (MTSS).
National Council for Social Policy Coordination
Committee for the Strategic Coordination of Child and Adolescent Policy
National and Departmental Emergency Committees
National Drug Board
National Road Safety Unit
Health-promoting schools
Productive and healthy communities
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NATIONAL CONTINGENCY PLANS
National Contingency Plan for an Influenza Pandemic
National Contingency Plan for a Dengue Epidemic
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The budget allocated for ASSE increased from US$ 185 million in 2004 to US$ 550 million in 2009.
Wages paid by ASSE have increased from NUr$ 2,370 million in 2004 to NUr$ 6,500 million in 2009, or 160%.
ASSE’s expenditure per user has increased from NUr$ 280/month/user in 2004 to NUr$ 820/month/user in 2009.
INCREASED BUDGET FOR THE COMPREHENSIVE STATE PROVIDER (ASSE)
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The long-forgotten Uruguayan primary care health system doubled its budget, and the salaries allocated to this level area more than doubled.
This has made it possible to strengthen the Montevideo primary care network and create a network in the country’s interior, using government funds, complementary agreements with the private sector, and complementary arrangements with municipalities to serve locales never before served.
ASSE investment totaled US$ 2 million in 2005, but grew by a factor of 25 by 2009. Although insufficient, this growth represents an enormous rise in the amount that the organization devotes to investment.
INCREASE IN ASSE BUDGET
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Minimum physician’s wage increased five-fold.
Wage improvements also include payments based on performance and on working the mandated hours
2 million workers have been added to the nursing staff, principally at the primary care level and in the country’s interior.
ASSE HUMAN RESOURCES POLICY
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Starting point: no such action in any form.
The current government has launched numerous initiatives in this respect:
A decree in March 2005 created the Advisory Committee for Change in health care. The Committee regularly invites all sectors involved (unions, businesses, professional schools, public sector, etc.) to discuss issues linked with the reform.
PROMOTION OF SOCIAL PARTICIPATION AND MANAGEMENT OVERSIGHT TO ENSURE QUALITY OF
HEALTH CARE
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Wage councils were reinstituted and are called on not only to negotiate wages, but working conditions as well and to develop the information needed for this.
Law 18131, which created FONASA, provides for a commission to monitor the fund, with the participation of workers and employers.
Law 18161 created ASSE as a decentralized entity whose board of directors includes a workers’ representative and a users’ representative.
Law 18211 created the National Health Board as the administrative organ of the National Health Insurance system. It includes a users’ representative, a workers’ representative, and a person representing health sector firms.
Under this law, each provider that wishes to join the SNIS must have a consultative and advisory body consisting not only of the firm, but of representatives of its workers and users.
PROMOTION OF SOCIAL PARTICIPATION AND MANAGEMENT OVERSIGHT TO ENSURE QUALITY OF
HEALTH CARE
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Impact of the three reforms on poverty and extreme poverty
ALL THREE REFORMS
TAX REFORM
HEALTH REFORM
EQUITY PLAN
Extreme Poverty Poverty
Before After Change Before After Change
Improvement
Scenario 1 – individual income tax (IRPF)
Improvement
Improvement
Source: Office of Planning and Budget (OPP), 2007.
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Citizen opinions of health system reform
Source: Author, based on Public Opinion Monitor.Equipos MORI report to the President of the Republic.
Fair
Poor
Very Poor Don’t know/Not familiar
Very Good
Good
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Opinions on health reform, Dec. 2007-Feb. 2009
December 2007 February 2008 April 2008 June 2008 February 2009
Source: Author, based on Public Opinion Monitor.Equipos MORI report to the President of the Republic.
Good/Very good Fair Poor/Very poor DK/NF