Integration of Programs in the Organization of Systems and Health Services Networks

Regional Consultation Meeting: Integrated Health Services Networks and Vertical ProgramsCusco, Peru, 11-12 November 2009

Gloria Delfim WalkerHealth Services ArchitectSpecialist in Health Care ManagementTechnical Adviser to Directorate of Health Care Networks, DARAS/SAS-MS

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Unified Health System (SUS): The Brazilian Experience 1. Brief Description of the SUS2. Challenges Facing the SUS3. The Integrated Health Networks Concept4. Guidelines for the Implementation of IHNs5. Ongoing Activities

1. BRIEF DESCRIPTION OF THE HEALTH SITUATION AND THE UNIFIED HEALTH SYSTEM (SUS)*

*42.6% in the Southeastern Region27.7% in the Northeastern Region14.6% in the Southern Region 8.0% in the Northern Region 7.1% in the Midwestern RegionDemographic AspectsNational territory: 8.5 million km226 states, 1 Federal District, and 5,564 municipalities, all with political, fiscal, and administrative autonomy and with no hierarchical links between them 184 million inhabitantsSource: IBGERegionsNorthernNorthernNortheastCentral/WesternSouthwestSouthern

*MacroregionsGreat diversityEconomicSocialCulturalEpidemiologicalAMAZON REGIONCENTRAL/SOUTHERNREGIONNORTHEASTREGION

*BRAZILSocial ContextThe challenge: Formulate national policies that allow for marked regional differencesHDI over 0.801HDI between 0.751 and 0.800HDI between 0.701 and 0.750HDI between 0.651 and 0.700HDI under 0.650Source: UNDP, 2000

*FEDERAL CONSTITUTION - LAW CREATING THE SUSArticle 196: Health is a right of all and a duty of the State and shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other threats and at the universal, equal access to actions and services for its promotion, protection and recovery.

Article 198: Health actions and public services make up a regionalized hierarchical network and constitute a single system, organized according to the principles of decentralization, regionalization, comprehensive care, and community participation.

Law 8,080 (Art. 2, par. 3): Health determinants include food, basic sanitation, environment, work, income, education, transportation, leisure, and access to goods and social services; a populations level of health is a reflection of the social and economic organization of the country. INTERSECTORAL APPROACH

*Health as a right of all and a duty of the StateDecentralization with independent management in each sphere of government: municipal, state, and federal Organization of health services based on universal care, equity in the delivery of services, and comprehensive care Participation of the population in monitoring of the system Responsibility for financing the system shared among the three levels of governmentTechnical and Political Pillarsof Brazilian Health Sector Reform

*Brazilian Health SystemUnified Health System (SUS): public, free, universal access

Supplementary Health System: private, benefi-ciaries subscribe to private health plans and insuranceDirect pay: access through direct payment from beneficiary to providerHealth expenditureas % of GDP:

7.4% (total)3.6% (public)

SOURCE: MS-SPO - MS-SIOPS - STUDIES QA. Year of Reference: 2007

Integration of Health Careand SUS Services*Law 8080/90 Article 7, paragraph II: (...) comprehensive health care, defined as a continuous articulated set of individual and collective actions and preventive and curative services (...)

Article 10 refers to organizational arrangements for local and regional networks operating through intermunicipal consortia and health districts to integrate and articulate resources and increase the coverage of actions.

National Programs1.National Program for Reproductive Health2.National Program for Health Promotion in Children and Youth 3. National Program for Oral Health Promotion4. National Program for Health in Schools5. National Program for Peoples Health6.National Program for Prevention of HIV/AIDS Infection and other Sexually Transmitted Diseases 7. National Vaccination Program8. National Program for Polio Eradication: Post-Elimination Phase9.National Program for Measles Elimination and Prevention of Congenital Rubella10.National Program to Combat Tuberculosis11.Integrated National Program for Clinical and Laboratory Surveillance of Flu - Information about the disease12.National Program for Prevention of Antimicrobial Drug Resistance13.National Program for Prevention of Hospital Infections 14.National Program for Prevention and Control of Oncological Diseases 15. National Program for Prevention and Control of Cardiovascular Disease 16. National Program for Control of Asthma17.National Program for the Prevention and Control of Chronic Obstructive Pulmonary Disease18.National Program for Control of Diabetes19. National Program to Combat Obesity20. National Program to Combat Rheumatic Diseases21. National Program for Eye Health22.National Program for Control of Hemoglobinopathies23.National Program to Combat Depression24.National Program on Post-Traumatic Stress Disorder25.National Program for Prevention of Alcohol-Associated Problems26.National Program on Prevention/Consumption of Illegal Drugs27. National Program on Pain Management28. National Program on Palliative Care29. National Program for Accident Prevention30.National Program to Fight Inequalities in Health31. National Program for Integrated Intervention in the Determinants of Health-Lifestyles32.National Program for Environmental Health33.National Program on Food Hygiene and Control34.National Program for Health Promotion and Protection in the Workplace35.National Program for Development of Health Human Resources36. National Program for Information and Knowledge Management37. National Program for Development of Organ Transplantation38.National Program on Accreditation of Hospitals39.National Program on Accreditation of Health Centers40.National Program for Laboratory External Quality Assessment

Critical Reflection20 years later ... Challenges remainMarked fragmentation of care and managementGaps in care and barriers to access Poor-quality services, lack of commitment on the part of health care and teamsTreat em and street em and physician-centered approaches to care (patients not taking a proactive role)Focus on hospital and physician (people going where they know they will be served); User dissatisfactionInsufficient financial resources (rising production costs)

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Facing the Challenge: HEALTH PACT Integration Strategy*PACT FOR LIFEHealth Situation of the Population

PACT TO UPHOLD THE SUSBasic PrinciplesSUS Stakeholders

PACT FOR MANAGEMENTDecentralizationRegionalizationFinancing, Planning, Social Monitoring, Health Education New Format for Intergovernmental Relationships:Coalitions for Regional Management

Integration of ActionsIn Terms of Service contracts of Municipios, States, and Ministry of Health Regional:

Joint Action in the 3 Spheres

Integrated Approach

Recognition of Relationships of Interdependency and CooperationResponsibilities under the PactBasic Principles

Facing the Challenge! (current Government proposal)*Strategy for Strengthening Regionalized Health22 Points from Inaugural AddressPact for LifeNational Health PlanPlurianual PlanStrategic ApproachBETTER HEALTH

Planning: Evidence x Results(rescue of SUS planning)*

Where does integration begin?

Regionalization of Health CareHealth Regions - spaces for sharing actions and health services.... Adequate secondary care and health surveillance actions (prevention, promotion)These can be: Intramunicipal: Joinville-Santa CatarinaIntermunicipal: Piau (Floriano region)Interstate: Juazeiro (Bahia) and Petrolina (Pernambuco)Border area Governance of IHNs ~ 390 coalitions involved in Regional Management *

Strengthening Regional PlanningHealth macroregions bring together two or more Health Regions to organize actions and share among themselves such services in this area as specialized outpatient care, third-level hospital facilities, and health surveillance. The criteria of scale, scope, subsidiarity, and flexibility are important in this process.

Agency responsible for governance:Regional Management Coalition, a co-managing entity in the Regionalized Health Care Network

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National Health Plan (PNS) 2007-2010 General Lines of ActionStep up the strategy calling for regionalization, social participation, and federative relations in keeping with the lines of action approved in the Pact for Health, seeking a decisive improvement in the systematic and organizational efficiency of the health services, revitalizing the role of the Federal Government in organizing regional integrated health networks throughout Brazil. Technical support for states and cities in implementing Integrated Health Care Territories (TEIAS) as the organizational model for health care networks.

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2. CHALLENGES FACING THE SUS*

Challenges x Opportunities for ImprovementDouble burden of disease (triple, if external causes are considered) Weak institutional capacity (managers and technical teams) Underfunding of health (resources for health promotion, increased costs); Poor quality of the health services offered User dissatisfaction (services and access)Minimal use of clinical management tools by the health services (clinical directives, clinical protocols, case management, treatment plan...)Lack of coordination of PHC

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Challenges (2) Demographic Transition*Life expectancy at birth: 72 yearsMORTALITY RATE from chronic diseases: Brazil ~ 600/100,000United Kingdom ~ 300/100,000THE AGING POPULATION6 older adults for every 12 children under 5 years 6 older adults for every 5 children under 5 years

Challenges (3) Production of Health Production of SubjectsRecognition of the interdependence between the need to enlist technology convergence for health production in construction/activation of the intra- and interinstitutional Human Relations Network, on the one hand, and high accountability, connectivity, and friendly, compassionate, complementary care, on the other. Rollo (2007)

Evaluation of SUS professionals: Leaders ManagementTeams*

Challenges (4) Health Management in the Territories

THE GREATEST CHALLENGE: TRANSFORM THE CURRENT HEALTH REGIONS INTO TEIAS!

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*Reorganizing UHS Management Organizing ManagementTEIASIntegrated Health Care TerritoriesOrganizing Management

*Organization of Integrated Health Care Territories

*Organization of Integrated Health Care Territories

*Organization of Integrated Health Care Territories

*Organization of Integrated Health Care Territories

Agenda for Implementing IHNs

*UnitPublic health commitments/ responsibilitiesResources neededAssignment of responsibility (management/goals)GEN.HOSP

Agenda for implementation of IHS*UnitPublic health commitmentsResources neededAssignment of responsibility (unit and manager)

What kind of NETWORKSare we talking about?

3. THE INTEGRATED NETWORKS CONCEPT*

Building a New Care ModelNational Policy on Basic Care (PNAB) (PHC) (Decree 648/GM of 28 March 2006)Focused on care of acute and chronic cases, surveillance, and health promotionPHC as the preferred gateway for the coordination of end-user health care, providing support for the case and following up throughout its course in the system in other words, a longitudinal approach to care over time and appropriate use of the technologies available in the health services networkWith these goals in mind, the best first step: development of a Plan for Strengthening PHC (FAPS)*

Systemic View Health Services Networks (RISS)The networks should be built on the presence of horizontal spaces that connect to form a POLYARCHY in which decisions are made by consensus. They should be capable of generating partnerships based on mutual trust, strengthening the meaning of networks as spaces for complementarity and creativity.The bases for co-management and the elements that hold the network together are: clear definition of common objectives and shared resources coupled with monitoring of outcomes.

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Definition of NetworksHealth Care Networks are organizational arrangements of health units and actions of different technological densities,integrated through diagnostic, logistic, and management support systems, designed to guarantee an integrated approach to care in a given territory/population(....)

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Technical & Political Implications - Promoting Synergies (Feasibility Strategy)Key ISSUE: In terms of resources, this meansCompensating for gaps and deficits in investmentsWorking toward unifying the transfer of per capita resourcesProviding incentives to implement regional management tools to promote health production, as well as logistic and administrative support tools, especiallyOptimizing, integrating, promoting synergies, and making resources already allocated under national SUS structural policies more efficient*

Ministry of Health Integrated Health Care NetworksArticulation with other policies Strengthening the constitutional foundation for the organization of health policy, including the expansion of integration through regionalized health care networks based on a public policy that is inclusive and also promotes citizen participation

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Implementation of the BRAZIL IHS/Ministry of Health ProgramSecretariat of Health Care:1. Department of Basic Care2. Department of Specialized Care 3. Department of Strategic Programming Actions4. Department of Regulation, Appraisal, and System Monitoring 5. Department of Hospital Management for the State of Rio de Janeiro 6. National Cancer Institute 7. National Institute of Cardiology8. National Institute of Traumatology and Orthopedics Article 14. The Secretariat of Health Care is responsible for: I Participating in the formulation and implementation of health care policy based on UHS principles and guidelines II Defining and coordinating integrated health actions and services networks; (DARAS, established in 05/2007)III - Establishing standards, criteria, parameters, and methods for monitoring quality and evaluating health care (...)*

DARAS: Directorate of Health Care NetworksGoal: Provide technical assistance to states and municipalities to build integrated health care networksInternal articulation through groups supporting Proposed Networks (UF) as well as experts in regionalization (SE), specialized care (SAS), urgent and emergency care (SAS), regulation and Information processing and retrieval (SE), participatory management (SGEP), health surveillance, promotion, and disease prevention (SVS), National Health Fund (SE), management of health education and the health professions (SGTES), among other areas; External articulation, once the project is formalized, establishment of collegiate management (via decree) for the Project through government agencies (CONASS, CONASEMS at the national level and COSEMS, CES, CMS, IES (institutions of higher education), providers (those operating under agreements, philanthropic, private, Ministries of Justice, Education, Agriculture, Armed Forces...)Development of educational strategies for training local and regional facilitators in the process of building health care networks

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4. GUIDELINES FOR THE IMPLEMENTATION OF IHNs*

FUNDAMENTAL ISSUESStarting point for building health systems in a given regional space (identifying health needs)Health care focused on the individual, family, and communityDefinition of a set of actions and services (public health services map) to be provided to a given population through health care delivery sites or functional units of different technological densitiesBroad application of the directive that the primary care level is the gateway to the system of integrated and coordinated care, which has to capacity to meet most of the health needs of the population*

FUNDAMENTAL ISSUESOrganization of care based on criteria of scale and scopeDevelopment of tools for clinical and managerial coordination Institutional integration through commitments to outcomesEfficiency and transparency in management of resourcesIntegrated structures for the provision of health actions and services with institutionalization through public policiesCollective and planned construction processEmphasis on the interdependencies between the stakeholders involved

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FUNDAMENTAL ISSUESSupport for rapid, unified geoinformation systems, as well as logistic, diagnostic, therapeutic support, and management systemsAccountability for costs and health outcomes in the subscriber populationFocus on continuity and quality of care through coordination and gains in effectivenessUnique participatory system of governance with broad intersectoral actionAdequate financing and financial incentives in alignment with system goals

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Expanded Integration of HealthProduction: A New Paradigm1. Needs-based organization of health services and actions, in tandem with implementation of a policy on Health Promotion and Monitoring 2. Implementation of SUS structural policies (PNAB, U/E, Mental Health, Workers Health, STD/AIDS...) and Clinical Guidelines (Pregnant Women and Newborns, Systemic Hypertension, Mental Disorders, Cancers of the Breast and Colon, Tuberculosis, Hansens Disease, etc. ) starting with PHC and taking into account the epidemiological profile of the region

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Integration of Care

3. Building the Regional Health Monitoring Nucleus (clinical support and collective health)Expansion of the clinical and collective effectiveness of the health team either through the direct action of other professionals or through the integration of basic care with environmental, public health, and epidemiological monitoring in the territory Directives on Care Delivery, Care Protocols, Pathology Management, and Case Management Peer review, discussion of cases Collective Health Projects based on Sentinel Events and tracers *

Integration of Care*4. Implementation of devices and tools for Clinical Management (Directives on Care, Individual Treatment Plan (ITP), Case Management ...) and the National National Humanization Policy (shelter, support for mothers ...) 5. Implementation of Family Health Support Nuclei (NASF)

Integrated Health Care Territories (TEIAS)Objective of the strategy: stimulate the initiative to turn the current Health Regions, which today are fragmented, into Integrated Health Care Territories, or TEIAS an acronym that spells the word for webs in Portuguese

With the awareness that it will be a gradual and complex process that will require constant input of knowledge and resources Rollo (2009)*

5. ONGOING ACTIVITIES*

*Issues under DiscussionHow to expand the PHC-level investment to strengthen its role as coordinator of care and of the implementation of TEIAS How to implement Lines of Care (Pact for Life) and the Policy on Regulation: ensure new contractual agreements, reduce fragmentation, guarantee connectivity, manage the waiting list

How to restructure Diagnostic Support Services and Specialized and Hospital Care while taking into account: Access,Regionalization, Trends in Density, Responsibility for Resolving Problems, Continuity of Care, Economies of Scale, Scope, and Quality of Care

How to implement actions under the Health Promotion Policy while at the same time focusing on the social determinants of health in the regions, acting both intersectorally and comprehensively with respect to other public policies

Issues under Discussion

How to improve logistical support for the networks: identification card, electronic messaging, patient transportation, maintenance, supplies

How to strengthen the governance of IHNs (Regional Coalition Managers - CGRs) with a view to improving their performance with such network management tools and strategies as: Review of Master Regionalization PlansPreparation of Regional Health Plans Investment Master PlansIntegrated Pact related ProgrammingContracts for Management and Setting TargetsMonitoring and Evaluation

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Issues under Discussion

How to implement the provisions of the National Humanization Policy (PNH) in terms of:Reception, including risk classification, clinical management, safety of patients and health production environments

How to operationalize the start of the Investment Project for SUS Qualification QualiSUS-NETWORKS: Lending Agreement with the World Bank, which will support 15/27 states in the organization of integrated health care networks in Brazil

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In short:Instead of priority programs > structural policiesInstead of basic, intermediate, and high-complexity levels of care > primary, secondary, and tertiary levels of careInstead of physician-centered and/or hospital-centered care > care centered on the individual, the family, and the community; delivery of quality services; and resolution of problems at all points along the chain of services in the network in response to the demands of system users

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and...Instead of users trying to figure out where they should go > first contact and longitudinality ensured through primary care, with links to professionals and teams responsible for the caseInstead of fragile, non-functioning local health systems >local health systems gradually improving their managerial capacity, with trained human capital, with technology appropriate for the types of situations they are expected to respond to, with financial resources ensured, and with their Health Plans implemented efficiently and effectivelyAnd finally:Instead of producing networks of services (ARS) > produce health, with the actors empowered to ensure user satisfaction and even sustainability of the SUS

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Thank you! Gracias!Our Contacts: Ministry of Health - BrazilSecretariat of Health Care - SASSecretary: Dr. Alberto BeltrameDIRECTORATE OF HEALTH CARE NETWORKS (DARAS) daras@saude.gov.brDirector of the Program: Adail de Almeida Rolloadail.almeida@saude.gov.brGeneral Coordinator: Gloria Delfim Walkergloria.walker@saude.gov.br55-61-3315 3196/ 3315 3969

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22 Points from Inaugural Address

Better Health

Legend[green square]ESF - Family Health Team ESB - Oral Health Team[complex icon] USF - Family Health UnitTerritories of approximately 100,000 inhabitants

Legend[mouth] CEO - Dental Specialties Center[brown square] APOIO [presumably this is an acronym] [blue cone] NASF - Family Health and Support Nucleus[gold pentagon] CAPS - Psycho-Social Support Center[Brazilian flag] Pharmacy[complex icon] UPA - Urgent Care Unit[red cross bag] Hospital

Territories of approximately 100,000 inhabitants