health system reform in federations: current situation and perspectives
DESCRIPTION
HEALTH POLICY AND FEDERALISM. HEALTH SYSTEM REFORM IN FEDERATIONS: CURRENT SITUATION AND PERSPECTIVES. Forum of Federations / Forum des fédérations www.forumfed.org [email protected]. THE MEXICAN EXPERIENCE. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO. DR. EDUARDO VELASCO - PowerPoint PPT PresentationTRANSCRIPT
HEALTH SYSTEM REFORM IN FEDERATIONS: CURRENT SITUATION
AND PERSPECTIVES
THE MEXICAN EXPERIENCE
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
DR. EDUARDO VELASCO
DR. ARMANDO ARREDONDO
HEALTH POLICY AND FEDERALISM
Presentado ante el Foro de Federaciones en Sao Paulo, Brasil, 15 de octubre de 2001
Forum of Federations / Forum des fédérations www.forumfed.org [email protected]
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE
Diagram 2
Insured and uninsured population by income level
Insured UninsuredP
riva
te I
nsur
ence
Soc
ial S
ecur
ity
IMS
S &
IS
SS
TE
Min
istr
y of
hea
lth
IMS
S S
olid
arid
ad
No
acc
ess
to h
ealt
h se
rvic
es
47 26 9 10
High income Low income
Populationin millions
Institutions
Coverage
Source: Ministry of Health, 1995
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISM
Variable SSA IMSS-ISSSTE PRIVATE INST.
Funding type
Funding source
% total health expenditures
Population coverage
Basic principle
Decentralization
Invest in promotion
in preventive care
in curative care
in rehabilitation
in research
Unipartite
Federal & state govt.
15%
40%
Citizenship & poverty
Yes (1985)
High
High
Medium
Low
Medium
Tripartite
Federal govt. , eployrs & workers
43%
50%
Corporative
Yes (1995, 1999)
Medium
Medium
High
Medium
Low
Unipartite
Users
42%
10%
Purchasing power
No
Very low
Low
Medium
Very low
Very low
THE MEXICAN EXPERIENCE
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE
Reform of the social security through pension reform to generate internal savings in the long run.
Financial restructuring to avoid bankruptcy of the social security system, including its health component.
Health reform formulation, legislation, and implementation is led by structural adjustment policies, through technocrats empowered to bring about policy change.
Efforts at reforming the IMSS health care provision have included decentralization and financial deconcentration to the local level.
Efforts to establish separation of the financing and provision functions.
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE
1) Deconcentration to shift power from the central offices to peripheral offices
2) Delegation
3) Devolution shifts responsibility and authority from the central offices of the Ministry of Health to separate administrative structures still within the public administration
4) Privatization. Prospective payment health insurance with private providers; reversion of fees to companies who purchase health services elsewhere.
The center retains policy making and monitoring roles and the periphery takes operational responsibility for administration.
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE
DECENTRALIZATION COMPONENTS:
-Competitional. Devolution to the states, of the direction, coordination, and operational implementation of medical care, public health, and sanitary control of concurrent general health services.
-Administrative. Creation of a structure to operate State Health Services.
-Patrimonial. The federal infrastructure was transferred at no cost to State Health Services.
-Occupational. Workers were protected under the labor and social security scheme and the employers’ individual faculties were delegated.
-Financial. A co-financing system was set up with federal and state contributions.
-Logistic. A mechanism was established to provide technical and logistic support required by decentralized services for their culmination and better development.
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE
link health to economic and social development
reduce health system gaps that affect the poor.
deal with emerging problems by establishing priorities
launch a national crusade for improving the quality of services
build a new cooperative federalist health system
strengthen the leading role of Secretaria de Salud ( SSA)
advance towards an Integrated Healthcare Model
strengthen investments in human resources, research, and infrastructure.
promote community participation in health and the free choice of medical care provider.
provide financial protection against catastrophic expenditures.
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE
IMSS
Financial restructuring
Deconcentration and rationalization of the IMSS
Institutional model for comprehensive health services (MIAIS)
Medical areas for deconcentrated management (AMGD)
Family health insurance (SSF)
Family doctor eligibility and performance incentives in family health care centers
Performance incentives
Costing according to diagnosis-related groups (DRGs)
Contracting-out of health servicesSSA
Extended Coverage Program (PAC)
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE
Health PoliciesHealth Care
Reforms
Entrepreneurs
Federal Government
SSA
President
IMSS
PRI
PAN
PRD
State governments
States with high incomes
States with middle and low
incomes
Insured Population
Uninsured Population
Communication media
Health Institution Unions
Other Unions
Civil society: low incomes
Civil sociaty:
high and middle incomes
HIGH INFLUENCE on health policies
MEDIUM INFLUENCEon health policies
LOW INFLUENCEon health policies
Health Researchers
GUIDING FORCE: DEMOCRATIZATION
LEADING PRINCIPLE: CITIZENSHIP
VALUES: • JUSTICE• LIBERTY• REPRESENTATION OF CITIZENS’ INTERESTS• SOCIAL PARTICIPATION• ACCOUNTABILITY
HEALTH REFORM STRATEGIES
HEALTH POLICY AND FEDERALISM
1. SUBSTANTIVE STRATEGIES
a) Linking health to economic developmentb) Decrease backlogs of disease and healthcarec) Respond to emerging problemsd) Crusade for qualitye) Financial protection
2. INSTRUMENTAL STRATEGIES
a) Federalizationb) Regulation (steering, stewardship)c) Universal Health Systemd) Freedom to choose provider and citizens
participatione) Advancement of knowledge
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
1. SUBSTANTIVE STRATEGIES
Linking health to development
- Healthy policies- Intersectoral cooperation- Healthy communities- Women and health- Healthy fiscal policies (15% tax to medications)
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
1. SUBSTANTIVE STRATEGIES
Decreasing backlogs of disease
- Improving the package of basic interventions- Cost-effectiveness- Modernization of biotechnology, informatics and telecommunications- 100 essential medications for all
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
1. SUBSTANTIVE STRATEGIES
Responding to emerging problems
- cost-effective interventions for emerging or priority problems such as injuries, tobacco smoking, substance abuse, depression, diabetes, high blood pressure, obesity.
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
1. SUBSTANTIVE STRATEGIES
Crusade for quality
- Ethics codes- Patients’ rights- Ethics education and information- Performance appraisal of personnel- Standardized processes and monitoring outcomes- Certification of health personnel- Rationalization of regulatory structures
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
1. SUBSTANTIVE STRATEGIES
Financial Protection
- Improve financial equity and justice- Decrease catastrophic expenditure in
70-80%- Strengthen preventive care- Liberate resources for productive use- Incentives for formal work/employment- Six-year cumulative cost: 1.2% of GNP
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
• INSTRUMENTAL STRATEGIES
Federalization
- Complete decentralization- Explicit formulation of resource allocation to states- Interstate cooperation
-in public health services- in high specialty areas and
services
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
• INSTRUMENTAL STRATEGIES
Stewardship
- Liaisons:• intersectoral (Consejo de Salud
General)• sectoral (Comisión Federal de
Políticas de Salud• territorial (Consejo Nacional de
Salud)• Through popular representatives
(through Oficina de Vinculación del Congreso de la Unión and citizen groups)
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
• INSTRUMENTAL STRATEGIES
Universal Health System
- Gradual elimination of population selective access to health care services- Interinstitutional master plans for high technology investments- Compensation fund among federal and state institutions
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
• INSTRUMENTAL STRATEGIES
Freedom to choose health provider and citizens’ participation
- Free choice of healthcare provider- Free choice of family physician- Citizen health committees at all levels of health care
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES
• INSTRUMENTAL STRATEGIES
Strengthening knowledge
- Promotion of mission-oriented research
- Information system for decision making
- Human resource development
HEALTH POLICY AND FEDERALISM
HEALTH REFORM STRATEGIES