REGIONAL MEETING Integrated Health Services Networks andVertical Programs: Maximizing Synergies for Collaborative WorkURUGUAY: Coordinating national health systems and priority programs Cuzco - PeruNovember 2009 Dr. Miguel Fernández Galeano Vice Minister of Public Health URUGUAY
NEW PARADIGMHealth as anessential 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
SOCIAL REFORM COMMON CRITERIA Universal access • User contributions scaled to income, andbenefits received according to need • Budget increase to supplement development resources from social policy • Priority to households with greatest number of under-18 members
SOCIAL POLICY: CONCEPTUAL CATEGORIES 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.
Key elements of health system reform • 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).
THE REFORM STRATEGY Change in care model IntegratedNational Health System Change in management model NationalHealth Fund Change in funding model
National Health Fund Contributions of the State Households Firms Per capita payment as a function of age, sex and service goals Payment as a function of income and family coverage USERS INSTITUTIONS Integrated with national public health system and private nonprofit system FREE CHOICE COMPREHENSIVE CARE Composition of National Health Fund(FONASA)
SOCIAL JUSTICE IN THE DISTRIBUTION OF EXPENDITURE Starting point Expenditure 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
ACCESS OF POPULATION TO HEALTH SYSTEM WITHCOMPREHENSIVE PROGRAMMED COVERAGE Guaranteed access to a comprehensive provider within the SNIS for the entirepopulation. 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.
Expansion of comprehensive care ASSE IAMC Private insurance Military and Policy Health Dec. 2007 Dec. 2008
ADVANCES IN COVERAGE THROUGH FONASA 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.
GREATER ACCESSFOR THE POPULATION 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.
STEERING FUNCTIONS and new institutional tools CONDUCT/LEAD GUARANTEE OF INSURANCE Policy Strategy Goals Participation and Consensus Intersectoral advocacy Implementation of comprehensive care plans Evaluation of sufficiency and quality of services REGULATION ORIENTATION OF FINANCING Qualification, accreditation, certification and monitoring of professionals, services, technology, and supplies Banco de Previsión Social (BPS) functions as FONASA administrative entity. ESSENTIAL PUBLIC HEALTH FUNCTIONS HARMONIZATION OF SERVICES DELIVERY Epidemiological surveillance Promotion/participation Human resources development Evaluation of quality of services Integrated system Levels of complexity Complementarity Referrals/counterreferrals
ESSENTIAL PUBLIC HEALTH FUNCTIONS(2002) Measurement Results EPHF 5 EPHF 8 EPHF 9 EPHF 11 EPHF 6 EPHF 7 EPHF 10 EPHF 1 EPHF 2 EPHF 3 EPHF 4 Essential Public Health Functions
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.
IMPROVED LEADERSHIP • National Health Board created. The Board will signservicecontracts 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 currentdecree 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 specialpayment 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 has150 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.
STRENGTHENING PRIMARY CAREAND CREATING COMPLEMENTARITY BETWEEN THE PUBLIC SECTOR AND THE NONPROFIT PRIVATE SECTOR . 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).
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
NATIONAL WOMEN’S HEALTH AND GENDER PROGRAM GENDER VIOLENCE CANCER IN WOMEN MEN’S CONDITION National Women’s Health and Gender Program SEXUAL AND REPRODUCTIVE HEALTH MENTAL HEALTH AND GENDER ADVISORY SERVICES, RESEARCH AND MANAGEMENT
NATIONAL CANCER CONTROL PROGRAM NATIONAL ONCOLOGICAL NETWORK (RED ONCOLÓGICA NACIONAL - RON) Ministry of Public Health – CHLCC NETWORK OF HEALTH PROVIDERS COMPUTARIZED SYSTEM MODULE 3 EPIDEMIOLOGY National cancer registry Epidemiological surveillance Care Screening Referrals MODULE 1 MANAGEMENT Patient • COMPUTERIZED HISTORY • Clinical • Laboratory • Surgery • Pathology • OM – Tumor Bank • RT – images MODULE 2 EDUCATION Oncologist Basic clinical platform (Plataforma básica clínica-PBC) Oncologist, pathologist, nurse Information for timely and effective action
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
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
NATIONALCONTINGENCY PLANS • National Contingency Plan for an Influenza Pandemic • National Contingency Plan for a Dengue Epidemic
INCREASED BUDGETFOR THE COMPREHENSIVE STATE PROVIDER (ASSE) • 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.
INCREASE IN ASSEBUDGET • 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.
ASSE HUMAN RESOURCES POLICY • 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.
PROMOTION OF SOCIAL PARTICIPATION ANDMANAGEMENT OVERSIGHT TO ENSURE QUALITY OF HEALTH CARE Starting point: no such action in any form. The current government has launched numerous initiatives in this respect: • A decree in March 2005 created theAdvisory 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 ANDMANAGEMENT OVERSIGHT TO ENSURE QUALITY OF HEALTH CARE • 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 acommission 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 theNational 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.
Impact of the three reforms on poverty and extreme poverty Poverty Extreme Poverty Before After Change Before After Change ALL THREE REFORMS Improvement TAX REFORM Scenario 1 – individual income tax (IRPF) HEALTH REFORM Improvement EQUITY PLAN Improvement Source: Office of Planning and Budget (OPP), 2007.
Citizen opinions of health system reform Very Poor Don’t know/ Not familiar Very Good Poor Fair Good Source: Author, based on Public Opinion Monitor. Equipos MORI report to the President of the Republic.
Opinions on health reform,Dec. 2007-Feb. 2009 December 2007 February 2008 April 2008 June 2008 February 2009 Good/Very good Poor/Very poor Fair DK/NF Source:Author, based on Public Opinion Monitor. Equipos MORI report to the President of the Republic.
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