HEALTH%20SYSTEM%20REFORM%20IN%20FEDERATIONS:%20CURRENT%20SITUATION%20AND%20PERSPECTIVES

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HEALTH POLICY AND FEDERALISM
HEALTH SYSTEM REFORM IN FEDERATIONS CURRENT
SITUATION AND PERSPECTIVES
Forum of Federations / Forum des fédérations ?
www.forumfed.org ? forum_at_forumfed.org
THE MEXICAN EXPERIENCE
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
DR. EDUARDO VELASCO DR. ARMANDO ARREDONDO
Presentado ante el Foro de Federaciones en Sao
Paulo, Brasil, 15 de octubre de 2001
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THE MEXICAN EXPERIENCE
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
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THE MEXICAN EXPERIENCE
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
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
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THE 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
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THE MEXICAN EXPERIENCE

• Deconcentration to shift power from the central
  offices to peripheral offices
• Delegation
• Devolution shifts responsibility and authority
  from the central offices of the Ministry of
  Health to separate administrative structures
  still within the public administration
• 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
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THE 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.  -Administr
ative. 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
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THE 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
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THE 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 services
• SSA
• Extended Coverage Program (PAC)

INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
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THE MEXICAN EXPERIENCE
Communication media
Civil society low incomes
Civil sociaty high and middle incomes
States with high incomes
Insured Population
Entrepreneurs
PRD
Health Policies Health Care Reforms
Uninsured Population
Health Researchers
IMSS
SSA
Federal Government
President
States with middle and low incomes
State governments
PAN
PRI
Health Institution Unions
Other Unions
HIGH INFLUENCE on health policies
MEDIUM INFLUENCE on health policies
LOW INFLUENCE on health policies
INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO
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HEALTH REFORM STRATEGIES

• GUIDING FORCE DEMOCRATIZATION
• LEADING PRINCIPLE CITIZENSHIP
• VALUES
• JUSTICE
• LIBERTY
• REPRESENTATION OF CITIZENS INTERESTS
• SOCIAL PARTICIPATION
• ACCOUNTABILITY

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HEALTH REFORM STRATEGIES

• SUBSTANTIVE STRATEGIES
• Linking health to economic development
• Decrease backlogs of disease and healthcare
• Respond to emerging problems
• Crusade for quality
• Financial protection
• INSTRUMENTAL STRATEGIES
• Federalization
• Regulation (steering, stewardship)
• Universal Health System
• Freedom to choose provider and citizens
  participation
• Advancement of knowledge

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HEALTH REFORM STRATEGIES

• SUBSTANTIVE STRATEGIES
• Linking health to development
• - Healthy policies
• - Intersectoral cooperation
• - Healthy communities
• - Women and health
• - Healthy fiscal policies (15 tax to
  medications)

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HEALTH REFORM STRATEGIES

• 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

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HEALTH REFORM STRATEGIES

• 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.

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HEALTH REFORM STRATEGIES

• 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

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HEALTH REFORM STRATEGIES

• 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

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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

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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)

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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

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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

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HEALTH REFORM STRATEGIES

• INSTRUMENTAL STRATEGIES
• Strengthening knowledge
• - Promotion of mission-oriented research
• - Information system for decision making
• - Human resource development