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Dr. Daniel Lopez-Acuna.Director.Division of Health Systems and Services Development

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MAJOR TRENDS INHEALTH SECTOR REFORM IN LATIN AMERICA AND THE CARIBBEAN Dr. Daniel Lopez-Acuna.Director.Division of Health Systems and Services Development – PowerPoint PPT presentation

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Title: Dr. Daniel Lopez-Acuna.Director.Division of Health Systems and Services Development


1
Dr. Daniel Lopez-Acuna.Director.Division of
Health Systems and Services Development
MAJOR TRENDS INHEALTH SECTOR REFORM IN
LATIN AMERICA AND THE CARIBBEAN
  • Pan American Health Organization
  • Regional Office for the Americas of the World
    Health Organization

2
HEALTH SECTOR REFORM
3
By the mid-1990s, virtually every Latin American
and Caribbean country had either embarked upon
health sector reform or was considering doing so.
4
THE NATURE OF HEALTH SECTOR REFORM
  • Agenda for change in the organization and
    financing of the health sector operations and
    its institutional set up
  • Country specific (no magic bullet, no
    prescription)
  • Window of opportunity for health sector
    development
  • Axis of health systems development efforts

5
WHY HEALTH SECTOR REFORM IN THE REGION?
  • Opportunities exist to improve health status
  • Changing demographic and epidemiological patterns
    and evolution of technology make necessary to
    reorient health care delivery models
  • Inequitable access to basic health services
  • Segmentation of the health care system
  • Inefficient allocation of scarce resources
  • Health Sector insufficiently financed in some
    countries
  • Lack of financial sustainability of sectoral
    operations

6
THE CONTEXT OF HEALTH SECTOR REFORM IN THE REGION
OF THE AMERICAS
  • Macroeconomic reorganization
  • Redefinition of the role of the State
  • Democratization and evolution towards more
    pluralistic societies
  • Governance hindered by lack of sufficient
    improvements in social development
  • Reorientation of Public Expenditure
  • Modernization of public management

7
MAJOR COMPONENTS OF HEALTH SECTOR REFORM PROCESSES
  • Strengthening the leadership and regulatory roles
    of health authorities
  • Extend coverage of health services
  • Target disadvantaged population groups
  • Redefine health care delivery models
  • Decentralization
  • Separation of functions of the health system
    (financing, insurance and services provision)

8
MAJOR COMPONENTS OF HEALTH SECTOR REFORM PROCESSES
  • Introduction of new forms of payment to health
    care providers
  • Diversification in number and nature of public
    and private health care providers
  • Redefinition of the benefits package of both
    social (public) and private insurance schemes
  • Rationalization of health expenditure
  • New modalities of health care financing

9
FRAMEWORK FOR MONITORING AND EVALUATION OF HEALTH
SECTOR REFORMS
10
THE MANDATE
  • Item 17 of the Plan of Action of the First Summit
    of the Americas of Heads of State and Government
    (Miami 1994) called for
  • advancing health sector reform efforts for
    attaining equitable access to basic health
    services, and
  • monitoring progress of health sector reforms in
    the countries of the Hemisphere asking PAHO/WHO
    to coordinate efforts to that end.

11
BACKGROUND
  • Special meeting on Health Sector Reform held in
    September 1995 in Washington D.C. as part of the
    Directing Council of PAHO/WHO jointly sponsored
    with IDB, World Bank, USAID, OAS, ECLAC, UNICEF,
    UNFPA and Health Canada

12
GUIDING PRINCIPLES OF HEALTH SECTOR REFORM
Equity
Social Participation
Effectiveness and Quality
Categories
Efficiency
Sustainability
13
HEALTH SECTOR REFORM ANALYSES
14
LAC HEALTH SECTOR REFORM INITIATIVE
  • Joint USAID and PAHO undertaking of 10.2 million
    dollars over a period of 5 years for developing
    regional support mechanisms to Health Sector
    Reform processes in the countries of the
    Americas.
  • Partnership of PAHO, PHR, DDM and FPMD for
    executing the activities of the initiative

15
(No Transcript)
16
MEASURIG REFORM PROGRESS
  • Monitoring of the processes
  • a) Dynamics
  • b) Contents
  • Evaluation of results

17
MEASURING REFORM PROGRESS
  • Dynamics
  • 1. Design
  • 2. Negotiation
  • 3. Implementation
  • 4. Evaluation

18
MEASURING REFORM PROGRESS
  • Contents
  • 1. Legal framework
  • 2. Right to health (insurance mechanisms)
  • 3. Steering Role
  • 4. Separation of functions
  • 5. Redefinition of roles and decentralization
  • 6. Social participation and control

19
MEASURING REFORM PROGRESS
  • Contents (continued)
  • 7. Finance and expenditure
  • 8. Services delivery
  • 9. Vulnerable groups
  • 10. Health care models
  • 11. Management models
  • 12. Human resources
  • 13. Quality of care

20
DIFFERENCES IN THE DEGREE OF DECENTRALIZATION OF
THE VARIOUS FUNCTIONS OF THE HEALTH SYSTEM
SYSTEMS FUNCTIONS
LEVELS OF GOVERNMENT
Health Authority
Financing
Insurance and Purchasing
Public Health Services
Personal Care Delivery
Central Governments
Intermediate Governments
Local Governments
21
MEASURING REFORM PROGRESS
  • Evaluation of results
  • 1. Equity
  • 2. Quality
  • 3. Efficiency
  • 4. Financial sustainability
  • 5. Social participation

22
Preliminary assessment of the impact of Health
Sector Reforms
  • Equity Only a few health sector reforms seem to
    be contributing to the reduction of gaps in the
    coverage of some basic services and programs. In
    most countries they are not contributing to the
    reduction of gaps in the distribution of
    resources.

23
Preliminary assessment of the impact of Health
Sector Reforms
  • Effectiveness and quality Relatively little
    progress has been attained in improving the
    global effectiveness of the system, or in
    improving adherence to normative aspects of
    quality of care or user satisfaction with
    quality. This may be a critical element of the
    second generation of reforms in coming years.

24
Preliminary assessment of the impact of Health
Sector Reforms
  • Efficiency Analysis suggests that there have
    been greater gains in productivity and
    development of purchasing practices than in
    reorienting resource allocation. For example,
    there have been no major shifts of resources in
    terms of channeling of resources to address
    problems with high externalities, or to
    increasing the degree of social protection in
    health.

25
Preliminary assessment of the impact of Health
Sector Reforms
  • Sustainability There is an attempt to adjust
    expenditures to the revenues of the system, but
    very few countries are improving the medium or
    long term horizons of resource generation for
    expanding or sustaining the current level of
    service provision. This situation is aggravated
    by the high dependency observed in many countries
    on external financing, and the lack of mechanisms
    for substituting these flows of resources when
    they cease.

26
Shortcomings of the reform processes
  • Driving motivations of reform have been centered
    on economic factors.
  • Equity considerations and public health concerns
    have been relegated to a secondary level.
  • Quality of care and redefinition of health care
    delivery models have been marginal.

27
Towards a New Generation of Health Sector
Reforms
28
Key Issues
  • Strengthening the Steering Role of Health
    Authorities specially the discharge of the
    Essential Public Health Functions.
  • Extension of social protection in health.
  • Reorienting health systems and services with
    health promotion criteria for increasing the
    effectiveness of health interventions, promoting
    quality of care and improving public health
    practice.

29
EXTENSION OF SOCIAL PROTECTION IN HEALTH
30
THE CHALLENGE
  • Magnitude of the problem
  • Total population 475 million
  • 25 of the population lack permanent access to
    basic health services
  • 120 million people are in this situation at the
    end of the Century
  • Some figures of importance
  • Average per capita G.N.P. for LAC 3289
    U.S.
  • Average National Health Expenditure as of
    G.N.P. 7.3
  • Average per capita N.H.E. 240 U.S.

31
Poverty in Latin America, 1970-95 (Number of
persons, in millions)
160 150 140 130 120 110 100 90 80
60 55 50 45 40 35 30 25 20
Percent of population
1970 1975 1980 1985 1990 1995
Proportion of poor
Number of poor
Source IDB, Latin America after a decade of
reforms, Londoño and Székely (1997).
32
Urban versus Rural Poverty
Millions of poor
Rural
Urban
Source ECLAC, Panorama Social 1997.
33
Inequality in Latin America, 1970-95 (Gini
coefficient)
57 56 55 54 53 52 51 50
24 22 20 18 16 14
1970 1975 1980 1985 1990 1995
Gini
Ratio of incomes, richest/poorest quintiles
Source IDB, Latin America after a decade of
reforms, Londoño and Székely (1997).
34
COMPOSITION OF NHE BY SUBSECTOR IN LAC COUNTRIES
35
PUBLIC EXPENDITURE IN HEALTH AS OF GNP
36
PUBLIC EXPENDITURE IN HEALTH AS OF NHE
37
PER CAPITA PUBLIC EXPENDITURE IN HEALTH (in US
Dollars)
38
PER CAPITA SPENDING BY PUBLIC INSTITUTIONS OF
HEALTH CARE IN MEXICO 1995, National average 100
Per capita spending
Per capita spending
300 250 200 150 100 50 0
300 250 200 150 100 50 0
533.3 PEMEX
IMSS-Solidaridad
IMSS
National average
DDF
No coverage
99.4
ISSSTE
SSA
0 9.3 18.7 22.2 52.8 63.0 100
Percentage of population covered
As the administrative support of
IMSS-Solidaridad is provided by IMSS, its cost is
recorded in IMSS and excluded from
IMSS-Solidaridad. Source Ministry of Health
39
LESSONS LEARNED
  • The problem calls for solutions that combine
    social policy reengineering, health services
    delivery redesigning, health care financing
    reforms, and reorganization of the segmented
    health care systems.
  • There are investment and or transitional costs
    that ought to be taken into account given the
    existing constraints in resources and
    institutional organization

40
LESSONS LEARNED (continued)
  • A careful design of the separation of functions
    is necessary, so the primary goal becomes
    universal coverage rather than insurance and/or
    services providers market creation or expansion.
  • A single insurer seems to be more efficient than
    multiple insurers for pooling risks and avoiding
    adverse selection

41
LESSONS LEARNED (continued)
  • The segmented model has to be overhauled, and a
    separation of functions has to take place
    within a framework of solidarity, so the
    universal coverage can be attained.

42
LESSONS LEARNED
  • It will be difficult to make progress without
    increasing the relatively low levels of public
    expenditure in health care.
  • There is a need for finding innovative mechanisms
    for expanding social insurance schemes that
    counterbalance the increase in poverty levels,
    the expanding informal sector and the low levels
    of taxation as of the G.N.P.

43
LESSONS LEARNED (continued)
  • There is little room for extending social
    protection in health to the excluded at the
    expense of privates sources of financing
  • Neither the pure Bismarckian nor the pure
    Beveridgean models will work there is a need of
    a third way that combines elements of both and
    apply them to the country specific institutional
    set up

44
LESSONS LEARNED (continued)
  • The solution to the problem is quite distant and
    more complex than the notion of a basic package
    of interventions defined with cost-effectiveness
    criteria.
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