Health Service Provision José Ruales Regional Advisor in Health Systems PAHO/WHO.

Health Service ProvisionJosé RualesRegional Advisor in Health SystemsPAHO/WHO

Functions and Objectives of the Health System

Health System

Values

Needs

Resources

StewardshipFinancing

Insurance

Provision

Maintain and improve health

Access – Quality - Efficiency

Protect financial risks

Satisfaction of expectations

Participation

Health Services: Definition

• Services delivered by health personnel in a direct manner, or by other people under the supervision of these personnel, with the goal of:

– Promoting, maintaining and/or recovering health

– Minimizing disparities both in access to health services and in the level of population health

(PAHO/WHO 2003; Modification of the IOM 1996)

Health Service Provision

•Public or Collective Health Services

– Disease prevention and control–Protection against environmental risks–Injury prevention–Promotion of healthy behaviors and mental health–Quality assurance and accessibility of health services

•Individual or Personal Health Services

–Individual prevention–Diagnosis–Recovery –Rehabilitation–Palliative care

Challenges for Health Services in the Americas

• Access to health services is not available for large segments of the population,

• The supply of health services does not always adjust to expectations, social values and cultural preferences,

• The provision of health services, for certain population groups, is of poor effectiveness and technical quality,

• There is fragmentation, duplication, concentration in urban areas, weak information and referral systems, with inefficiency and inequity in the supply.

Health Services in Social Protection Schemes

• 7/7 aim to extend coverage and increase access by reducing exclusion and economic barriers

• 4/7 increased equity in terms of access and use, but 3/7 increased inequity

• 2/7 the elimination of economic barriers was insufficient among the dispersed and indigenous populations

• 3/7 increased the demand without expanding the supply of resources or the infrastructure, which leads to overload and reduction of quality

Needs, expectations, demand and use of health services by people, families and communities

Response

Model ofcare

Model oforganization &management

Challenge

Other systemicvariablesthat are determinantsof health services

SUPPLY

DEMAND

AC

CES

S

• Concrete existence of services aimed at promoting, preventing, recovering and rehabilitating the target population’s health, both at the individual and collective level, under the conditions of the people and the environment.

• Human Resources

• Physical Resources

• Technological Resources

Health Service Supply

Health Service Demand

– Formal (explicit) requirements for health services.

– Utilization: Demand that is met through the supply of services to a target population in a specific time period.

– Access: Probability of obtaining health care when needed.

Comprehensive access

• Conditions of effective coverage:– Availability– Elimination of barriers (geographic, cultural,

economic and social)– Timeliness (moment and time)– Acceptability (satisfaction and respect)– Contact and real use (first contact or other)– Appropriate, effective services (procedures and

levels)• Ex. Maternal-Newborn Care: Contraceptives, Skilled

delivery care, Emergency obstetric and newborn care

– Based on social protection

Social Protection - Adequate access:

– Timeliness– Quality– Dignity

– Independent of ability to pay

– Includes•Health service coverage•Coverage for the entire population•Financial solidarity

Determinants of Access

• Prior to using health services:– The need for care should exist

• (pain, convincing, risk of death)

– Should believe in services’ efficacy

• (confidence in the provider)

– Should have the ability to access services

• (availability of income or insurance, time, transport)

Source: Restrepo, JH, 2006

Barriers to access: supply side

At the entranceAt the entrance Initial contact:•Travel time•Means of transport•Distance to service•Hours of operation

InsideInside Obtaining the service•Bureaucracy for the appointment•Waiting times

At the exitAt the exit Continuity•Regular source•Hours

Source: Restrepo, JH, 2006

Barriers to access: demand sidePredisposition •Demographic

•Social structure•Culture, ethnicity and religion

Ability Resources for demanding services:Income or Health Insurance, Recognition of Rights

Needs Illness episodes or preventive actions, which in their opinion warrant health care

Utilization Characteristics of the resources themselves:•Type of service, Purpose, Concentration

Satisfaction Provider perceptions:•Information and attitude of professionals, Length of doctor’s visit•Quality of waiting rooms, Size of exam rooms, Waiting times•Cure / Solution

Source: Restrepo, JH, 2006

Factors that influence access

Provision / Use of

Services

Socio-economic development

Health situation Health needs and care

Socio-cultural aspects

Geographic, environ-mental, road access

Resources, organization and management of services

Social protection in health

Policies, plans and resources related to health

Biological – demographic characteristics

Cultural access

Geographic access

Economic access

Social determinants of health

Need for health

Perceived

Unperceived

Expressed

Unmet

Repressed Access

How the factors interact

Demand for health

Met

Equitable

Inequitable

Social protection in health scheme

Health outcomes

Supply of Services

Health Care Model

• Content of health care and principal characteristics of the interaction between the service provider and service user.

• Includes:• Pertinence of the supply of services

to users’ needs and demands,• Accessibility and acceptability of

services,• Services oriented to people, families

and communities,• Role of people, families and the

community in self-care,• Level of integration of services.

Trends in the model of care

• Balance between personal services and public health services; curative, promotion and prevention services

• Services oriented to families and the community

• Promotion of self-care for the health of people, families and the community

• Search for the integrality of services:

– Comprehensive– Continuous– Longitudinal

Model of organization and management

• The manner in which the components of the health system are organized and managed with the goal of achieving the objectives proposed and facilitating its collective function.

Trends in the models of organization and

management• Organization of services based on

primary care• Definition of a population base• Prioritization of the most vulnerable

population groups• Emphasis on ambulatory care and

care beyond traditional clinical environments

• Decentralization of services• Management focused on quality and

results• Organization and management of

integrated health systems

Fragmentation

• Coexistence of many units or entities that are not integrated into the health service network.

• does not allow the standardization of contents, quality, cost and provision

• leads to providers not working in a coordinated or synergetic manner

• generates increases in the costs of care

• promotes inefficient allocation of resources in the system.

Segmentation of the system and Fragmentation of services

Tertiary Care

Primary Care

Social Security

Private, high complexity

MOH Professional Risks

Private, low complexity

NGOs

Municipalities

Universities

Secondary Care

Traditional Medicine

STRATEGIES FOR CONFRONTING SEGMENTATION AND

FRAGMENTATION

INTER-INSTITUTIONAL COORDINATION

OPERATIONAL INTEGRATION

Strengthening of the STEWARDSHIP / MANAGEMENT

of the Sectoral Policy

Leadership, Alignment and Harmonization of International

Cooperation

• Management of Integrated Service

NETWORKS •Integration of the

Programs in the System

Integration of the Population

• Involves the availability and the timeliness of access

• Guarantees the flow of users through all levels of care and complexity in order to ensure the continuity of care,

• Develops referral and counter-referral mechanisms, between different health services and, when required, other social services.

INTEGRATED HEALTH SERVICE SYSTEM

• ESTABLISHMENT OF AN INTEGRATED NETWORK OF HEALTH CARE DELIVERY THAT

– ALLOWS THE PROVISION OF CONTINUOUS CARE TO A SPECIFIC POPULATION

– AT A SPECIFIC TIME AND PLACE AND WITH DEFINED COST AND QUALITY

– IS RESPONSIBLE FOR THE HEALTH AND ECONOMIC OUTCOMES OF THIS POPULATION.

Source: MENDES (2001)

COMPONENTS OF INTEGRATED HEALTH SERVICE SYSTEMS

• COLLABORATIVE MANAGEMENT OF CARE

• MANAGEMENT OF POPULATION RISKS

• MANAGEMENT OF POINTS OF HEALTH CARE DELIVERY

• CLINICAL MANAGEMENT

SOURCE: MENDES (2001)

Levels of construction of networks

Level Actions Value at play5th Floor

AssociateShare objectives and projects

Confidence

4th Floor

CooperateShare activities and/or resources

Solidarity

3rd Floor

CollaborateProvide intermittent help

Reciprocity

2nd Floor

Gain knowledgeKnowledge of what the other is or does

Interest

1st Floor

RecognizeRecognize that the other exists as a peer or collaborator

Acceptance

Source: Rovere, M. 2004

Organization and management of networked services

Segmentation of the resources, supply and population ORGANIZATION INTO

A NETWORK

PHC

Primary Care

Social Security

Private, high complexity

MOH Professional Risks

Private, low complexity

NGOs

Municipalities

Universities

Secondary Care

Traditional Medicine

Tertiary Care

HOSPITAL

DAY HOSPITAL

NURSING CENTER

HOME-BASED CARE

BASIC HEALTH

UNIT

SPECIALIZED AMBULATORY

CARE

HOSPITAL

DAY HOSPITAL

NURSING CENTER

HOME-BASED CARE

SPECIALIZED AMBULATORY

CARE

BASIC HEALTH

UNIT

HOSPITAL

A

AMBULA-TÓRY

B

AMBULA-TÓRY

A

HOSPITAL

B

From fragmentation to integration in a network

1

2

3

SOURCE: MENDES (2001)

From the INTEGRATION OF SOCIAL PROTECTION to INTER-SECTORAL

INTEGRATION

HEALTH SERVICE SYSTEM

SOCIAL PROTECTION

SYSTEM

HEALTH

CULTURESOCIAL PROTECTION

EDUCATION

HOUSING

EMPLOY-MENT

SOURCE: MENDES (2001)

José RualesRegional Advisor in Health SystemsPAHO/WHO

[email protected]