Integrated Health Services Networks and Vertical Programs Regional Consultation Meeting Ministry of Health of Paraguay Vice Minister Dr. Edgar Giménez.

Integrated Health Services Networks and Vertical

ProgramsRegional Consultation Meeting

Ministry of Health of ParaguayVice Minister Dr. Edgar Giménez

Cusco Peru, 11-12 November 20091

Ministerio de Salud Pública y Bienestar Social

Health System of Paraguay

Quo vadis…?

Dr. Edgar Giménez CaballeroVice Minister of Health

Paraguay - August 2008 - 2009

Introduction: The Context•Health Situation

•6,000,000 inhabitants•Young country•35% of population living in poverty; 19% in extreme poverty•High infant and maternal mortality rates•Morbidity due to preventable causes and epidemics•Vulnerable population: poor and indigenous

•Health System•Fragmented and segmented•40% social exclusion•High out-of-pocket expenditure on drugs•Only 20% of population has insurance

•Health Policies• 1989: Military dictatorship falls after 35 years •1990-95: Deconcentration of health services network•1996: National Health System and health councils created•2008: Change in government after more than 60 years significantly raises expectations•The government declares decentralization as a strategy•Focus on gender rights and equity is established in social policies•Health policies incorporate principles of equity, solidarity, universality, and comprehensiveness

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• World financial crisis• Climate change and

environmental events• Migration• Regional and global

epidemiological events

Conclusions of the National Technical Team

• Persistent slow and prolonged epidemiological transition

• High levels of social exclusion in health due basically to socioeconomic factors

• The system is fragmented and centralized, with little coordination, and is financed mainly by out-of-pocket expenditure, especially for drugs

• Structure and action taken have not had an impact in the medium term despite the substantial increase in resources

• It is necessary to make the system less fragmented, and to generate synergies and networks to improve performance, effectiveness, and efficiency

• Strengthening the current model by injecting more resources only leads to increased frustration

• We should address urgent problems with intelligent action but at the same time plan for the medium and long term 4

• Change should be guided by general strategies such as: - Reforms based on primary health care

- Building networks based on strengthened services

- Policy on access to drugs

- Policy on human resources development

- Strengthening of epidemiological surveillance

- Modernization of structure, administration, and management

- Intersectoral coordination/partnerships

- Social participation and focus on social territories

- Decentralization• These general strategies should gradually provide comprehensive and

universal attention to priority public health problems and health care needs

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Conclusions of the National Technical Team

Public Policies on:Public Policies on:

Quality of life and health with equity in Paraguay

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We CAN live longer and better in a country that

promotes social justice with respect to the quality of

life and health, that guarantees the rights of the

people and protects life through the State’s

responsibility to build a National Public Health System

for all throughout the country with citizen

participation.

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Political Philosophy

Universality of the right to health and other human and social rights.

Integrated responses to social needs.

Equity as a principle of justice so that everyone can enjoy the highest attainable standard of health and quality of life, with social and economic security.

Participation of communities and all citizens as a factor in the democratization and transparency of the State and the guarantee of rights.

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Factors to Consider in a New Approach to Public Health in Paraguay

• Human rights approach in health• Progressive, ongoing, and sustainable application• Application of the current legal framework• Articulation, coordination, and complementarity of actions and

resources of the National Health System• Programs to promote health and quality of life• Organization of care networks • Universalization of primary health care• Decentralization, territories for social action and citizen

participation

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Factor to Consider for Policy Implementation

• Internal and external factors: • Financing and budgetary feasibility• Technical feasibility and productive capacity• Political feasibility • State policies• Governance and other political aspects• The health debate and its ideological aspects• Regulatory and legal aspects• Other

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Stages for Action

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2008 2009 2010 2011 2012 2013

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Contingency: Health Center Plan

Improvements and innovations

Beginning of structural reform

Gradually and steadily moving towards universal comprehensive care.Stage 1A proposal

Objectives Implement a series of immediate actions that address the

most important aspects of priority public health problems Begin preparations for the introduction of substantial

improvements and innovations Create a working group for results-based management Build political sustainability for the development of the

health plan at least through 2013

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1. High levels of social exclusion and out-of-pocket expenditure

2. Heavy health, social, and economic burden due to preventable diseases

3. Poor-quality services4. Fragmentation,

centralization, bureaucracy, and little transparency

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Priority Problems

ACTIONS - 1

High levels of social exclusion and out-of-pocket expenditure• Progressive elimination of tariffs and

restructuring of financing• Increased access to drugs with

strengthening in four specialties of urgent care

• Increase in budgetary execution• Greater efficiency and transparency• Care for the indigenous population• Prevention of cervical and breast cancer• Street children• Rural settlements• Basic sanitation in selected districts• Drinking water in selected districts• Mental health and human rights

Heavy social and health burden due to preventable diseases

• Substantial increase in the coverage of the Expanded Program on Immunization

• Prevention and mitigation of dengue and yellow fever through vector control and implementation of the Integrated Management Strategy

• Intersectoral coordination for priority programs

• Healthy schools• Road safety

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ACTIONS - 2Poor-quality services

• Implementation of primary health care units

• New hospital projects• Funding for organ transplants• Greater availability of intensive care

units• Upgrading of teams/equipment in

strategic hospitals

Fragmentation, centralization, bureaucracy, and little transparency

• Simplification of processes• Restructuring of the General Bureau of

Administration and Finance (DGAF)• Restructuring of the General Bureau of

Human Resources in Health (DGRRHH)• Creation of the General Bureau for

Management of Strategic Inputs• Audit• Transparency and accountability• Master plan: 310/350/530• Creation of the Decentralization Fund• Amendments to agreements and

conditioned transfer• Local and Regional Plans with goals• Creation of the National Technical Board• Integration of new councils• Activation of National Health Accounts 16

Gradually and steadily moving towards universal comprehensive care.Stage 2A proposal

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Priority Problems

• High levels of social exclusion and high household expenditure for accessing health services, which especially affects poor and vulnerable populations.

• Significant deterioration in the health of the population due to preventable diseases, communicable diseases, chronic noncommunicable diseases, epidemics, and external injuries.

• Fragmentation, centralization, high levels of bureaucracy, and little transparency.

• Poor performance in intermediate results (efficiency, effectiveness, access, use, and quality)

Objectives Increase availability and coverage of

services throughout the life cycle Increase access to services and use and

quality of services Reduce out-of-pocket expenditure Bridge the exclusion gap Increase efficiency and transparency of

the Ministry of Public Health

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Strategic Lines of Action1. Renewal of the Primary Health Care Strategy in Paraguay with

development and coordination of a network of accessible, quality services.

2. Strengthening the leadership of the Ministry of Public Health and the National Health System

3. Development and management of human resources in health4. Intersectoral coordination, governance, and social

participation5. Development of the Health Information System6. Social and environmental determinants of health7. Drinking water and basic sanitation.

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Gradually and steadily moving towards universal comprehensive care.Stage 3A proposal

Objectives• Coordinate a social, political, and economic pact for the reforms,

guaranteeing the right to health based on explicit guarantees that consolidate a rights-based National Health System to ensure universal comprehensive care to an integrated package of services with social equity

• Set up legal and regulatory mechanisms that ensure and regulate implementation of the guaranteed benefits

• Set up a funding model that consolidates a National Health Fund• Exercise stronger and more effective leadership, regulation, and control of

the system, as well as public/public and public/private coordination and interinstitutional strategic partnerships

• Design and implement a model of care for regulated public services• Consolidate primary health care as the core strategy of the sectoral reforms• Set up mechanisms for ongoing quality improvement

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Explicit guarantees

Social, Economic, and Political Pact for the Reforms:

Legal and Financial Regulatory Regulation and Leadership

UNIVERSAL COMPREHENSIVE CARE: GRADUALLY AND STEADILY

With how much? What? How?

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Priority problems

High levels of social exclusion and out-of-pocket expenditure. . Significant deterioration in the health of the population due to preventable events, communicable diseases, chronic noncommunicable diseases, and external injuries, including high rates of maternal and child mortality.Fragmentation, centralization, poor quality of bureaucracy and transparency in the public subsystem.

Strategic objectives

Bridge the social exclusion gap in health, guaranteeing the right to health as a human right that includes health care, well-being, and citizen participation.

Reduce the health, social, and economic burden of communicable and noncommunicable diseases, malnutrition, and external injuries, comprehensively addressing health needs throughout the life cycle.Coordinate and consolidate the National Health System in care networks.

Strategic lines of action

Renewal of the primary health care strategy with the development of a network of accessible and quality services. Strengthening the leadership of the Ministry of Public Health and the National Health System.Development and management of human resources in health.Intersectoral coordination, governance, and social participationDevelopment of the Health Information System.Social and environmental determinants of health.Drinking water and basic sanitation.

Funding

General budget for expenditures approved by the National Congress.Contributions of subnational governments.International cooperation.Special fund projects.

Formal instruments

National Constitution, current laws, agreements, and international commitments. Decrees and resolutions.National Health Plan, National Policy for Human Resources Development in Health, National Policy on Access to Essential DrugsAgreements on decentralization in health; agreement with the Social Security Institute (IPS); agreement with the University of Asuncion Medical School (FCM); agreements with the private sector, cooperation agencies, and civil society organizations; strategic partnerships with the Ministry of Education and Culture, Ministry of Public Works and Communications, Public Functions Secretariat, Secretariat on Childhood,

Secretariat for Women, Secretariat for Youth, Environmental Secretariat, and other government agencies. Consensus-building for the development of a parliamentary agenda for the health sector.

Principles

Universality of the right to health and other human and social rights.Comprehensive responses to social needs.Equity as a principle of justice so that all people can enjoy the highest attainable standards of health and quality of life, with social and economic security.Participation of communities and all citizens as a factor in democratization and the transparency of the State and a guarantee of rights.

Stages of action

Stage 1: 2008-2009: Contingency Health PlanStage 2: 2009-2011: Plan for Substantial Improvements and InnovationsStage 3: 2011-2013: Plan for Structural Reforms

Tesai Ñembyaty - United for HealthProgress and Challenges in Paraguay

August 2008 – August 2009

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Meetings with Health Councils1. Introduction: The Context and the Situation

2. New health policies in Paraguay: Decentralization, a strategy based on the principles of equity and universal comprehensive care

3. What are the main contributions of decentralization?

4. Immediate progress and challenges in decentralization04/18/23 26

Principal Approaches• Human rights approach • Gradual and sustainable application• Articulation, coordination, and

complementarity of actions and resources of the National Health System

• Organization of care networks • Universalization of primary health

care• Decentralization, territories for social

action and citizen participation• Modernization of management• Transparency• Human resources development

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Principal Achievements in 15 Months• Development of the

information system with funding for a strategic five-year plan.

• Development of a modernization plan for management with funding for five years.

• Implementation of a system for accountability.

• Public and private coordination.

• Restoration of citizen trust.

• Development of a logistics system for strategic inputs.

• Creation of the Equity in Health Fund.

• Creation of 130 Health Councils to execute local and regional plans

• Creation of 150 Family Care Units.

• Improved epidemiological surveillance and adequate response to epidemics.

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Principal Lessons Learned• Lead the health debate• Unify the language and

concepts• Develop a holistic view• Consolidate a working

team• Weave a network of

partners• Good communications

system

• Synchronize with financial processes

• Develop formal instruments

• Position the health agenda on the social policy agenda

• Ensure participation of the Ministry of Finance

• Governance• Development of human

resources in health 29

Immediate Actions to Address Challenges Facing Integrated Services Networks

• Define social territories for action

• Organize territories into a services and regulatory network

• Integrate vertical programs into health services

• Advance toward strengthening the health system

• Establish a policy to develop human resources in health

• Synchronize with social and economic policies

• Hold workshops on regional definitions for results-based management

• Diabetes, cardiovascular diseases, TB, HIV, dengue, yellow fever, etc.

• Leadership, coordination, National Health Fund, logistics and information system

• Management based on primary health care

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