Integration of Programs in the Organization of Systems and Health Services Networks Regional Consultation Meeting: Integrated Health Services Networks.

 Integration of Programs in the

Organization of Systems and Health Services Networks

Regional Consultation Meeting: Integrated Health Services Networks and Vertical Programs

Cusco, Peru, 11-12 November 2009

Gloria Delfim WalkerHealth Services Architect

Specialist in Health Care ManagementTechnical Adviser to Directorate of Health Care Networks, DARAS/SAS-MS

1

2

Unified Health System (SUS): The Brazilian Experience

1. Brief Description of the SUS

2. Challenges Facing the SUS

3. The Integrated Health Networks Concept

4. Guidelines for the Implementation of IHNs

5. Ongoing Activities

1. BRIEF DESCRIPTION OF THE HEALTH SITUATION AND THE

UNIFIED HEALTH SYSTEM (SUS)

3

4

42.6% in the Southeastern Region

27.7% in the Northeastern Region

14.6% in the Southern Region

8.0% in the Northern Region

7.1% in the Midwestern Region

Demographic AspectsDemographic Aspects

National territory: National territory: 8.5 million km28.5 million km226 states, 1 Federal District, and 26 states, 1 Federal District, and 5,564 5,564 municipalities, all with political, fiscal, and municipalities, all with political, fiscal, and administrative autonomy and with no hierarchical administrative autonomy and with no hierarchical links between themlinks between them

184 million 184 million inhabitants inhabitants

Source: IBGE

Regions

NorthernNorthern

Northeast

Central/Western

Southwest

Southern

5

MacroregionsMacroregions

Great diversity

1. Economic

2. Social

3. Cultural

4. Epidemiological

AMAZON

REGION

CENTRAL/

SOUTHERN

REGION

NORTHEAST

REGION

6

BRAZILBRAZILSocial ContextSocial Context

The challenge: The challenge:

FormulateFormulate national national policies that allow policies that allow

for marked for marked regional regional

differencesdifferences

HDI over 0.801HDI between 0.751 and 0.800HDI between 0.701 and 0.750HDI between 0.651 and 0.700HDI under 0.650

Source: UNDP, 2000

7

FEDERAL CONSTITUTION FEDERAL CONSTITUTION - LAW CREATING THE - LAW CREATING THE SUSSUSArticle 196Article 196: “: “Health is a right of all Health is a right of all and a duty of the State and shall be and a duty of the State and shall be guaranteed by means of social and guaranteed by means of social and

economic policies aimed at reducing economic policies aimed at reducing the risk of illness and other threats and the risk of illness and other threats and

at the universal, equal access to at the universal, equal access to actions and services for its promotion, actions and services for its promotion,

protection and recovery.”protection and recovery.”

Article 198: Article 198: “Health actions and Health actions and public services make up a public services make up a regionalized hierarchical regionalized hierarchical

network and constitute a single network and constitute a single system, organizedsystem, organized according to according to

thethe principles …” of principles …” of decentralization, regionalization, decentralization, regionalization,

comprehensive care, and comprehensive care, and community participation.community participation.

Law 8,080 (Art. 2, par. 3): Law 8,080 (Art. 2, par. 3): Health determinants include Health determinants include

food, basic sanitation, food, basic sanitation, environment, work, income, environment, work, income, education, transportation, education, transportation,

leisure, and access to goods leisure, and access to goods and social services; a and social services; a

population’s level of health is a population’s level of health is a reflection of the social and reflection of the social and

economic organization of the economic organization of the country. country.

INTERSECTORAL APPROACHINTERSECTORAL APPROACH

8

Health as a right of all and a duty of the State Decentralization with independent management in

each sphere of government: municipal, state, and federal

Organization of health services based on universal care, equity in the delivery of services, and comprehensive care

Participation of the population in monitoring of the system

Responsibility for financing the system shared among the three levels of government

Technical and Political PillarsTechnical and Political Pillarsof Brazilian Health Sector of Brazilian Health Sector Reform Reform

9

Brazilian Health SystemBrazilian Health System

Unified Health System (SUS): public, free,

universal accessSupplementary Health System: private, benefi-

ciaries subscribe to

private health plans and insurance

Direct pay: access through direct payment

from beneficiary to

provider

Health Health expenditureexpenditureas % of GDP:as % of GDP:

7.4% (total)7.4% (total)3.6% (public)3.6% (public)

SOURCE: MS-SPO - MS-SIOPS - STUDIES QA. Year of Reference: 2007

Integration of Health CareIntegration of Health Careand SUS Servicesand SUS Services

10

Law 8080/90Law 8080/90 Article 7, paragraph II: (...) comprehensive Article 7, paragraph II: (...) comprehensive

health care, defined as ahealth care, defined as a continuous continuous articulated setarticulated set of individual and collective of individual and collective actions and preventive and curative services actions and preventive and curative services (...) (...)

Article 10 refers to Article 10 refers to organizational organizational arrangements for local and regional networks arrangements for local and regional networks operating through intermunicipal consortia operating through intermunicipal consortia and health districts toand health districts to integrate and integrate and articulate resources and increase the articulate resources and increase the coverage of actions. coverage of actions.

National Programs1. National Program for Reproductive Health

2. National Program for Health Promotion in Children and Youth

3. National Program for Oral Health Promotion

4. National Program for Health in Schools

5. National Program for People’s Health

6. National Program for Prevention of HIV/AIDS Infection and other Sexually Transmitted Diseases  

7. National Vaccination Program

8. National Program for Polio Eradication: Post-Elimination Phase

9. National Program for Measles Elimination and Prevention of Congenital Rubella

10. National Program to Combat Tuberculosis

11. Integrated National Program for Clinical and Laboratory Surveillance of Flu - Information about the disease

12. National Program for Prevention of Antimicrobial Drug Resistance

13. National Program for Prevention of Hospital Infections

14. National Program for Prevention and Control of Oncological Diseases

15. National Program for Prevention and Control of Cardiovascular Disease

16. National Program for Control of Asthma

17. National Program for the Prevention and Control of Chronic Obstructive Pulmonary Disease

18. National Program for Control of Diabetes

19. National Program to Combat Obesity

20. National Program to Combat Rheumatic Diseases

21. National Program for Eye Health

22. National Program for Control of Hemoglobinopathies

23. National Program to Combat Depression

24. National Program on Post-Traumatic Stress Disorder

25. National Program for Prevention of Alcohol-Associated Problems

26. National Program on Prevention/Consumption of Illegal Drugs

27. National Program on Pain Management

28. National Program on Palliative Care 

29.  National Program for Accident Prevention

30. National Program to Fight Inequalities in Health

31. National Program for Integrated Intervention in the Determinants of Health-Lifestyles

32. National Program for Environmental Health

33. National Program on Food Hygiene and Control

34. National Program for Health Promotion and Protection in the Workplace

35. National Program for Development of Health Human Resources

36.  National Program for Information and Knowledge Management

37. National Program for Development of Organ Transplantation

38. National Program on Accreditation of Hospitals

39. National Program on Accreditation of Health Centers

40. National Program for Laboratory External Quality Assessment

Critical Reflection20 years later ... Challenges remain1. Marked fragmentation of care and management2. Gaps in care and barriers to access 3. Poor-quality services, lack of commitment on

the part of health care and teams4. “Treat ‘em and street ‘em” and physician-

centered approaches to care (patients not taking a proactive role)

5. Focus on hospital and physician (people going where they know they will be served);

User dissatisfactionUser dissatisfaction Insufficient financial resources (rising production costs)Insufficient financial resources (rising production costs)

12

Facing the Challenge: HEALTH PACT Integration Strategy

13

PACT FOR LIFEHealth Situation of

the Population

PACT TO UPHOLD THE SUS

Basic PrinciplesSUS Stakeholders

PACT FOR MANAGEMENTDecentralizationRegionalization

Financing, Planning, Social

Monitoring, Health Education

New Format for Intergovernmental Relationships:

Coalitions for Regional

Management

Integration of Actions

In Terms of Service

contracts of Municipios, States, and Ministry of

Health

Regional:

• Joint Action in the 3 Spheres

• Integrated Approach

• Recognition of Relationships of Interdependency and Cooperation

Res

po

nsi

bil

itie

s u

nd

er t

he

Pac

t

Bas

ic P

rin

cip

les

Facing the Challenge!Facing the Challenge! (current Government proposal)(current Government proposal)

14Strategy for Strengthening Regionalized Health

22 Points from Inaugural Address

Pact for LifeNational

Health Plan

Plurianual Plan

Strategic Approach

BETTER HEALTH

Planning: Planning: Evidence x ResultsEvidence x Results((rescuerescue of SUS planning) of SUS planning)

15

Where does integration begin?

Regionalization of Health Care

Health Regions - spaces for sharing actions and health services.... Adequate secondary care and health surveillance actions (prevention, promotion)These can be:

• Intramunicipal: Joinville-Santa Catarina

• Intermunicipal: Piauí (Floriano region)

• Interstate: Juazeiro (Bahia) and Petrolina (Pernambuco)

• Border area

• Governance of IHNs ~ 390 coalitions involved

in Regional Management 16

Strengthening Regional Planning• Health macroregions bring together two or

more Health Regions to organize actions and share among themselves such services in this area as specialized outpatient care, third-level hospital facilities, and health surveillance.

“The criteria of scale, scope, subsidiarity, and flexibility are important in this process.”

Agency responsible for governance:

• Regional Management Coalition, a co-managing entity in the Regionalized Health Care Network

17

National Health Plan (PNS) 2007-2010 – General Lines of Action

1.Step up the strategy calling for regionalization, social participation, and federative relations in keeping in keeping with the lines of action approved in the Pact for Health, with the lines of action approved in the Pact for Health, seeking a decisive improvement in the systematic and seeking a decisive improvement in the systematic and organizational efficiency of the health servicesorganizational efficiency of the health services,, revitalizing the role of the Federal Government in organizing regional integrated health networks throughout Brazil.

2.2.Technical support for states and cities in Technical support for states and cities in implementing Integrated Health Care Territories (TEIAS) implementing Integrated Health Care Territories (TEIAS) as the organizational model for health care networks.as the organizational model for health care networks.

18

2. CHALLENGES FACING THE SUS

19

Challenges x Opportunities

for Improvement• Double burden of disease (triple, if external causes are considered)

• Weak institutional capacity (managers and technical teams)

• Underfunding of health (resources for health promotion, increased costs);

• Poor quality of the health services offered • User dissatisfaction (services and access)• Minimal use of clinical management tools by the

health services (clinical directives, clinical protocols, case management, treatment plan...)

• Lack of coordination of PHC

20

Challenges (2) Demographic Transition

21

Life expectancy at birth: 72 years

MORTALITY RATE from chronic diseases:

Brazil ~ 600/100,000United Kingdom ~ 300/100,000

THE AGING POPULATION

6 older adults for every 12

children under 5 years 6 older adults for every 5

children under 5 years

Challenges (3) Production of Health Production of Subjects• Recognition of the interdependence between the need

to enlist technology convergence for health production in construction/activation of the intra- and interinstitutional Human Relations Network, on the one hand, and high accountability, connectivity, and friendly, compassionate, complementary care, on the other. Rollo (2007)

• Evaluation of SUS professionals: – Leaders – Management– Teams

22

Challenges (4) Health Management in the Territories

THE GREATEST CHALLENGE:

TRANSFORM THE CURRENT

HEALTH REGIONS INTO TEIAS!

23

24

Reorganizing UHS Management

Organizing Management

TEIASIntegrated Health Care Territories

Organizing Management

25

Organization of Integrated Health Care Territories

26

Organization of Integrated Health Care Territories

27

Organization of Integrated Health Care Territories

28

Organization of Integrated Health Care Territories

Agenda for Implementing IHNs

29

Unit Public health commitments/

responsibilities

Resources needed

Assignment of responsibility

(management/goals)

GEN.

HOSP

Agenda for implementation of IHS

30

Unit Public health commitments

Resources needed

Assignment of responsibility (unit

and manager)

What kind of NETWORKSare we talking about?

3. THE INTEGRATED NETWORKS CONCEPT

31

Building a New Care ModelNational Policy on Basic Care (PNAB) (PHC) (Decree 648/GM of 28 March 2006)

• Focused on care of acute and chronic cases, surveillance, and Focused on care of acute and chronic cases, surveillance, and

health promotionhealth promotion

• PHC as the preferred gateway for the coordination of end-user PHC as the preferred gateway for the coordination of end-user

health care, providing support for the case and following up health care, providing support for the case and following up

throughout its course in the system – in other words, a throughout its course in the system – in other words, a

longitudinal approach longitudinal approach to care over time and appropriate use of the to care over time and appropriate use of the

technologies available in the health services networktechnologies available in the health services network

• With these goals in mind, the best first step: development of a With these goals in mind, the best first step: development of a

Plan for Strengthening PHC (FAPS)Plan for Strengthening PHC (FAPS)

32

Systemic View Health Services Networks (RISS)• The networks should be built on the presence of The networks should be built on the presence of horizontal

spaces that connect to form a POLYARCHY in which

decisions are made by consensus. .

• They should be capable of generating partnerships based They should be capable of generating partnerships based

on mutual trust, strengthening the on mutual trust, strengthening the meaning of networks as meaning of networks as

spaces for complementarity and creativityspaces for complementarity and creativity..

• The bases for co-management and the elements that The bases for co-management and the elements that

hold the network together are: clear definition of hold the network together are: clear definition of

common objectives and shared resources coupled common objectives and shared resources coupled

with monitoring of outcomes. with monitoring of outcomes.

33

Definition of Networks

Health Care Networks areHealth Care Networks are organizational organizational

arrangements of health units and actions of arrangements of health units and actions of

different technological densities,different technological densities,

integrated through diagnostic, logistic, and integrated through diagnostic, logistic, and

management support systems, designed to management support systems, designed to

guarantee an integrated approach to care in a guarantee an integrated approach to care in a

given territory/population(....)given territory/population(....)

34

Technical & Political Implications - Promoting Synergies (Feasibility Strategy)• Key ISSUE: In terms of resources, this meansKey ISSUE: In terms of resources, this means

Compensating for gaps and deficits in investmentsCompensating for gaps and deficits in investments

Working toward unifying the Working toward unifying the transfer of per capita resources

Providing incentives to implement regional management tools

to promote health production, as well as logistic and

administrative support tools, especiallyespecially

Optimizing, integrating, promoting synergies, and Optimizing, integrating, promoting synergies, and making resources making resources

already allocated under national SUS structural policies more efficientalready allocated under national SUS structural policies more efficient

35

Ministry of Health Integrated Health Care Networks

• Articulation with other policies

• Strengthening the constitutional foundation for

the organization of health policy, including the

expansion of integration through regionalized

health care networks based on a public policy

that is inclusive and also promotes citizen

participation

36

Implementation of the BRAZIL IHS/Ministry of Health Program

Secretariat of Health Care:Secretariat of Health Care:1. Department of Basic Care2. Department of Specialized Care 3. Department of Strategic Programming Actions4. Department of Regulation, Appraisal, and System Monitoring 5. Department of Hospital Management for the State of Rio de Janeiro 6. National Cancer Institute 7. National Institute of Cardiology8. National Institute of Traumatology and Orthopedics

Article 14. The Secretariat of Health Care is responsible for: Article 14. The Secretariat of Health Care is responsible for: I – Participating in the formulation and implementation of health care policy

based on UHS principles and guidelines II – Defining and coordinating integrated health actions and services II – Defining and coordinating integrated health actions and services

networks; (DARAS, established in 05/2007)networks; (DARAS, established in 05/2007)

III - Establishing standards, criteria, parameters, and methods for monitoring quality and evaluating health care (...) 37

DARAS: Directorate of Health Care Networks• Goal: Provide technical assistance to states and Provide technical assistance to states and

municipalities to build integrated health care networksmunicipalities to build integrated health care networks

– Internal articulation through groups supporting Proposed Networks (UF) as well as experts in regionalization (SE), specialized care (SAS), urgent and emergency care (SAS), regulation and Information processing and retrieval (SE), participatory management (SGEP), health surveillance, promotion, and disease prevention (SVS), National Health Fund (SE), management of health education and the health professions (SGTES), among other areas;

– External articulation, once the project is formalized, establishment of collegiate management (via decree) for the Project through government agencies (CONASS, CONASEMS at the national level and COSEMS, CES, CMS, IES (institutions of higher education), providers (those operating under agreements, philanthropic, private, Ministries of Justice, Education, Agriculture, Armed Forces...)

– Development of educational strategies for training local and regional Development of educational strategies for training local and regional facilitators in the process of building health care networksfacilitators in the process of building health care networks

38

4. GUIDELINES FOR THE IMPLEMENTATION OF IHNs

39

FUNDAMENTAL ISSUES

• Starting point for Starting point for building health systems in a given building health systems in a given regional spaceregional space (identifying health needs) (identifying health needs)

• Health care focused on the individual, family, and Health care focused on the individual, family, and communitycommunity

• Definition of a set of actions and services (public health Definition of a set of actions and services (public health services map) to be provided to a given population through services map) to be provided to a given population through health care delivery sites or functional units of different health care delivery sites or functional units of different technological densitiestechnological densities

• Broad application of the directive Broad application of the directive that the primary care that the primary care level is the gateway to the system of integrated and level is the gateway to the system of integrated and coordinated care, which has to capacity to meet coordinated care, which has to capacity to meet

most of the healthmost of the health needs of the populationneeds of the population

40

FUNDAMENTAL ISSUES

• Organization of care based on criteria of scale and scopeOrganization of care based on criteria of scale and scope

• Development of tools for clinical and managerial Development of tools for clinical and managerial coordination coordination

• Institutional integration throughInstitutional integration through commitments to commitments to outcomesoutcomes

• Efficiency and transparency in management of resourcesEfficiency and transparency in management of resources

• Integrated structures for the provision of health actions and Integrated structures for the provision of health actions and services with institutionalization through public policiesservices with institutionalization through public policies

• Collective and planned construction processCollective and planned construction process

• Emphasis on the interdependencies between the Emphasis on the interdependencies between the stakeholders involvedstakeholders involved

41

FUNDAMENTAL ISSUES

• Support for rapid, unified geoinformation systems, as well as logistic, diagnostic, therapeutic support, and management systems

• Accountability for costs and health outcomes in the subscriber population

• Focus on continuity and quality of care through coordination and gains in effectiveness

• Unique participatory system of governance with broad intersectoral action

• Adequate financing and financial incentives in Adequate financing and financial incentives in alignment with system goalsalignment with system goals

42

Expanded Integration of HealthProduction: A New Paradigm

1. Needs-based organization of health services and actions, in tandem with implementation of a policy on Health Promotion and Monitoring

2. . ImplementationImplementation of SUS structural policies (PNAB, U/E, of SUS structural policies (PNAB, U/E, Mental Health, Workers Health, STD/AIDS...) and Mental Health, Workers Health, STD/AIDS...) and Clinical Guidelines (Pregnant Women and Newborns, Clinical Guidelines (Pregnant Women and Newborns, Systemic Hypertension, Mental Disorders, Cancers of Systemic Hypertension, Mental Disorders, Cancers of the Breast and Colon, Tuberculosis, Hansen’s the Breast and Colon, Tuberculosis, Hansen’s Disease, etc. …) Disease, etc. …) starting with PHC and taking into starting with PHC and taking into account the epidemiological profile of the regionaccount the epidemiological profile of the region

43

Integration of Care

3. Building the Regional Health Monitoring Nucleus (clinical support and collective health)

Expansion of the clinical and collective effectiveness of the health

team either through the direct action of other professionals or

through the integration of basic care with environmental, public

health, and epidemiological monitoring in the territory

Directives on Care Delivery, Care Protocols, Pathology

Management, and Case Management

Peer review, discussion of cases

Collective Health Projects based on Sentinel Events and tracers

44

Integration of Care

45

4. Implementation of devices and tools for

Clinical Management (Directives on Care,

Individual Treatment Plan (ITP), Case

Management ...) and the National National

Humanization Policy (shelter, support for

mothers ...)

5. Implementation of Family Health Support

Nuclei (NASF)

Integrated Health Care Territories (TEIAS)

• Objective of the strategy: stimulate the initiative

to turn the current Health Regions, which today are

fragmented, into Integrated Health Care Territories, or Integrated Health Care Territories, or

TEIAS – an acronym that spells the word for ‘webs’ in TEIAS – an acronym that spells the word for ‘webs’ in

PortuguesePortuguese

With the awareness that it will be a gradual and complex process that will require constant input

of knowledge and resources

Rollo (2009)

46

5. ONGOING ACTIVITIES

47

48

Issues under Discussion• How to expand the PHC-level investment to strengthen its How to expand the PHC-level investment to strengthen its

role as coordinator of care and of the implementation of role as coordinator of care and of the implementation of TEIAS TEIAS

• How to implement Lines of Care (Pact for Life) and the Policy on Regulation: ensure new contractual agreements, reduce fragmentation, guarantee connectivity, manage the waiting list

• How to restructure Diagnostic Support Services and Specialized and Hospital Care while taking into

account: Access,Regionalization, Trends in Density, Responsibility for

Resolving Problems, Continuity of Care, Economies of Scale, Scope, and Quality of Care

• How to implement actions under the Health Promotion Policy while at the same time focusing on the social determinants of health in the regions, acting both intersectorally and intersectorally and comprehensively with respect to other public policiescomprehensively with respect to other public policies

Issues under Discussion • How to improve logistical support for the networks:

identification card, electronic messaging, patient transportation, maintenance, supplies

• How to strengthen the governance of IHNs (Regional Coalition Managers - CGRs) with a view to improving their performance with such network management tools and strategies as:

– Review of Master Regionalization Plans– Preparation of Regional Health Plans – Investment Master Plans– Integrated Pact related Programming– Contracts for Management and Setting Targets– Monitoring and Evaluation

49

Issues under Discussion

• How to implement the provisions of the National Humanization Policy (PNH) in terms of:Reception, including risk classification, clinical management, safety of patients and health production environments

• How to operationalize the start of the Investment Project for SUS Qualification “QualiSUS-NETWORKS: Lending Agreement with the

World Bank,” which will support 15/27 states in the organization of integrated health care networks in Brazil

50

In short:

• Instead of priority programs Instead of priority programs >> structural policiesstructural policies

• Instead of basic, intermediate, and high-complexity levels of care Instead of basic, intermediate, and high-complexity levels of care >> primary, secondary, and tertiary levels of careprimary, secondary, and tertiary levels of care

• Instead of physician-centered and/or hospital-centered care Instead of physician-centered and/or hospital-centered care > > care care

centered on the individual, the family, and the community; delivery ofcentered on the individual, the family, and the community; delivery of quality services; and resolution of problems at all points along the chain quality services; and resolution of problems at all points along the chain of services in the network in response to the demands of system users of services in the network in response to the demands of system users

51

and...• Instead of users trying to figure out where they should go Instead of users trying to figure out where they should go >>

first contact and longitudinality ensured through primary care, with first contact and longitudinality ensured through primary care, with links to professionals and teams responsible for the caselinks to professionals and teams responsible for the case

• Instead of fragile, non-functioning local health systems Instead of fragile, non-functioning local health systems >>

local health systems gradually improving their managerial capacity, local health systems gradually improving their managerial capacity, with trained human capital, with technology appropriate for the types with trained human capital, with technology appropriate for the types of situations they are expected to respond to, with financial of situations they are expected to respond to, with financial resources ensured, and with their Health Plans implemented resources ensured, and with their Health Plans implemented efficiently and effectivelyefficiently and effectively

And finally:And finally:

• Instead of producing networks of services (ARS) Instead of producing networks of services (ARS) >>

produce health, with the actors empowered to ensure user produce health, with the actors empowered to ensure user satisfaction and even sustainability of the SUSsatisfaction and even sustainability of the SUS

52

Thank you! Gracias!

Our Contacts: • Ministry of Health - Brazil• Secretariat of Health Care - SAS• Secretary: Dr. Alberto Beltrame• DIRECTORATE OF HEALTH CARE NETWORKS (DARAS)

[email protected]• Director of the Program: Adail de Almeida Rollo

[email protected]• General Coordinator: Gloria Delfim Walker• [email protected]• 55-61-3315 3196/ 3315 3969

53