Office of the Assistant Director Health Systems Strengthening
Area DYNAMICS OF HEALTH POLICIES AND CHALLENGES FOR HEALTH SYSTEMS
STRENGTHENING IN LATIN AMERICA AND THE CARIBBEAN Eduardo Levcovitz,
MD, MSC, Ph.D Unit Chief, Health Policies and Systems Development
Pan-American Health Organization - PAHO/WHO Health Systems
Strengthening Workshop Belize, May/June2006 Slide 2 Office of the
Assistant Director Health Systems Strengthening Area OUTLINE
DYNAMICS OF HEALTH POLICIES HEALTH SYSTEMS CHANGES/ REFORMS IN LAC
Monitoring and Evaluation General Trends THE WAY AHEAD Challenges
for health systems strengthening Health Systems Strengthening
Workshop Belize, May/June2006 Slide 3 Office of the Assistant
Director Health Systems Strengthening Area EVOLUTION OF THE
ETHICS/IDEOLOGIES/VALUES IMBEDDED IN HEALTH POLICIES 20s/40s
80s/90s50s/70s XXIst Century Formal Social Security for industrial
workers Public assistance and charity for the poor and indigent
XXth Century Welfare state Segmented systems according to ability
to pay UNIVERSAL SOCIAL PROTECTION AS CITIZENSHIP RIGHTS Slide 4
Office of the Assistant Director Health Systems Strengthening Area
Resolutions PAHO-CSP26/12- 2002 and WHA58.33 2005 UNIVERSAL SOCIAL
PROTECTION AS CITIZENSHIP RIGHTS Ensure to all citizens the
UNIVERSAL SOCIAL PROTECTION IN HEALTH, eliminating or reducing the
avoidable inequities in coverage, access and utilization of
services and stimulating that everyone receives care according to
its needs and contributes to the financing of the system according
to its possibilities. Slide 5 Office of the Assistant Director
Health Systems Strengthening Area INTRINSIC ELEMENTS OF HEALTH AND
SOCIAL POLICIES IDEAS VALUES PRINCIPLES INTERESTS INFORMATION
KNOWLEDGE Slide 6 Office of the Assistant Director Health Systems
Strengthening Area Politics (Power, Gobernability) HEALTH SECTOR
Industrial (economic interest) Social Protection (citizenship
right) Ethics (respect to life) DIMENSIONS OF THE HEALTH SECTOR
Slide 7 Office of the Assistant Director Health Systems
Strengthening Area Social Protection : Subsystem of the Welfare
State Politics: Subsystem of the Democratic Pluralist State
Industrial: Subsystem of the Industrial Capitalist State Ethics:
Subsystem of the Code of Global, Regional and National
Values/Commitments of each Country/Society DIMENSIONS OF THE HEALTH
SECTOR Slide 8 Office of the Assistant Director Health Systems
Strengthening Area HEALTH SYSTEMS IN LAC NATIONAL HEALTH SERVICE
SOCIAL HEALTH INSURANCE ENTREPRENEURIAL SEGMENTED Although the
classical types of health systems influenced the development of the
health sector in the Americas, neither of those models were fully
implemented in the Region, where most of the countries have highly
SEGMENTED HEALTH CARE SYSTEMS PRIVATE SOCIAL INSURANCE PUBLIC Slide
9 Office of the Assistant Director Health Systems Strengthening
Area .. any other typology or classification is arbitrary.
TYPOLOGIES OF HEALTH SYSTEMS With the exception of the MENDELEYEVs
PERIODIC TABLE OF ELEMENTS Slide 10 Office of the Assistant
Director Health Systems Strengthening Area HEALTH SYSTEMS REFORMS
IN LAC: MONITORING AND EVALUATION www.lachsr.org Slide 11 Office of
the Assistant Director Health Systems Strengthening Area HEALTH
SYSTEMS REFORMS IN LAC: GENERAL TRENDS It looks like deregulation
reached even the diseases Look doctor, my glucose raised until 250
than went down to 85 and than raised again to 170 Health Systems
Reforms has followed the processes of fiscal adjustment, reduction
of the size and role of the State and market deregulation that
happened throughout the Region during the 1980s and 1990s HEALTH
REFORMS PUBLIC SECTOR REFORMS Slide 12 Office of the Assistant
Director Health Systems Strengthening Area HEALTH SYSTEMS REFORMS
IN LAC: GENERAL TRENDS HSR did not respect the unique
characteristics of each country related to their history, political
culture and health systems organization, and with few exceptions
adopted the fashion patterns and general receipts dictated the
International Financial Institutions IFIs Slide 13 Office of the
Assistant Director Health Systems Strengthening Area HSR did not
increase INVESTMENT IN HEALTH, even within a context of some
increase in social expenditures Health HEALTH SYSTEMS REFORMS IN
LAC: GENERAL TRENDS Slide 14 Office of the Assistant Director
Health Systems Strengthening Area HSR has produced LOW IMPACT ON
THE SIGNIFICANT DIFFERENCES in ensured rights, levels of percapita
expenditure and degree of access to services between the various
groups of population HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS
Slide 15 Office of the Assistant Director Health Systems
Strengthening Area HSR were NOT CONVERGENT WITH THE SOCIAL SECURITY
REFORMS in a way to generate synergistic actions to expand coverage
of social protection HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS
(5) Slide 16 Office of the Assistant Director Health Systems
Strengthening Area Few countries have faced the challenge of HUMAN
RESOURCES DEVELOPMENT to adapt to the new reality of the public
sector and to cope with the demands generated by the Health Sector
Reforms HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS Slide 17
Office of the Assistant Director Health Systems Strengthening Area
Matters related to PUBLIC HEALTH, quality and continuity of care
and integration between prevention, promotion and treatment in a
comprehensive approach have remained marginal subjects in the
debates on HSR HEALTH SYSTEMS REFORMS IN LAC : GENERAL TRENDS EPHF
in the Americas Slide 18 Office of the Assistant Director Health
Systems Strengthening Area There has been little or no progress in
the improvement of the overall systems performance and general
effectiveness, nor in overcoming the inequity and
segmentation/fragmentation of health systems, as HSR has focused on
MICROECONOMIC EFFICIENCY, decentralization, separation of functions
of financing/provision and hospital autonomy. HEALTH SYSTEMS
REFORMS IN LAC: GENERAL TRENDS Slide 19 Office of the Assistant
Director Health Systems Strengthening Area REFORMS LAC (80s &
90s) : CHANGES IN HEALTH CARE SYSTEMS SEGMENTED SYSTEMS Slide 20
Office of the Assistant Director Health Systems Strengthening Area
Inequities in access to and utilization of resources
LIMITATIONS/RISKS OF SEGMENTED SYSTEMS Stratification of the
population causing huge differences in access to services, goods
and opportunities in health, and levels of per capita expenditure
Slide 21 Office of the Assistant Director Health Systems
Strengthening Area Example: Per capita health spending El Salvador
2004 Institution Population covered (% of total population) Per
capita spending US$ Ministry of Health80%48.00 Social Security
(ISSS)17%283.00 Military health services1%247.00 Teachers health
services1%417.00 Inequities in access to and utilization of
resources LIMITATIONS/RISKS OF SEGMENTED SYSTEMS Slide 22 Office of
the Assistant Director Health Systems Strengthening Area SOCIAL
INSURANCE CONTRIBUTIONS INTERNATIONAL GRANTS AND LOANS GENERAL
TAXES PRIVATE PAYMENTS CONTRIBUTIONS FROM HOUSEHOLDS TO COMMUNITY
FUNDS PUBLIC PRIVATE EXTERNAL Segmentation of financial
contributions/ risk pools SOURCES LIMITATIONS/RISKS OF SEGMENTED
SYSTEMS Slide 23 Office of the Assistant Director Health Systems
Strengthening Area Example: MEXICO LIMITATIONS/RISKS OF SEGMENTED
SYSTEMS Segmentation of financial contributions/ risk pools Slide
24 Office of the Assistant Director Health Systems Strengthening
Area Example: Chile LIMITATIONS/RISKS OF SEGMENTED SYSTEMS
Segmentation of financial contributions/ risk pools Slide 25 Office
of the Assistant Director Health Systems Strengthening Area MEXICO
Segmentation of financial contributions/ risk pools
LIMITATIONS/RISKS OF SEGMENTED SYSTEMS Slide 26 Office of the
Assistant Director Health Systems Strengthening Area SEGMENTED
SYSTEMS FROM THE USERS POINT OF VIEW: OUT-OF-POCKET PAYMENTS Slide
27 Office of the Assistant Director Health Systems Strengthening
Area NGO MOHs Health Center Social Security Clinic Hospital
Municipal Ambulatory Operational fragmentation SEGMENTED SYSTEMS
FROM THE USERS POINT OF VIEW: FRAGMENTED DELIVERY NETWORKS Slide 28
Office of the Assistant Director Health Systems Strengthening Area
Health Systems in LAC EQUITY EFFICIENCY LIMITATIONS/RISKS OF
SEGMENTED SYSTEMS Mainstream economics: Trade Off: Equity X
Efficiency Slide 29 Office of the Assistant Director Health Systems
Strengthening Area Segmentation according to ability to pay
Fragmentation of the services delivery network A GHOST THREATENS
HEALTH CARE SYSTEMS IN LAC Slide 30 Office of the Assistant
Director Health Systems Strengthening Area CHALLENGES FOR HEALTH
SYSTEMS STRENGTHENING INTER- INSTITUTIONAL COORDINATION +
OPERATIONAL INTEGRATION Slide 31 Office of the Assistant Director
Health Systems Strengthening Area INTER-INSTITUTIONAL COORDINATION
OPERATIONAL INTEGRATION Strengthening the STEERING ROLE of National
Health Authorities ALIGNMENT AND HARMONIZATION of International
Cooperation INTEGRATED health care delivery networks Reorganization
of health systems based on PHC STRATEGIES Incorporating scientific
KNOWLEDGE from public health programs into the scaling up of health
systems STRATEGIES TO REDUCE/ELIMINATE SEGMENTATION AND
FRAGMENTATION SOCIAL/POLICY DIALOGUE among multiple stakeholders
Harmonization and integration of FINANCING mechanisms CHALLENGES
FOR HEALTH SYSTEMS STRENGTHENING Slide 32 Office of the Assistant
Director Health Systems Strengthening Area FRAMEWORK FOR HEALTH
ACTION IN THE AMERICAS FOR THE XXI CENTURY
Addressingtheunfinishedagenda Protecting the
achievementsFacingthenewChallenges Slide 33 Office of the Assistant
Director Health Systems Strengthening Area POLICY FRAMEWORK FOR
HEALTH SYSTEMS STRENGTHENING primary health care health promotion
social protection in health health as a human right information and
knowledge management Health For All Slide 34 Office of the
Assistant Director Health Systems Strengthening Area LEADERSHIP AND
INSTITUTIONAL CAPACITY BUILDING INFORMATION, KNOWLEDGE AND
INNOVATION PLANNING AND COORDINATION INTELLIGENCE, CREATIVITY, OPEN
DEBATE AND COMMITMENT CHALLENGES FOR HEALTH SYSTEMS
STRENGTHENING