PUBLIC INSURANCES IN PUBLIC INSURANCES IN BOLIVIA BOLIVIA BOLIVIA Ministry of Health and Sports Public Insurances Unit Dr. Margarita Flores
Mar 31, 2015
PUBLIC INSURANCES IN PUBLIC INSURANCES IN BOLIVIABOLIVIA
BOLIVIA
Ministry of Health and SportsPublic Insurances Unit
Dr. Margarita Flores
Ministry of Health and Sports
Health protection, disaggregated by provider – 2003 (National Health Insurance Institute - INASES)
Public health: 30%
Short-term social security (SSCP): 25%
Private health services: 12%
“33% of the Bolivian population is unprotected”
INTRODUCTION
INTRODUCTIONHealth protection, disaggregated by provider – 2003 (INASES)
33%
unprotected population
30%
public health
25%
SSCP
12% private
30% unprotected population
30% public sub-sector
28% SSCP sub-sector
12% private sub-sector
NATIONAL CONTEXT
Health protection coverage, 2004
Sources: National Health Information System - SNIS, National Institute of Statistics - INE and INASES, 2003-2004
National Health Spending, disaggregated by source of financing – 2002 (in thousands of current dollars)
Sources Total Percentage
Public Sector 113,416 20.94%
SSCP
Private Insurance
NGO
Households
Percentage of GDPTOTAL
222,410 41.07%
3.83%
1.49%
541,547
32.67%
6.95%
176,908
8,086
20,727
Source: Estudio CNFGS. Cuentas Nacionales de Financiamiento y Gasto en Salud. Segunda Edición. Marina Cárdenas. Bolivia – 2004.
INTRODUCTION
INTRODUCTION
Public health: US$ 42 per capita
(30%)
SSCP: US$ 91.5 per capita
(25%)
Private: US$ 190 per capita
(12%)
National Maternal and Child InsuranceD.S. 24403 in 199632 Services.
Basic Health InsuranceD.S. 25265 in 199892 Services.
Free Old-Age Health InsuranceLaw 1886 in 1998Comprehensive Health Care.
Universal Maternal and Child Insurance Law 2426 in 2002500 Services.
Expanded SUMI Law 3250 in 200527 Services in Sexual and Reproductive Health, Women of Reproductive Age.
Health Insurance for the Older Adult (SSPAM)Law 3323 in 2006Comprehensive Care, Payment is 100% Municipal.
PUBLIC HEALTH INSURANCES
Current situationCurrent situationSUMISUMI
Current situationCurrent situationSUMISUMI
Ministry of Health and Sports
WHAT IS THE SUMIWHAT IS THE SUMI
Component of of the Bolivian Poverty Reduction Strategy.
It is a state policy and health strategy for reducing maternal and child morbi-mortality.
It provides free services for the child under five years of age and the pregnant woman up to 6 months following delivery, in a compulsory, restrictive manner in public and social security establishments.
The services are provided using the existing technology and problem-solving capacity that corresponds to the levels of care and according to established protocols.
It is a State Policy created by the Law of the Republic 2426
Priority within the Health Policy of the Ministry of Health and Sports
Component of the Bolivian Poverty Reduction Strategy
Primary instrument for meeting the Millennium Development Goals
SUMISUMI
SUMISUMI
Reduce maternal and child morbidity and mortality
Protect the most vulnerable population groups in the country, where the highest mortality rates are concentrated
SUMISUMI
BENEFICIARIESBENEFICIARIES
Girls and boys from birth to five years of age
Pregnant women, from the start of pregnancy until 6 months following the birth
TARGET POPULATION:
– 1,279,269 children under 5 years of age
– 328,682 pregnant women
2002 327,216.99 1,235,582
2003 327,700.37 1,252,157
2004 328,190.95 1,267,325
2005 328,681.52 1,279,269
2006 329,172.10 1,287,469
2007 397,520.00 1,293,130
2008 398,193.00 1,297,041
2009 398,893.00 1,300,020
2010 399,280.00 1,302,868
CHILDREN UNDER 5 YEARS OLD
YEARS EXPECTED PREGNANCIES
POPULATION PROJECTIONS
SOURCE: National Institute of Statistics - INE
SUMISUMI WHERE IS IT PROVIDED?WHERE IS IT PROVIDED?
Throughout the country, in 2,259 health establishments, in urban and rural areas
In Public Health and Short-Term Social Security Establishments (National Health Insurance) and others that are included through agreements
At all levels of care, according to problem-solving capacity and available technology
HOW IS IT PROVIDED?HOW IS IT PROVIDED?SUMISUMI
It is universal, comprehensive and free (For the user)
Provided in a compulsory, restrictive manner
For communities with difficult access or without health infrastructure, there are Mobile Brigades through the Extend (Extensa) Program
EXPANSION OF THE SUMIEXPANSION OF THE SUMI
In December 2005, Law Number 3250 for the expansion of the SUMI was passed
Services that have a close link with safe maternity:
1. Prevention of Cervical Cancer
2. Treatment of Pre-malignant Injuries
3. Voluntary Contraceptive Methods
4. Treatment of STIs
FINANCIAL ADMINISTRATIONFINANCIAL ADMINISTRATIONFINANCIAL ADMINISTRATIONFINANCIAL ADMINISTRATION
Ministry of Health and Sports
Financing of the SUMITributary
Co-Participation7% in 20038% in 2004
10% starting in 2005
Tributary Co-Participation
7% in 20038% in 2004
10% starting in 2005
ExceedsExceeds
Investment in Health Infrastructure, Basic
Sanitation and Special Health Insurance Programs
Lacks Lacks National Solidarity Fund
National Solidarity Fund
Up to 10% of the resources from the Dialogue Account 2000
Up to 10% of the resources from the Dialogue Account 2000
Essential medicines, supplies and reagents
Essential medicines, supplies and reagents
Human Resources
Public: National Treasury - TGN
Social Security: Own resources
Human Resources
Public: National Treasury - TGN
Social Security: Own resources
Ministry of Health and
Sports
ACHIEVEMENTS OF ACHIEVEMENTS OF THE PUBLIC HEALTH THE PUBLIC HEALTH
INSURANCESINSURANCES
ACHIEVEMENTS OF ACHIEVEMENTS OF THE PUBLIC HEALTH THE PUBLIC HEALTH
INSURANCESINSURANCES
Ministry of Health and Sports
Ministerio de Salud y Deportes
One of the contributions of the Public Insurances implemented in the country is the reduction of the mortality rates. Although this represents an important process, we remain nevertheless the country with the second highest maternal mortality ratio and child and neonatal mortality rates.
Contribution to reductions in the Mortality Rates
ENDSA: Demographic and Health Survey
Source : Monitoring and Evaluation of the Poverty Reduction Strategy – PRS
75
92
116
142
0
20
40
60
80
100
120
140
160
ENDSA 89 ENDSA 94 ENDSA 98 ENDSA 03
De
ath
s x
1,0
00
liv
e b
irth
sMORTALITY RATES IN CHILDREN < 5 YEARS OLD
-47%
54
6775
96
0
20
40
60
80
100
120
ENDSA 89 ENDSA 94 ENDSA 98 ENDSA 03
De
ath
s x
1,0
00
liv
e b
irth
s
INFANT MORTALITY RATES < 1 YEAR OLD-44%
INFANT MORTALITY RATES < 1 YEAR OLDP
er
1,0
00 li
ve b
irth
s
Infant MR
Urban
Rural
Years
MATERNAL MORTALITY RATEP
er
10
0,0
00
live
bir
ths
Years
MDGs
PRS Project
5%
9%
5%18%
27%
1%
6%
4%
25%CHUQUISACA
LA PAZ
COCHABAMBA
ORURO
POTOSÍ
TARIJA
SANTA CRUZ
BENI
PANDO
PERCENTAGE OF TRIBUTARY CO-PARTICIPATION BY DEPARTMENT, SUMI 2004
81%
19%
135,558,560.00 100% Amount Paid Out109,590,618.00 81% Amount Utilized25,967,942.00 19% Unused Balance - Surplus
MUNICIPAL TRIBUTARY CO-PARTICIPATIONSUMI 2004
Expressed in Bs. and %
DepartmentsTotal
Municipalities
Municipalities that
accessed funds%
La Paz 75 2 3%Cochabamba 44 4 9%Santa Cruz 50 10 20%Chuquisaca 28 4 14%Potosí 38 1 3%Tarija 11 2 18%Oruro 34 0 0%Beni 19 3 16%Pando 15 2 13%
314 28 9%
Percentage of Municipalities that accessed the National Solidarity Fund (FSN), by Department 2004
61%
39%
Porcentaje de ejecución
Porcentaje no ejecutado
28,172,160 100.00% Amount Allocated
17,313,275 61.46% Amount Utilized
10,858,885 38.54% Balance Not Utilized
NATIONAL SOLIDARITY FUNDSUMI - 2004 - Expressed in Bs.
Percentage used
Percentage unused
ANALYSIS OF THE S.U.M.I.ANALYSIS OF THE S.U.M.I.
Expansion of Coverage and Services,
Extension of Health to impoverished sectors,
Participation in Service Networks,
Standardization of care through Protocols,
Overall reduction of Maternal and Child Mortality,
Insufficient Information in the National SUMI Management Unit,
Lack of Technical Provisions in the Presentation and Application of the SUMI Expansion Law,
Mechanisms for controlling deficient Affiliation,
Unreal reference costs for services,
Care for the SUMI target population, with preference for the third level of care,
Irrationality in the selection of services and packages by level,
Complexity in administrative processes,
Bureaucracy and deficient management at the municipal level, which impedes timely payment to health establishments for services provided under the SUMI
Population that is highly concentrated in urban areas (64%), principally in the capital cities of La Paz (Including El Alto), Cochabamba and Santa Cruz
Work-related instability and high rotation of personnel, without information about the procedures, knowledge and norms for new human resources in the management sphere
Problems identified
ChallengeChallengeUNIVERSAL HEALTH UNIVERSAL HEALTH INSURANCE (SUSINSURANCE (SUS))
Ministry of Health and Sports
Gathering the experiences with public insurances, as a gradual building process, in
order to achieve UNIVERSAL HEALTH INSURANCE - SUS
FROM THE CURRENT GOVERNMENT AND THE MINISTRY
OF HEALTH AND SPORTS
FROM THE CURRENT GOVERNMENT AND THE MINISTRY
OF HEALTH AND SPORTS
UNIVERSAL HEALTH INSURANCEUNIVERSAL HEALTH INSURANCEOBJECTIVEOBJECTIVE
ACHIEVE ACCESS TO HEALTH SERVICES FOR THE ENTIRE BOLIVIAN POPULATION, THROUGHOUT THE WHOLE NATIONAL TERRITORY AND IN A COMPREHENSIVE MANNER
•Participation of the entire National Health System,
•Improve the quality of medical care,
•Implement the Model of Family, Community and Intercultural Health as an operational arm of the Insurance,
•Ensure that Health Promotion and Prevention are pillars of the Health System,
•Establish instruments to provide quality and efficiency in the provision of Health Services.
UNIVERSAL HEALTH INSURANCEUNIVERSAL HEALTH INSURANCESPECIFIC OBJECTIVESSPECIFIC OBJECTIVES
Source of FinancingPercentag
eUS$ / Annual
Municipal Tributary Co-participation
10%30,500,000
HIPC-II* ResourcesNational Solidarity Fund
10% 2,900,000
HDI (Human Development Index) by Prefecture
14% 32,400,000
T O T A LT O T A L 65,800,00065,800,000
First PhaseYears 0-21
Implementation January2007
* HIPC: Heavily Indebted Poor CountriesSource: Ministry of Housing
SOURCE OF FINANCINGSOURCE OF FINANCING
Population Over Age 60
(SSPAM)6%
Short-Term Insured
Population (National Health
Insurance)25%
S.U.S. Target
Population69%
TARGET POPULATIONTARGET POPULATION
From 0 to 59 Years of AgeFrom 0 to 59 Years of Age
Legal Study
Socio-Economic
Study
Study ofthe
EpidemiologicalProfile
ActuarialMathematic
Study
SustainabilityStudy
Medical Technical
Study
Multi-disciplinaryTechnical
Team
CoveragePremium
SUS TargetPopulation
UNIVERSAL HEALTH INSURANCEUNIVERSAL HEALTH INSURANCE ANALYSIS FOR ITS IMPLEMENTATIONANALYSIS FOR ITS IMPLEMENTATION
FIRST PHASE
2006 ADMINISTRATIOND.S. 28748 – Financing of the harmonization of Health insurance measures- from years 5 to 21-
Development of the draft project for the SUS Law
REQUIRED STUDIES
Study of Population Projections,
Actuarial Study disaggregated by levels of care,
Analysis and Evaluation of the Cost-Effectiveness of Public Insurances,
Study of the structure of costs based on Public Insurances,
UNIVERSAL HEALTH INSURANCE UNIVERSAL HEALTH INSURANCE
FIRST PHASE
2006 ADMINISTRATIONREQUIRED STUDIES
Study of general costing of SUS services,
Study of the Sustainability and Economic-Financial Viability of the SUS,
Analysis of information on prevalent pathologies using statistics from the National Health Information System - SNIS, the National Health Insurance Institute - INASES, the National Health Insurance - Cajas de Salud, and others,
Analysis of information on Incidence, Prevalence and Frequency
Technical-medical-financial proposal for the Universal Health Insurance
Analysis of indicators.
UNIVERSAL HEALTH INSURANCE UNIVERSAL HEALTH INSURANCE
FIRST ACHIEVEMENT
D.S. 28748 – Financing of the harmonization of public health insurance measures
SECOND ACHIEVEMENT
Draft project of the SUS Law
THIRD ACHIEVEMENT
Health Care Model: Family, intercultural and community
Quality management
UNIVERSAL HEALTH INSURANCE (SUS) 2006 Administration
UNIVERSAL HEALTH INSURANCE (SUS) 2006 Administration
“THOSE THAT ATTEMPT REFORM WILL HAVE AS ENEMIES EVERYONE THAT TAKES ADVANTAGE OF THE OLD SYSTEM, AND AS WARM ADMIRERS ONLY THOSE THAT HOPE TO OBTAIN SOME TYPE OF BENEFIT FROM THE NEW ORDER”
Anonymous
Ministry of Health and Sports