Experiences and Lessons Learned from the Region of the Americas: Case Studies

1. Experiences and LessonsLearned from the Region of the Americas: Case Studies Regional Consultation Meeting: Integrated Health Services Networksand Vertical Programs Cusco, Peru 11 and 12 November 2009 Hernán Montenegro and Caroline Ramagem Area of Health Systems and Services PAHO/WHO

2. Content • Background • Summary of case studies • Lessons learned • Facilitating factors and barriers • Future PAHO work

3. Health Services Fragmentation Poor performance of health services • Access problems • Poor technical quality of services • Inefficient use of resources • Increased production costs • Low levels of user satisfaction Other causes of poor system performance (For example, insufficient financing, weak governance of the health authority, lack of qualified human resources, etc.) Why Integrate Service Networks and Vertical Programs?

4. Integration Initiatives in LAC

5. Progress of PAHO Technical Cooperation on Services Integration *Link with Global Health Initiatives.

6. Summary of Case Studies Lima Workshop, 9 November 2009

7. Some General Observations On cases: • Diversity of experiences reflect the regional reality • Of the 11 cases: • 4-5 cases: exemplify fragmentation or have had little success in terms of integration, including sustainability • 6 cases: varied success in terms of integration and improvements in access, quality, efficiency, social participation, and impact on health* On the dynamic of the discussion: • Issue that arouses passions • Positions were identified • Confusion in managing basic concepts of integration(what is understood as a vertical program)

8. Framework to Analyze the Implementationof Health Policies Context Actors As individuals As members of groups Contents Processes Walt and Gibson (1994)

9. Lessons Learned

10. Facilitators: Political commitment and backing Availability of financial resources Leadership of health authorities and service managers Decentralization and flexibility of local management Alignment of financial and nonfinancial incentives Culture of collaboration and teamwork Active participation of stakeholders Structural barriers: Segmentation and weakness of health systems Reforms of the 1980s and 1990s: Privatization of insurance Differentiated service portfolios Provider competition Diversification and instability of labor regimes Regressive cost-recovery schemes Powerful opposing Interest groups: Specialists and super-specialists* Private insurers and social security Pharmaceutical industry, supply industry , etc. External financing modalities (Global Health Initiatives) Nonstructural barriers: Deficiencies in information, monitoring, and evaluation systems* Management weaknesses Facilitating Factors and Barriers

12. Future Work for PAHO • Integrated Health Services Networks: • Consolidate work on integrated health services networks • Integration of Vertical Programs: • Produce a position paper that addresses: • Definitions and analytical framework • Indications for vertical programs, being the exception • Strategy for integrating programs into health systems • Develop technical cooperation that provides: • Instruments • Direct technical assistance • Educational programs • Research