Eduardo Levcovitz, MD, MSC, Ph.D Unit Chief, Health Policies and Systems Development

1. Health Systems Strengthening Workshop Belize, May/June2006 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

2. Health Systems Strengthening Workshop Belize, May/June2006 OUTLINE • DYNAMICS OF HEALTH POLICIES • HEALTH SYSTEMS CHANGES/ REFORMS IN LAC • Monitoring and Evaluation • General Trends • THE WAY AHEAD • Challenges for health systems strengthening

3. EVOLUTION OF THE ETHICS/IDEOLOGIES/VALUES IMBEDDED IN HEALTH POLICIES Public assistance and charity for the poor and indigent Welfare state UNIVERSAL SOCIAL PROTECTION AS CITIZENSHIP RIGHTS Segmented systems according to ability to pay FormalSocial Security for industrial workers XXIst Century 50’s/70’s 80’s/90’s 20’s/40’s XXth Century

4. 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. Resolutions PAHO-CSP26/12-2002 and WHA58.33 – 2005

5. INTRINSIC ELEMENTS OF HEALTH AND SOCIAL POLICIES IDEAS VALUES PRINCIPLES INFORMATION KNOWLEDGE INTERESTS

6. DIMENSIONS OF THE HEALTH SECTOR Politics (Power, “Gobernability”) Social Protection (citizenship right) HEALTH SECTOR Industrial (economic interest) Ethics (respect to life)

7. DIMENSIONS OF THE HEALTH SECTOR • Social Protection: Subsystem of the Welfare State • Industrial: Subsystem of the Industrial Capitalist State • Politics: Subsystem of the Democratic Pluralist State • Ethics: Subsystem of the Code of Global, Regional and NationalValues/Commitments of each Country/Society

8. HEALTH SYSTEMS IN LAC 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 NATIONAL HEALTH SERVICE SOCIAL HEALTH INSURANCE PRIVATE SEGMENTED SOCIAL INSURANCE PUBLIC ENTREPRENEURIAL

9. TYPOLOGIES OF HEALTH SYSTEMS With the exception of the MENDELEYEV’s PERIODIC TABLE OF ELEMENTS… ….. any other typology or classification is arbitrary.

10. HEALTH SYSTEMS REFORMS IN LAC: MONITORING AND EVALUATION www.lachsr.org

11. HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS HEALTH REFORMSPUBLIC SECTOR REFORMS Look doctor, my glucose raised until 250 than went down to 85 and than raised again to 170 It looks like deregulation reached even the diseases Health SystemsReforms 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 1980´s and 1990´s

12. 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 – IFI’s

13. HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS Health • HSR did not increase INVESTMENT IN HEALTH, even within a context of some increase in social expenditures

14. HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS • 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

15. HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS (5) • HSR were NOT CONVERGENT WITH THE SOCIAL SECURITY REFORMS in a way to generate synergistic actions to expand coverage of social protection

16. HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS • 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

17. HEALTH SYSTEMS REFORMS IN LAC : GENERAL TRENDS • 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 CARE PREVENTION PROMOTION EPHF in the Americas

18. HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS • 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.

19. LAC (80’s & 90’s) : CHANGES IN HEALTH CARE SYSTEMS REFORMS SEGMENTED SYSTEMS

20. LIMITATIONS/RISKS OF SEGMENTEDSYSTEMS Inequities in access to and utilization of resources • Stratification of the population causing huge differences in access to services, goods and opportunities in health, and levels of per capita expenditure

21. LIMITATIONS/RISKS OF SEGMENTEDSYSTEMS Inequities in access to and utilization of resources Example: Per capita health spending El Salvador 2004

22. LIMITATIONS/RISKS OF SEGMENTEDSYSTEMS Segmentation of financial contributions/ risk pools SOURCES SOCIAL INSURANCE CONTRIBUTIONS GENERAL TAXES PUBLIC PRIVATE CONTRIBUTIONS FROM HOUSEHOLDS TO COMMUNITY FUNDS PRIVATE PAYMENTS EXTERNAL INTERNATIONAL GRANTS AND LOANS

23. LIMITATIONS/RISKS OF SEGMENTEDSYSTEMS Segmentation of financial contributions/ risk pools Example: MEXICO

24. LIMITATIONS/RISKS OF SEGMENTEDSYSTEMS Segmentation of financial contributions/ risk pools Example: Chile

25. LIMITATIONS/RISKS OF SEGMENTEDSYSTEMS Segmentation of financial contributions/ risk pools MEXICO

26. SEGMENTED SYSTEMS FROM THE USER’S POINT OF VIEW: OUT-OF-POCKET PAYMENTS

27. SEGMENTED SYSTEMS FROM THE USER’S POINT OF VIEW: FRAGMENTED DELIVERY NETWORKS Operational fragmentation Hospital NGO Municipal Ambulatory Social Security Clinic MOH’s Health Center

28. LIMITATIONS/RISKS OF SEGMENTEDSYSTEMS Mainstream economics: Trade Off: Equity X Efficiency Health Systems in LAC EQUITYEFFICIENCY

29. A GHOST THREATENS HEALTH CARE SYSTEMS IN LAC Segmentation according to ability to pay Fragmentation of the services’ delivery network

30. CHALLENGES FOR HEALTH SYSTEMS STRENGTHENING INTER-INSTITUTIONAL COORDINATION + OPERATIONAL INTEGRATION

31. CHALLENGES FOR HEALTH SYSTEMS STRENGTHENING Strengthening the STEERING ROLE of National Health Authorities INTER-INSTITUTIONAL COORDINATION SOCIAL/POLICY DIALOGUE among multiple stakeholders Harmonization and integration of FINANCING mechanisms STRATEGIES TO REDUCE/ELIMINATE SEGMENTATION AND FRAGMENTATION ALIGNMENT AND HARMONIZATION of International Cooperation INTEGRATED health care delivery networks Reorganization of health systems based on PHC STRATEGIES OPERATIONAL INTEGRATION Incorporating scientific KNOWLEDGE from public health programs into the scaling up of health systems

32. FRAMEWORK FOR HEALTH ACTION IN THE AMERICAS FOR THE XXI CENTURY Addressing the unfinished agenda Protecting the achievements Facing the new Challenges

33. social protection in health health promotion health as a human right primary health care information and knowledge management POLICY FRAMEWORK FOR HEALTH SYSTEMS STRENGTHENING Health For All

34. CHALLENGES FOR HEALTH SYSTEMS STRENGTHENING • LEADERSHIP AND INSTITUTIONAL CAPACITY BUILDING • INFORMATION, KNOWLEDGE AND INNOVATION • INTELLIGENCE, CREATIVITY, OPEN DEBATE AND COMMITMENT • PLANNING AND COORDINATION