Building the Foundations for Better Health

1. Building the Foundations for Better Health Health Services Organization

2. Policy Options for the Integration of Health Systems and Services VII REGIONAL FORUM Strengthening of Health Systems Based on Primary Health Care (PHC) Quito, Ecuador 29-31 October 2007

3. Health Systems Based on Primary Health Care Universal coverage First contact Intersectoral action Comprehensive, Integrated, and continuous care Capacity to respond to health needs Resources adapted to needs Focus on quality Family and community orientation Intersectoral approach Right to Health Adequate human resources Equity Responsibility and accountability Emphasis on promotion and prevention Participation Solidarity Optimal organization and management Social justice Appropriate care Sustainability Pro-equity policies and programs Mechanisms for active participation Acceptable legal, policy, and institutional framework

4. Health Services • The greatest challenge in terms of the organization and delivery of health services is fragmentation.

5. Policy Options for the Integration ofHealth Systems and Services • Starting Point … • Segmentation of health systems and fragmentation of health services • Pressures on health systems • Shortcomings of care and organizational models • Progress worldwide and in countries of the Region

6. Fragmentation Problems • Quality of Care and Results • Lack of continuity in care • Lack of coordination between the first level and specialized levels of care • Many practices and interventions are not evidence-based • Wide variety of clinical practices • No incentives for health promotion • Costs • Inefficient management of resources - Duplication (services,procedures, diagnostic tests, etc.) • Lack of incentives for quality. Disparitybetween levels of care

7. Policy Options for the Integration ofHealth Systems and Services • The Tower of Babel? : • Networks: • “Not all networks are integrated networks” • Coordination – Integration • Segmentation and Fragmentation • Primary health care (PHC) vs. primary care or first-level of care • Public health and public health services

9. Policy Options for the Integration ofHealth Systems and Services What does the project aim to contribute?

10. Policy Options for the Integration ofHealth Systems and Services • Key questions: • What is the most appropriate response to the fragmentation of health services and the problems that it creates? • What defines an Integrated Health Services Network? • How can we measure the extent of health services integration? • How can we address the organization of integrated networks?

11. Definitions: • Integrated Delivery Systems (IDS): “An integrated system is a network oforganizations that provides, or is organized to provide, ongoing and coordinated services to a particular population, and that takes responsibility for the clinical and financial results and the health outcomes of the population it serves. These systems, widely participatory and vertically integrated, offer a wide range of outpatient and in-patient services, care for acute and chronic illness, and home care.” (Shortell et al.)

12. Additional elements: • Based on the Primary Health Care Strategy and coordinated from the first level of care • With geographic responsibility • Integrated vertically and coordinated horizontally • Also integrates public health services

13. Policy Options for the Integration ofHealth Systems and Services • An expanded definition: Integrated Systems of Health Services: “A network of organizations that provides, or is organized to provide, ongoing services based on primary health care and coordinated from the first level to a particular population in a particular territory, and that is accountable for the clinical and financial results and the health status of the population it serves. These systems, widely participatory, vertically integrated, and horizontally coordinated, offer a wide range of services to address the ongoing needs of their users, from promotion and prevention to outpatient and in-patient services, care for acute and chronic illnesses, home care, rehabilitation, palliative care, and public health services.”

14. Policy Options for the Integration ofHealth Systems and Services • Attributes of integrated networks: • Reference population is in a defined area • Support systems are organized • Health needs and priorities • Scope of services • Distribution of roles • Integrated and coordinated care model • Measurement of the impact of services

15. Policy Options for the Integration ofHealth Systems and Services • Strategic and operational attributes for measuring integration: • Governance • Financial mechanisms • Management of the network • Computer support systems • Integration mechanisms • Identification of health needs • Care model • Intersectoral action • Monitoring and evaluation model • 62 Operational Attributes

16. Evaluation of the Health Services Network

17. Policy Options for the Integration ofHealth Systems and Services • Policy options for integration: • Options for governance: • Legal security for organization in an integrated network • Legal structure and framework for governance • Financing, payment mechanisms, incentives, financial protection for the population • Options for financing: • Capitation • New payment mechanisms for providers • Incentives

18. Policy Options for the Integration ofHealth Systems and Services • Insurance policies and protection of the population • Policies for the procurement of services • Public providers • Private providers • Public-private participation (legal framework) • Policies for the organization of services • Care model • Vertical integration and horizontal coordination

19. Policy Options for the Integration ofHealth Systems and Services • Policies for the generation and use of resources: • Human resources policies • Education • Training • Substitution • Continuing education • Evaluation and introduction of technologies

20. Policy Options for the Integration ofHealth Systems and Services • Phases in the configuration of integrated health services systems • Situation analysis of health care and population-based health networks • Definition of the care model • Delimitation of health areas and levels of care • Design of services network • Configuration of the first level of care • Configuration of the second and third levels of care • Configuration of support services and logistical systems • Vertical integration of the services network • Configuration of the governance model • Design of monitoring and evaluation systems.

21. Success Factors • Align the delivery network with community needs • Strengthen primary health care and the first level of care • Strengthen and integrate the information system • Provide relevant information on costs, quality, and clinical results • Adopt a culture of shared risk • Align suppliers, managers, and government structures.

22. Health Systems Based on PHC Universal coverage First contact Intersectoral action Comprehensive, integrated, and continuous care Capacity to respond to health needs Resources adapted to needs Focus on quality Family and community orientation Intersectoral approach Right to Health Adequate human resources Equity Responsibility and accountability Emphasis on promotion and prevention Participation Solidarity Optimal organization and management Social justice Appropriate care Sustainability Pro-equity policies and Programs Mechanisms for active participation Acceptable legal, policy, and institutional framework

23. Building the Foundation for Better Health Health Services OrganizationIntegrated Hospitals and Health Services Systems Dr. Reynaldo Holder Regional Adviser holderre@paho.org