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Dr. Armando De Negri Filho armandodenegri@yahoo

Towards universal, comprehensive and equitable National Health Systems: The 20 Years Brasilian Experience in its context. Dr. Armando De Negri Filho armandodenegri@yahoo.com PHM – Brasil / World Social Forum on Health / International Society for Equity on Health

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Dr. Armando De Negri Filho armandodenegri@yahoo

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  1. Towards universal, comprehensive and equitable National Health Systems:The 20 Years Brasilian Experience in its context Dr. Armando De Negri Filho armandodenegri@yahoo.com PHM – Brasil / World Social Forum on Health / International Society for Equity on Health Cairo IPHU Short Training Course – March 23, 2008

  2. People - Human Rights - Centered Health Systems X Market driven health services – (systems?)

  3. The basis of the political debate around the human rights approach for health, generating a political movement and its conquests… The indivisible triad for the right to health: • Universality means for every person during the entire life • Comprehensive means all individual and social needs all life long – means to achieve the integral / full answer to the needs derived from the interdependent rights understood as a system / all necessary to make rights real • Equity means social justice achieved trough the warranty of all people rights on time for their needs, with no differences to who have the same needs. It implies the equity on the access to the resources on policies, its financing, its services, quality of care and the health and social results of its application.

  4. EQUITY… • The equity approach does not establish the “minimum” but generates the tension between the the necessary (what is fair, just, the right) for everybody and the already possible for some individuals or groups (the privileges)… • The very illustrative example of the crossed subsides and the per capita inequities… • Inequities as the distance of each group in relation to the desirable fair / right, and the intolerable differences between groups in relation to the desired standard of the rights achievement

  5. The good, for all, the fair, the desirable as an expression of the logic and doctrine of the social and human rights – “the reasonable” A B C Inequities among groups Distance towards what is good, fair, desirable

  6. INFANT SURVIVAL / CHILDREN QUALITY OF LIFE CHILDREN DEVELOPMENT LITERACY OF THE MOTHERS - - + + ADECUATED HOUSING MOTHERS EMPLOYMENT AND OTHER ASSOCIATED VARIABLES INSPIRED BY DIMENSIONS AND CONTÍNUUMSOFMAX WEBER

  7. Insurances ????? INEQUITY Universality Targeting EQUITY INSUFFICIENCY Tax funded Inspired by :Targeting and Universalism in Poverty Reduction, Thandika Makandawire, UNRISD, dic. 2005. Armando De Negri Filho, 2006

  8. According to Dr. Tandika the concern with “efficiency” of the public systems increased at the same time that the redistributive justice and social development concerns are reduced or disappeared.

  9. The “estructured pluralism”:neoclassical theories and the neo institucionalism for the health reforms in Latin America(WB, 1987, 1993; Frenk and Londoño, 1997) Dr. Mario Hernandez Alvarez, 2006 Private goods: Diseases centered health care Public goods:Actions towards health problems with high externalities (Public Health) Rational elections Descentralized State Regulated market of health insurances Principal agent delegation Targeted Subsidies to the demands Incorporation of the poor to the market via public / state assistance Regulated competition

  10. Brasil - Population and Territory • Territorial extension – 8,5 millionsof Km2 • Population – 194 millions • 05 geopolitical macroregions • 26 states + Federal District • 5561 municipalities Ceará Pará RG do Norte Amazonas Paraíba Piauí Tocantins Pernambuco Mato Grosso Alagoas Sergipe Bahia Goiás Brasília Minas Gerais Mato Grosso do Sul Espirito Santo Rio de Janeiro São Paulo (FOSP) Paraná Santa Catarina Rio Grande do Sul

  11. The Brazilian Experience in the conquest of the Human Right to Health • The formulation of a concept and its political intention – the brazilian social health reform as the expression of the struggle for health as a right of every woman and man in the country  • The conquest of a new concept to order the health system – trough a political mobilization motivated by the insatisfied needs of the population regards their fundamental rights • Political achievements at the VIII National Health Conference in 1986 and the New National Constitution adopted in 1988

  12. The SUS (Unique Health System) • 1988 National Constitution: “Health is a right of everyone and the duty of the State” • The SUS: ensemble of policies, services and actions that are developed by state institutions of the three levels of government – national, regional and local, with complementary participation of the private sector – composing a public organization oriented to fulfill the universal right to health with comprehensiveness and equity. Public Dimension composed by: 1 - State owned structures 2- Non profit private and private for profit Ordered by public contracts

  13. The principles of the SUS • Universalaccess; • Comprehensive care; • Equality on access and quality of care; • Social and community participation with decision power; • Descentralization of the system management with exclusive direction at each level of government.

  14. Our experience in this process: • The Federal Constitution of 1988 and the Organic Laws of 1990: • Law 8080 of 1990, establish the definitions of an unique national health system in order to warranty the organization of an unique national public health system to make real the universality, the comprehensiveness and the equity in terms of health for all population, establishing the public orders that will discipline the private activities – building the public esphere composed by the state owned services and the private services, oriented by the constitutional public relevance that health has achieved nationally and internationally

  15. Our experience in this process: • The organic law 8142/90, establish the creation and the implementation of the health councils, and the conferences, • The councils are health decision making bodies at each level of the republic: national, regional / states and local / municipalities.

  16. National Conferences of Health Union the SUS National Council of Health Ministery of Health CIT InterManagers Comission Tripartite Municipal secretaries State Secretaries CIB InterManagers Comission Bipartite States Municipalities State Council of Health Municipal Council of Health

  17. Our experience in this process: • The radical descentralization – as radical democratization - towards the municipalities – NOB 93  • The creation of the intergovernment agreement bodies – Primary Health Care minimun value transfer - NOB 96 • In search of the financing estability – CPMF and constitutional amendement 29 (2000), towards its regulamentation (2008) • The struggle for enough financing support and the human resources on health.

  18. SUS Financing Health Ministery State Secretaries Municipal Secretaries Health Units National Fund State Funds Municipal Funds National Budget 9,8% of General Income of the State Municipal Budgets 15% State Budgets 12%

  19. The State is the rector, financer, regulator and provider. • Regular and automatic transference of financial resources among the health funds. • Totally free care, financed by the global tax income of the State. • **Public Expenditure is 50% of the total health expenditure, around 160 dollars per capita / per year`. 3,7 % of the GNP.

  20. Our experience in this process: • Today the system is already installed in all the 5561 municipalities, where there are health local authorities and health councils, as well as health plans established. • There are health goals established and compromises of accomplishment, public accountability exercises each three months and transparency trough a web system - SIOPS. • There is a daily struggle to keep and perfeccionate the System as an integral health care system.

  21. Sistema Único de Salud GENERAL DATA ABOUT THE OUPATIENTS CARE IN THE SUS 63.650 Ambulatory Units that produced in average of 153 millions of medical care per year • Per year / year base 2006 • 1 billion of procedures of primary health care 251 millions of clinical lab tests 8,1 millions of ultrasound examinations 132,5 millions of high complexity care 140 millions of vaccines applied 150 mil persons receiving ARTV

  22. Sistema Único de Saude SUS GENERALES DATA ABOUT INPATIENT CARE IN THE SUS 5.794 Hospitals / 441.045 hospital beds/ 900 thousand patients are admitted per month/ 11,7 millions of admissions per year • Per year / year base 2006 2,6 millions of child deliveries 83.000 cardiac surgeries 60.000oncological surgeries 92.900 varices surgeries 23.400 organ transplantations

  23. A Primary Health Care Strategy as a political decision related to the building of an universal health system Situationof the Implementation of Family Health Teams, Dental Health and Community Health Agents BRASIL, APRIL/2003 ESF/ACS/SB ESF/ACS ACS ESF SEM ESF, ACS E ESB Nº TEAMS – 17.608 Nº MUNICIPALITIES - 4.276 Nº AGENTES – 177.367 Nº MUNICIPALITIES - 5.078 Nº TEAMS OF ORAL HEALTH – 4.568 Nº MUNICIPALITIES – 2.451 FONTE: SIAB - Sistema de Informação da Atenção Básica

  24. Evolution of the Number Family Teams Implemented BRASIL - 1994 – ApRIL/2003 ESF FONTE: SIAB - Sistema de Informação da Atenção Básica

  25. “Family Health” a ComprehensivePrimary Health Care StrategyFigures of 2007 • 28.000 teams with a full time team: medical doctor, nurse, 1-2 auxiliary nurses , 4 to 6 community health agents for each 800 to 1200 families. • 235.000 community health agents • 14 thousand teams of dental care (dentistry professional, dental technician and a dentistry consultant assistant) at more than 5000 municipalities with 476 specialized centers

  26. National Network for Emergencies Health Care • At march 2007: • Pre Hospital Care began 2003 • Now there are 113 emergency medical regulatory centers that make medical coordination 24 hours a day • 1358 ambulances ( 360 for Advanced Life Support with MD) • 92.539.000 inhabitants covered • 925 Municipalities covered • Humanization of 120 hospital emergency services

  27. Pharmaceutical Assistance • List of Essential Drugs for free provision for a patients doing follow up at the PHC and beyond • Popular Drugstore / commercial establishments convened / prices control

  28. SUS – next steps and its challenges • Financial stability and sufficiency • Human resources profiles and economical sustainability • New health care mode – promotional strategy – a possible pathway – universal, comprehensive and equitable answer to the social (health) needs of the people / needs derived from the human and social rights

  29. **BySocial Classes and itsSocial Territories **By Genders Four Structuring Projects **By Ethnics Structuring Project on Equity in the Quality of Life and Health of the Childhood Structuring Project on Equity in the Quality of Life and Health of the Teenagers and Youth Structuring Project on Equity in the Quality of Life and Health of the Adults Structuring Project on Equity in the Quality of Life and Health of the Elderly **with three transversal perspectives

  30. SOCIAL LIFE ITINERARY OR VITAL CYCLE Territories or social classes Sex or genders EthnicsandRaces

  31. Physical Activity Nutrition/Food Security Adictions Discapacities Ocupation Environments ADP-CDD ADP-IPD ADP-SRH SPEQLH - CH SPEQLH TEEN/YOUTH SPEQLH - ADULTS SPEQLH - ELDERLY ADP - ORAL ADP-INJURIES ADP-MH ZeroVision Transversal Project on Autonomy Development

  32. Government and social movements agendas ZERO VISION AS INTERNATIONAL STANDARD NATIONAL STANDARD DYNAMICS OF ZERO VISION BEST GROUP STANDARD SOCIAL NETWORKS BEST INTERNAL OR LOCAL STANDARD Progressive answer to the deficits and gaps

  33. SOCIETY Social Estratification (I) INDIVIDUALS Influencesover the estratification (A) Social Position Differential frailty III Reducing the social exposures(B) Acces to public systemsand services Social Context Differential Exposition II Especific exposures Reducing the frailty (C)damage and illness prevention / health protection Differentials on consecuences IV Preventing inequities on the social consequences of the damages or diseases / injuries (D) Disease Treatment / Social Protection Disease, injury or damage Political Context Impacts on Social Estratification(I) Social and EconomicalConsequences of the health –disease process Mechanisms that act in the stratification of the health achievements Adapted by Armando De Negri Filho from the original of Diderichsen and Hallqvist - 1998 Entrance points of the state or public policies

  34. SOCIAL INCLUSION WITHIN THE FRAME OF THE HUMAN DEVELOPMENT ECONOMICAL SECURITY SOCIAL SECURITY SECTORIAL POLICY ON HEALTH TOWARDS EQUITY

  35. Necessary impact at 5 fronts of social inclusion: • -with universalistic public policies as in the case of health, education and social security as a protection against inequities and against the loss of opportunities. • -at the taxes policies in order to be progressive - fair • -at the transference of richness and universal income • -at the strenghtening of the participative democracy and the democratic institucionality • -at the promotion of job quality, safety and income level, social security inclusion Comprehensive answers to the radical needs of people as expression of their radical social needs at defined social territories.

  36. World Conference on the Development of the Universal Health and Social Security Systems • An initiative of the II World Social Forum on Health, as decided in the Thematic Final Plenary of the VII World Social Forum / Nairobi in January 2007 • Host Organization – the National Health Council of Brasil • Place and date: Brasilia – last week of November 2008

  37. Objectives • 1.To permit a equitable dialogue among governments, parliaments, academic institutions, intergovernmental agencies and social, popular and labor movements about the development of universal systems as an alternative for countries and regions • 2.To strength the existing universal health systems through the share of its historical experiences, achievements and challenges • 3.To stimulate other countries, governments and societies to adopt the universal, comprehensive and equitable systems as a valid and feasible option on the process of the national reforms and the regional integration process • 4.To develop the necessary approach of the role of universal systems in its relationships with the economical and social development of the countries towards poverty eradication and social justice as equity • 5.To establish a network of governments, movements and academic institutions motivated to develop the policies, systems and services / actions, technologies and human capacities towards universal, comprehensive and pro-equity in health and social security.

  38. Program Subjects 1/3 • 1. The political/ ethical basis for the assumption and development of universal, comprehensive and pro-equity systems of health and social security – historical background and present rationality – national, regional and international perspectives • 2. The economical feasibility and the political sustainability of the universal approach – analysis of conceptual frameworks, tax systems and universal and comprehensive insurances with case studies from the various Continents

  39. Program Subjects 2/3 • 3. The dynamics of the technological incorporation and dependency, intellectual property, research patents policy and the sovereignty around the universal systems • 4. The challenge of the human resources for the development of universal systems – professional profiles, careers and salaries, brain drain, public investment and the educational policies • 5. The state / private relationship and the building of national and international public goods around the universal systems • 6. Health and welfare social accountability of the universal systems, relationship with poverty erradication efforts and multidimensional development - achievements and challenges

  40. Program Subjects 3/3 • 7. The roles of international aid and cooperation and humanitarian aid ( north-south, south-south and multilateral, private) and its potentials and compromises regards the development of universal systems • 8. An international network of governments, social and popular movements and academic centers to support the development of universal systems • 9. Management challenges and new capacities needed in the development of universal systems • 10. Democracy strenghtening and protagonic social participation in the development and dynamics of universal systems

  41. Goals Participation: • Around 750 participants • From 75 countries Preparatory meetings already considered: • In Senegal for western Africa • In Angola for southern Africa • In the WHA of WHO • In Spain, Belgium or Italy for Occidental Europe (?) • In Argentina for Southern America • In Venezuela for the Andean and Caribbean Region • In Sweden for Scandinavian Countries • New ideas: north african countries in Tunisia ? , Middle East in Lebanon ?,

  42. Thank you for your attention! armandodenegri@yahoo.com

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