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Eduardo Levcovitz, MD, MSC, Ph.D Chief, Health Policies and Systems Unit “SOCIAL PROTECTION IN HEALTH FOR WOMEN, NEWBORNS AND CHILDREN IN LAC” Regional.

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Presentation on theme: "Eduardo Levcovitz, MD, MSC, Ph.D Chief, Health Policies and Systems Unit “SOCIAL PROTECTION IN HEALTH FOR WOMEN, NEWBORNS AND CHILDREN IN LAC” Regional."— Presentation transcript:

1 Eduardo Levcovitz, MD, MSC, Ph.D Chief, Health Policies and Systems Unit “SOCIAL PROTECTION IN HEALTH FOR WOMEN, NEWBORNS AND CHILDREN IN LAC” Regional Forum 2006 Tegucigalpa, Honduras

2 DEMOCRATIZATION and decentralization MDGHFA Crisis of the welfare state and social security Economic reforms and State reforms Health sector reforms GLOBALIZATION and a new economic order DEMOGRAPHIC TRANSITION : population growth, urbanization and aging EPIDEMIOLOGICAL POLARIZATION: coexistence of opposing risk and disease profiles Overwhelming ENVIRONMENTAL and ECOLOGICAL impact bipolar world cold war capitalism vs. socialism anti-colonialist movement Third World multilateralism unipolar world war against terrorism hegemony of capitalism globalization unilateralism human insecurity and vulnerability Political panorama of population health in the Americas EXPANSION OF DISPARITIES GROWTH OF EXCLUSION

3 Evolution of the regional demographic profile PAHO; Health of the Americas, 2002 edition

4 Epidemiological polarization of the mortality burden PAHO; Health of the Americas, 2002 edition all other causes external perinatal cardiovascular cancer infectious external expected years of life lost up to 85 years of age, 2000

5 Evolution of the ethics/ideology/values that guide social protection systems 20s/40s 80s/90s50s/70s XXI Century Formal Social Security for industrial workers Public Assistance and Charity for the poor and indigent XX Century WELFARE STATE Segmented systems according to ability to pay UNIVERSAL SOCIAL PROTECTION AS A CITIZEN RIGHT MDG

6 Main causes of mortality in children under five in the Americas Infectious Diseases 58, % Respiratory 59, % Malnutrition 14, % Peri-Neonatal 186, % Accidents 28, % Others (congenital anomalies, cardiovascular diseases, etc.) 143, % 132,194 annual deaths 26.9% of all deaths Perinatales 38.0% Problems during Pregnancy and Delivery, 76,750 (41.1%) Asphyxia, 39,200 (21.0%) Low Weight, 22,590 (12.1%) Sepsis, 11,200 (6%) Others, 36,960 (19.8%) Source: Estimates by the Child and Adolescent Health Unit (FCH/CA), using a database from the Health Analysis and Information Systems Area (AIS). Pan American Health Organization (PAHO) Estimates

7 Percentage of average annual decline in the under-5 mortality rate in the Region of the Americas 2.4% 4.0% Observed Required according to Summit Goals % 4.3% 6.3% Observed Required according to the MDGs Required to meet the MDGs starting in 2003 Required Increase: 142% Comparison of values observed and values proposed at International Summits Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

8 2.6% % 1.8% 2.9% 2.4% 5.0% 1.2% 1.8% 6.3% 7.8% 5.3% 10.1% 6.3% 3.1% 5.1% 6.4% 6.3% Regional Total HaitiBoliviaGuyanaHondurasNicaraguaPeruBrazilMexico Percentage of average annual decline Registered in Needed between 2003 and 2015 in order to meet MDG 4 Percentage of average annual decline in the under-5 mortality rate in the Region of the Americas Comparison of observed values and values proposed at International Summits

9 22,000 avoidable maternal deaths each year l Unnecessary, harmful practices l Indirect causes (HIV/AIDS, Malaria, Violence) l Child malnutrition / Poverty / Illiteracy l Lack of access to health services l Deficient quality of care l Provision of unqualified services l Early pregnancies l Under-registration of maternal deaths Sepsis 14.9% Hemorrhages 24.8% Indirect causes 19.8% Other direct causes 7.9% Complications of abortion 12.9% Obstructed delivery 6.9% Hypertensive disorders 12.9% Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

10 Social exclusion in health LAC, million inhabitants (46%) do not have health insurance 125 million (25%) do not have permanent access to basic health services 17% of births are without a skilled attendant 680,000 children do not complete their DPT3 vaccination program 152 million people do not have access to potable water and basic sanitation Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

11 Regional strategic framework: PAHO mandates and commitments by the Member States (Resolutions CSP 26/13 and 14, 2002) Development of public policies at the national and local levels Improve quality of care Guarantee access: ensure the provision of essential obstetric care, access to family planning, prenatal care and newborn care Skilled delivery care Empower women, families and communities Monitoring systems for the reduction of maternal mortality Epidemiological surveillance of maternal morbi-mortality Financing mechanisms for ensuring equity, solidarity and sustainability.

12 WORLD HEALTH ASSEMBLY – 2005 PAN AMERICAN SANITARY CONFERENCE Resolution WHA58.33 Extension of social protection in health

13 The fundamental challenge confronting the health systems of the countries in the Region is …… “Guarantee all citizens with UNIVERSAL SOCIAL PROTECTION in health, eliminating or reducing to the greatest degree possible the avoidable inequalities in coverage, access and use of services and ensuring that every person receives care according to his or her need and contributes to the financing of the system according to his or her possibilities” Extension of social protection in health

14 Strategies for the extension of social protection in health GUARANTEE EQUITABLE ACCESS AND UTILIZATION with the objective of providing social groups, that until today have been excluded with the opportunity to receive integral care, independent of their ability to pay DISTRIBUTION OF CHILD MORTALITY BY INCOME QUINTILES IN SELECTED COUNTRIES – LATIN AMERICA, 1999 Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5 Source: PAHO/WHO, Health of the Americas, Volume

15 Fundamental elements of social protection systems IDEAS PRINCIPLES VALUES INTERESTS INFORMATION KNOWLEDGE

16 Conditions for the extension of social protection in health SOLIDARIDATY IN FINANCING: intergenerational, among different occupational categories, among diverse income groups, and among populations exposed to health risks. FINANCIAL SECURITY OF THE HOUSEHOLD: that the financing of health services not represent a threat to the economic stability of families or the development of their members.

17 ACCESS TO SERVICES: availability of the necessary, timely supply for the provision of services and the elimination of physical, geographic and economic barriers. DIGNITY IN CARE: provision of care with quality, warmth and opportunity and under conditions that respect ethnicity, culture, gender, age and sexual orientation. Conditions for the extension of social protection in health

18 Integrated Health Insurance - SIS (Peru) Universal Maternal and Child Insurance - SUMI (Bolivia) Popular Health Insurance (Mexico) Free and universal health care (Mexico DF) SGSSS Subsidized Scheme (Dominican Republic) Free Maternity Law (Ecuador) Community Insurance in Caazapá (Paraguay) Country-based initiatives for the extension of social protection in health

19 Unified Health System - SUS (Brazil) National Health Insurance (Bahamas, Trinidad & Tobago, Aruba) Subsidized affiliation by the State to the Costa Rican Social Security System - CCSS (Costa Rica) Revision and expansion of the Obligatory Medical Program (Argentina) Legislative review of Law 100 (Colombia) Extension of benefits to dependent family members in the Social Security system (El Salvador) Extension of PHC Coverage in rural areas (Guatemala) Explicit Health Guarantees (Chile) Universal Basic Insurance (Massachusetts, USA) Inside the Neighborhood (Misión Barrio Adentro) (Venezuela) Country-based initiatives for the extension of social protection in health

20 Strategies for the extension of social protection in health: SYNERGY AND COHERENCE EXTENSION OF SOCIAL PROTECTION IN HEALTH Expansion of classic social insurance schemes, including the incorporation of informal workers Promotion and development of innovative protection strategies, including community-based initiatives Expansion of the mechanisms and projects for the extension of health systems coverage Establishment of links between previous mechanisms and other protection mechanisms and public initiatives (overcome fragmentation and segmentation and improve equity)

21 NATIONAL HEALTH SERVICE SOCIAL SECURITY IN HEALTH “BUSINESS” HEALTH SYSTEMS IN LAC HEALTH SECTOR REFORMS

22 A GHOST TRAVERSES THE HEALTH SYSTEMS OF LAC ….. Segmentation according to ability to pay Operational fragmentation

23 Inequities in access and utilization Limitations of segmented systems Large differences in guaranteed rights, per capita spending levels, and the degree of access to health services, benefits and opportunities across different population strata BIRTHS ATTENDED BY SKILLED PERSONNEL, AROUND 2002 PoorestQuintile 2Richest Source: World Bank, Socio-Economic Differences in Health, Nutrition, and Population, Washington, DC Quintile 3Quintile 4

24 FORMAL EMPLOYMENT CONTRIBUTIONS INTERNATIONAL LOANS AND DONATIONS GENERAL AND SPECIFIC TAXES PRIVATE PREMIUMS HOUSEHOLD CONTRIBUTIONS TO COMMUNITY FUNDS Public Private External Segmentation of financial contributions / risk pools Sources Limitations of segmented systems

25 Per capita spending on health, El Salvador 2004 Sub-System of Affiliation by Income, Chile, 1998 Institution Population covered (% of total population) Per capita spending, US$ Ministry of Health80%48.00 Social Security (ISSS)17% Military Health Services1% Teacher Health Insurance1% Limitations of segmented systems

26 Regressivity and insufficient financing, with the predominance of out-of-pocket expenditures Limitations of segmented systems

27 Limitations of segmented systems: out-of-pocket expenditures

28 Limitations of segmented systems: catastrophic expenditures At the global level: –Annually 150 million people and 44 million households confront financial catastrophes as a direct result of health expenditures. –25 million households and 100 million people are pushed into poverty given the need to pay for health services. In the Americas: –The family contribution, through out-of-pocket spending, represents 37% of total health expenditures and in several countries, exceeds 50%. –Family expenditures on health are considerably greater in families with lower incomes. –Out-of-pocket expenditures on health are 16% to 40% higher for women than men.

29 High transaction costs Administration, propaganda, sales and intermediation Absence of integrated planning and programming Targeting and micro-insurances that constitute pools of reduced risks Clientelism, corporativism and corruption Insufficient capacity for developing contracts with providers and the use of payment mechanisms that generate perverse incentives Weak stewardship: insufficient regulatory framework and inadequate fiscalization Limitations of segmented systems

30 NGO Health Center Social Security Hospital Walk-In, Mayor’s Office EFFICIENCYEQUITY Operational fragmentation Limitations of segmented systems

31 INTERINSTITUTIONAL COORDINATION OPERATIONAL INTEGRATION Strengthening of the STEWARDSHIP / MANAGEMENT of Sectoral Policies Alignment and harmonization of INTERNATIONAL COOPERATION Integrated and integral Service NETWORKS Health Systems based on PHC Incorporation of the knowledge from PROGRAMS into the organization of SYSTEMS POLITICAL / SOCIAL DIALOGUE among multiple actors Harmonization and integration of FINANCING STRATEGIES FOR CONFRONTING SEGMENTATION AND FRAGMENTATION

32 Final reflections …. and stimuli for the debate at our Regional Forum

33 HEALTH FOR ALL Information and knowledge Human Rights Primary Health Care Social Protection Health Promotion FOUNDATIONS OF PUBLIC HEALTH POLICY AIMED AT HEALTH FOR ALL

34 INSTITUTIONAL LEADERSHIP AND CAPACITY INFORMATION, KNOWLEDGE AND INNOVATION PLANNING AND COORDINATION INTELLIGENCE, CREATIVITY, DISCUSSION, COMMITMENT AND BOLDNESS OPPORTUNITIES FOR INTERVENTION


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