1. 1 REGIONAL MEETING Integrated Health Services Networks and Vertical Programs: Maximizing Synergies for Collaborative Work URUGUAY: Coordinating national health systems and priority programs Cuzco - Peru November 2009 Dr. Miguel Fernández Galeano Vice Minister of Public Health URUGUAY

2. 2 NEW PARADIGM Health as an essential human right, a public resource, and a social and responsibility of State and government “The goal we have defined is that all Uruguayans enjoy access to comprehensive health care – all Uruguayans – through an integrated, nonprofit National Health System with a public-private mix, funded by national health insurance.” Dr. Tabaré Vázquez President of the Eastern Republic of Uruguay 25 September 2005

3. 3 COMMON CRITERIA Universal access User contributions scaled to income, and benefits received according to need Budget increase to supplement development resources from social policy Priority to households with greatest number of under-18 members SOCIAL REFORM

4. 4 SOCIAL POLICY: CONCEPTUAL CATEGORIES Function of social policyType of policy – orientation and objectives Social goals Temporary protection of sectors in critical poverty. Ensure minimum social conditions. Provide targeted assistance. Critical needs Permanent or semi-permanent protection: satisfaction of basic needs and legal protection of rights (children, young people, jobs, food, urban public facilities). Ensure minimum conditions, and improve quality of life for specific groups – assistance accompanied by targeted social promotion. Needs + capacities Classic well-being and traditional social rights (education, health, social security, labor sectors). Invest in human capital and address common risks; promote universal citizenship. Risks + capacities + opportunities Well-being in terms of inclusion, equity and modern citizenship (gender, ethnicity, human rights, community building). Incorporate new demands and social participation – combine universal and local approaches. Equal opportunity Source: Raczynski, D. and C. Serrano (2005), “Las políticas y estrategias de desarrollo social. Aportes de los años 90 y desafíos futuros,” in La paradoja aparente: resolviendo el dilema. Patricio Meller (ed.), Santiago, Chile. Modified ICP-FCS team (Institute of Political Science, School of Social Sciences, University of the Republic), 2006.

5. 5 Passage of three laws, creating the National Health Fund (FONASA), the Integrated National Health System (SNIS), and making ASSE a decentralized entity independent of the Ministry of Public Health. Development of a public health policy that guarantees the rights of the population and promotes healthy lifestyles (programs to reduce smoking, promote healthy eating, reduce traffic accidents, etc.) Development of a policy to improve public services and generate complementarity between public and private providers of social services, with emphasis on the primary care level. Implementation of regulations that guarantee quality service to users. For this purpose, social participation was called on to help design a National Health Board (JUNASA) to function as the administrative entity of the National Health Fund (FONASA). Key elements of health system reform

6. 6 THE REFORM STRATEGY Change in care model Change in management model Change in funding model Integrated National Health System National Health Fund

7. 7 Contributions of the State Households Firms USERS Payment as a function of income and family coverage Per capita payment as a function of age, sex and service goals INSTITUTIONS Integrated with national public health system and private nonprofit system FREE CHOICE COMPREHENSIVE CARE Composition of National Health Fund (FONASA)

8. 8 RATES GOVERNING CONTRIBUTIONS TO FONASA Contributions to FONASAContributions as a percentage of income Health care entitlements Workers with incomes below 2.5 BPC units 3%Care provided to worker and worker’s children through the provider selected by them. On retirement, workers are still covered by the insurance. Workers with incomes above 2.5 BPC units 3% + 1.5% Workers with dependent children and incomes above 2.5 BPC units 3% + 3% Firms5%

9. 9 STRUCTURE OF HEALTH CARE PREMIUMS BY AGE AND SEX Man Women

10. 10 Starting point Expenditure per user in NUr$ 900/month (US$ 45.00) collective medical care institutions (CMCIs) (private nonprofit) Spending per user in ASSE NUr$ 280/month (US$ 14.00) (State) 3:1 ratio Current situation, including allocations that will be proposed in the accounting: The budget of the State provider (ASSE) rose from US$ 185 million to US$ 550 million, the highest ASSE budget in the country’s history. As a result: Expenditure per user in CMCIs (private nonprofit) NUr$ 1,000/month (US$ 50.00) Expenditure per user in ASSE (State) NUr$ 820/month (US$ 41.00) 1.2:1 ratio SOCIAL JUSTICE IN THE DISTRIBUTION OF EXPENDITURE

11. 11 Guaranteed access to a comprehensive provider within the SNIS for the entire population. Current total users of:  CMCIs – medical cooperatives  Private insurance  ASSE  Military and police health These users represent 100% of the population. Example: individuals under 18: 500,000 joined FONASA. 170,000 were in CMCIs and parents stopped paying out-of-pocket premium. 130,000 were in ASSE and moved to CMCIs. 200,000 did not have comprehensive coverage and acquired it within the SNIS. ACCESS OF POPULATION TO HEALTH SYSTEM WITH COMPREHENSIVE PROGRAMMED COVERAGE

12. 12 Expansion of comprehensive care ASSE Dec. 2007Dec. 2008 IAMC Private insurance Military and Policy Health

13. 13 Starting point: DISSE covered 588,000 workers (only private-sector, and with no benefits for children). As of May 2009, FONASA covers 1,485,000 individuals, including 500,000 children of workers. An example of accessibility: Between 1996 and 2007, 50,000 retirees had social security coverage. Between August 2007 and May 2009, 35,000 more entered the system, i.e., two years saw the entry of 70% of the number who had entered over the previous 11 years. Reason: The policy of reducing tickets and orders in the CMCI membership contract. ADVANCES IN COVERAGE THROUGH FONASA

14. 14 Lower copayments. 40% reduction for drug vouchers Access without charge for diabetics Free pregnancy tests Free preventive tests for women: mammograms, Pap smear. Price of drug vouchers for hypertensives lowered to a maximum of NUr$ 50. Free set of vouchers for retirees entering through FONASA. Totally free preventive care for people under 18. GREATER ACCESS FOR THE POPULATION

15. 15 STEERING FUNCTIONS and new institutional tools CONDUCT/LEAD REGULATION ESSENTIAL PUBLIC HEALTH FUNCTIONS GUARANTEE OF INSURANCE ORIENTATION OF FINANCING HARMONIZATION OF SERVICES DELIVERY Policy Strategy Goals Participation and Consensus Intersectoral advocacy Qualification, accreditation, certification and monitoring of professionals, services, technology, and supplies Epidemiological surveillance Promotion/participation Human resources development Evaluation of quality of services Implementation of comprehensive care plans Evaluation of sufficiency and quality of services Banco de Previsión Social (BPS) functions as FONASA administrative entity. Integrated system Levels of complexity Complementarity Referrals/counterreferrals

16. 16 ESSENTIAL PUBLIC HEALTH FUNCTIONS (2002) Measurement Results Essential Public Health Functions EPHF 1EPHF 2EPHF 3 EPHF 4 EPHF 5 EPHF 6EPHF 7 EPHF 8EPHF 9 EPHF 10 EPHF 11

17. 17 GUARANTEE QUALITY CARE FOR USERS OF SNIS OBJECTIVE IS TO EXERCISE THE LEADERSHIP NEEDED TO GUARANTEE QUALITY CARE FOR USERS OF SNIS. Exercise proper regulation to guarantee quality care for users of SNIS. The starting point was the exhaustive deregulation of the 1990s. This included a policy of fait accompli in which things were done and approval was requested ex post facto if at all. Framework of sanctions imposed on providers by JUNASA according to the frequency with which they fail to meet contractual conditions. MinorGreaterSerious First time Note in provider’s fileTemporary suspension of up to 20% Temporary suspension of up to 50% Second time Temporary suspension of up to 35% Temporary 100% suspension Permanent suspension of up to 12% Third time Permanent 4% suspension Permanent suspension of up to 8% Permanent suspension of up to 100% Source: Decree 464/008, Article 10.

18. 18  National Health Board created. The Board will sign service contracts with all public- and private-sector care providers, and enforce requirements that guarantee quality care for users. The Board has the power to impose sanctions if agreed care model or management model goals are not met.  The current decree regarding maximum waiting period gives every user of the SNIS the right to see a general practitioner, pediatrician, or gynecologist within 24 hours, and other specialists within 30 days.  Providers receive a special payment for meeting service goals. In order to qualify, they must examine all pregnant women in their system and provide nine free exams during the first 14 months of life for children. Failing this, the institution does not receive its bonus from FONASA.  The Ministry of Public Health has 150 inspectors whose pay has been raised. They are subject to an accountability arrangement that requires a high degree of dedication, and prohibits them from carrying out any functions in the institutions that they inspect. IMPROVED LEADERSHIP

19. 19. Within the framework of a changed care model and in addition to public health policy, budgetary improvements for primary care, and strengthening of human resources, the new care model implies a strategy to ensure: the presence of public health programs, since the health of the population is not solely the result of the action of health service providers. People’s habits and the environment in which their activity takes place are also important determinants of health. (Thus, for example, the strategy addresses smoking, healthy living and eating habits). STRENGTHENING PRIMARY CARE AND CREATING COMPLEMENTARITY BETWEEN THE PUBLIC SECTOR AND THE NONPROFIT PRIVATE SECTOR

20. 20 PRIORITY PROGRAMS Population groups National Women’s Health and Gender Program National Child Health Program National Adolescent Health Program National Adult Health Program National Elder Health Program

21. 21 NATIONAL WOMEN’S HEALTH AND GENDER PROGRAM National Women’s Health and Gender Program GENDER VIOLENCE MEN’S CONDITION SEXUAL AND REPRODUCTIVE HEALTH ADVISORY SERVICES, RESEARCH AND MANAGEMENT MENTAL HEALTH AND GENDER CANCER IN WOMEN

22. 22 NATIONAL CANCER CONTROL PROGRAM NATIONAL ONCOLOGICAL NETWORK (RED ONCOLÓGICA NACIONAL - RON) Ministry of Public Health – CHLCC MODULE 3 EPIDEMIOLOGY National cancer registry Epidemiological surveillance MODULE 1 MANAGEMENT Patient MODULE 2 EDUCATION Oncologist Care Screening Referrals COMPUTERIZED HISTORY Clinical Laboratory Surgery Pathology OM – Tumor Bank RT – images Information for timely and effective action NETWORK OF HEALTH PROVIDERS COMPUTARIZED SYSTEM Basic clinical platform (Plataforma básica clínica-PBC) Oncologist, pathologist, nurse

23. 23 PRIORITY PROGRAMS Prevalent health problems Priority chronic noncommunicable diseases program: - Cardiovascular health (CHLCV) - Kidney Health - Diabetes National Cancer Control Program (Comisión Honoraria de Lucha Contra el Cáncer, CHLCC) National Smoking Control Program National Mental Health Program National Eye Health Program National Oral Health Program National STI-AIDS Health Program National Nutrition Program

24. 24 INTERSECTORAL AND INTERGOVERNMENTAL COORDINATION MECHANISMS Social cabinet: Ministry of Economy and Finance (MEF); Ministry of Development (MIDES); Ministry of Housing, Land management and Environment (MVOTMA), Ministry of Public Health (MSP), Ministry of Education and Culture (MEC), Ministry of Tourism and Sports (MTD), Ministry of Labor and Social Security (MTSS). National Council for Social Policy Coordination Committee for the Strategic Coordination of Child and Adolescent Policy National and Departmental Emergency Committees National Drug Board National Road Safety Unit Health-promoting schools Productive and healthy communities

25. 25 NATIONAL CONTINGENCY PLANS National Contingency Plan for an Influenza Pandemic National Contingency Plan for a Dengue Epidemic

26. 26 The budget allocated for ASSE increased from US$ 185 million in 2004 to US$ 550 million in 2009. Wages paid by ASSE have increased from NUr$ 2,370 million in 2004 to NUr$ 6,500 million in 2009, or 160%. ASSE’s expenditure per user has increased from NUr$ 280/month/user in 2004 to NUr$ 820/month/user in 2009. INCREASED BUDGET FOR THE COMPREHENSIVE STATE PROVIDER (ASSE)

27. 27 The long-forgotten Uruguayan primary care health system doubled its budget, and the salaries allocated to this level area more than doubled. This has made it possible to strengthen the Montevideo primary care network and create a network in the country’s interior, using government funds, complementary agreements with the private sector, and complementary arrangements with municipalities to serve locales never before served. ASSE investment totaled US$ 2 million in 2005, but grew by a factor of 25 by 2009. Although insufficient, this growth represents an enormous rise in the amount that the organization devotes to investment. INCREASE IN ASSE BUDGET

28. 28  Minimum physician’s wage increased five- fold.  Wage improvements also include payments based on performance and on working the mandated hours  2 million workers have been added to the nursing staff, principally at the primary care level and in the country’s interior. ASSE HUMAN RESOURCES POLICY

29. 29 Starting point: no such action in any form. The current government has launched numerous initiatives in this respect:  A decree in March 2005 created the Advisory Committee for Change in health care. The Committee regularly invites all sectors involved (unions, businesses, professional schools, public sector, etc.) to discuss issues linked with the reform. PROMOTION OF SOCIAL PARTICIPATION AND MANAGEMENT OVERSIGHT TO ENSURE QUALITY OF HEALTH CARE

30. 30  Wage councils were reinstituted and are called on not only to negotiate wages, but working conditions as well and to develop the information needed for this.  Law 18131, which created FONASA, provides for a commission to monitor the fund, with the participation of workers and employers.  Law 18161 created ASSE as a decentralized entity whose board of directors includes a workers’ representative and a users’ representative.  Law 18211 created the National Health Board as the administrative organ of the National Health Insurance system. It includes a users’ representative, a workers’ representative, and a person representing health sector firms.  Under this law, each provider that wishes to join the SNIS must have a consultative and advisory body consisting not only of the firm, but of representatives of its workers and users. PROMOTION OF SOCIAL PARTICIPATION AND MANAGEMENT OVERSIGHT TO ENSURE QUALITY OF HEALTH CARE

31. 31 Impact of the three reforms on poverty and extreme poverty ALL THREE REFORMS TAX REFORM HEALTH REFORM EQUITY PLAN Extreme Poverty Poverty BeforeAfterChangeBeforeAfterChange Improvement Scenario 1 – individual income tax (IRPF) Improvement Source: Office of Planning and Budget (OPP), 2007.

32. 32 Citizen opinions of health system reform Source: Author, based on Public Opinion Monitor. Equipos MORI report to the President of the Republic. Fair Poor Very Poor Don’t know/ Not familiar Very Good Good

33. 33 Opinions on health reform, Dec. 2007- Feb. 2009 December 2007 February 2008April 2008June 2008February 2009 Source: Author, based on Public Opinion Monitor. Equipos MORI report to the President of the Republic. Good/Very good Fair Poor/Very poor DK/NF

34. 34 mafgaleano@msp.gub.uy www.msp.gub.uy THANK YOU VERY MUCH