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GOVERNMENT OF THE CITIZENS’ REVOLUTION President Rafael Correa Delgado Management by Dr. Caroline Chang Campos MINISTER OF PUBLIC HEALTH.

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Presentation on theme: "GOVERNMENT OF THE CITIZENS’ REVOLUTION President Rafael Correa Delgado Management by Dr. Caroline Chang Campos MINISTER OF PUBLIC HEALTH."— Presentation transcript:

1 GOVERNMENT OF THE CITIZENS’ REVOLUTION President Rafael Correa Delgado Management by Dr. Caroline Chang Campos MINISTER OF PUBLIC HEALTH

2 FRAGMENTATION OFHEALTH SERVICES IN THE METROPOLITAN DISTRICT OF QUITO FRAGMENTATION OF HEALTH SERVICES IN THE METROPOLITAN DISTRICT OF QUITO A Problem of the Ecuadorian National Health System Quito, October 2007

3

4 Contents Ecuador: overview National Health System: Fragmentation Difficulties in integrating MPH - IESS Fragmentation: case of the Metropolitan District of Quito Proposal for constructing the National Health System

5 Starfield 10/ ECUORAD ECU OR AD Land area: 256,370 Km 2 Population estimated 2006: 13/408,270 inhabitants Population density: /Km 2 ECUORAD ECU OR AD Land area: 256,370 Km 2 Population estimated 2006: 13/408,270 inhabitants Population density: 52.30/Km 2 ECUADOR Land area: 256,370 km population (est.): 13,408,270 Population density: 52.3 people per km2

6 MAP OF POVERTY BY PROVINCE ACCORDING TO UNMET BASIC NEEDS (UBN) Source: INEC. CVD, fifth round

7 Haiti Peru Guatemala Honduras Colombia Nicaragua Dom. Republic Belize Venezuela Argentina Costa Rica Chile T. and Tobago Ecuador MATERNAL MORTALITY RATES IN LATIN AMERICA AND THE CARIBBEAN (per 100,000 live births)

8 A view of the south…

9 NATIONAL HEALTH SYSTEM: FRAGMENTATION

10 FRAGMENTATION OF THE HEALTH SYSTEM MPHIESSFFAA-PN J. BENEF O. PUBLNGOsPRIVATE 30% 19%2.5%3%2%17% 1.5% Population with access to institutional health services 75% 19% 2.0%3.5% Population with health insurance 25%

11 FRAGMENTATION AND ACCESS TOSERVICES (grouping Q1-Q2) FRAGMENTATION AND ACCESS TO SERVICES (grouping Q1-Q2) SOURCE: ENDEMAIN 2004 OTHERS: FFAA/Police hospitals; JBG; Municipios; Centers Naturopaths; healers, etc.

12 DISTRIBUTION OF HR (Urban and Rural Sector) Source: INEC, Anuario de Recursos y Actividades de Salud, From: FESALUD 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% kjhkjh DoctorsDentistsNursesMidwivesAdm.-Stat. Personnel Health Professionals MINISTRY OF PUBLIC HEALTH OF ECUADOR Distribution of human resources by urban-rural sector : 2000 Urban Rural

13 COMPOSITION OF JOB SUPPLY: 1990 JOB SUPPLY, 1990 Public: 49939; 82% Private: 9446; 18%

14 COMPOSITION OF JOB SUPPLY: 2004 JOB SUPPLY IN 2004 PUBLIC: 49939; 68% PRIVATE: 23676; 32%

15 HUMAN RESOURCES: Effects/Results PERCENTAGE OF PARTICIPATION IN THE SECTOR REAL GROWTH 78% -17% -20% 0% 20% 40% 60% 80% PRIVATEPUBLIC 364% 111% 0% 50% 100% 150% 200% 250% 300% 350% 400% PRIVATEPUBLIC

16 Ministry of Public Health_Human Resources_2008: by type of professional , ,0001,5002,0002,500 NUMBER OF PROFESSIONALS OTHER PROFESSIONALS MED. SPECIALISTS MED. RESIDENT HOSP. NURSES BAS. NURSES TECHNICIANS ADMINISTRATIVE P. TYPE OF PROFESSIONAL MINISTRY OF PUBLIC HEALTH UNDERSECRETARIATE FOR THE EXTENSION OF SOCIAL PROTECTION IN HEALTH CREATION OF BUDGET LINES_4573: BY TYPE OF PROFESSIONAL

17 Effects of fragmentation Debilitation of the public sector Social exclusion Inequity Higher out-of-pocket expenditure Medicalized model of care High costs and inefficiency from duplication of actions Concentration of human resources in urban areas Pauperization of the workforce Little quality in spending

18 At the middle of the world

19 THE PROBLEM OF COORDINATION: MPH-IESS

20 HEALTH SERVICE LEVELS 6% 1% 93% 2% 1% 97% 1 st Level 2 nd Level 3 rd Level MPH ESTABLISHMENTS IESS-SSC ESTABLISHMENTS 657

21 THE PROBLEM OF INTEGRATION ANDCONTINUITY OF SERVICES THE PROBLEM OF INTEGRATION AND CONTINUITY OF SERVICES 2 nd HOSPITALS 3 rd HOSPITALS 1st HEALTH AREAS 2ndHOSPITALSCLINICS 3rdHOSPITALS 1 st MEDICALCLINICS MPH ESTABLISHMENTS IESS (SSC) ESTABLISHMENTS REFERRALREFERRALREFERRALREFERRAL COUN TER RREFERRAL C OUN TER RREFERRAL COUN TER RREFERRAL C OUN TER RREFERRAL REFERRALREFERRALREFERRALREFERRAL COUNTERREFERRALC OUNTERREFERRALCOUNTERREFERRALC OUNTERREFERRAL

22 THE PROBLEM OF INTEGRATION ANDCONTINUITY OF SERVICES THE PROBLEM OF INTEGRATION AND CONTINUITY OF SERVICES 2 nd 3 rd 1 st 2 nd 3 rd 1 st MPH ESTABLISHMENTS IESS (SCC) ESTABLISHMENTS REF ERRALREF ERRALREF ERRALREF ERRAL BACK-RRE FERRAL BACK-RRE FERRAL BACK-RRE FERRAL BACK-RRE FERRAL REFERRALREFERRALREFERRALREFERRAL COUNTERREFERRALC OUNTERREFERRALCOUNTERREFERRALC OUNTERREFERRAL  Vertical integration not achieved because:  The majority of 2nd- and 3rd-level establishments are not integrated with the network of 1st-level establishments because no resolution by levels has been defined  Traditional budget is for the supply of services, with nothing for network management.  Population NOT assigned by geographical jurisdiction

23 THE PROBLEM OF INTEGRATION ANDCONTINUITY OF SERVICES THE PROBLEM OF INTEGRATION AND CONTINUITY OF SERVICES 2 nd 3 rd 1 st 2 nd 3 rd 1 st MPH ESTABLISHMENTS IESS (SSC) ESTABLISHMENTS REFERRRALR EFERRRALREFERRRALR EFERRRAL BACK-RREFERRALBACK-RREFERRALBACK-RREFERRALBACK-RREFERRAL REFERRALREFERRALREFERRALREFERRAL COUNTERREFERRALC OUNTERREFERRALCOUNTERREFERRALC OUNTERREFERRAL  Vertical integration achieved through:  Leadership of the network assumed by the insurer (General Bureau, individual and family enrollment)  Budget based on billing carried out in each financial year  Specifically assigned population (members)  Revenue coming into the network is from first-level care.

24 THE PROBLEM OF INTEGRATION ANDCONTINUITY OF SERVICES THE PROBLEM OF INTEGRATION AND CONTINUITY OF SERVICES 2 nd 3 rd 1 st 2 nd 3 rd 1 st MPH ESTABLISHMENTS IESS (SSC) ESTABLISHMENTS Interinstitutional integration(horizontal) is not achieved due to: Interinstitutional integration (horizontal) is not achieved due to:  No budget for horizontal integration  Lack of common pricing, common clinical guidelines (protocols)  Lack of common instruments for billing and audits (clinic and financing)

25 Santo Domingo

26 FRAGMENTATION: CASE OF THE METROPOLITAN DISTRICT OF QUITO

27 METROPOLITAN DISTRICT OF QUITO OF QUITO Land area: 12,000 km population (est): 2,036,241 Population density: /km 2.

28 THE PROBLEM OF THE INTEGRATION IN QUITO PUBLIC SUBSECTOR PUBLIC (OTHER) PRIVATE FINANCING ORGANIZATION INFRASTRUCTURE CONSUMERS STATE (traditional budget) Recovery (Dec. 502)STATEEMPLOYERSEMPLOYEES STATE CONTRI BU- TIONS INDIVIDUALS (fee for service and/or premiums) DPSP HOSPITALS HEALTH AREASDGS IESS SSC HEALTH UNITS DGSINS.UNITSDGS UNITS DIRECTORY DIRECTORY HEALTHUNITS HEALTH UNITS PREPAID MEDICINE 1 SPECIALTY HOSP. 6 SPECIALIZED HOSP; 2 GENERAL HOSP; 2 BASIC HOSP.; 17 C.S; 75 SC.S U; 38 SC.S R; 4 PS 13rd LEVEL HOSPITAL 1 3rd LEVEL HOSPITAL 13 DISPENSARIES 2 GEN. HOSP 3 HOSP. 14 CLINICS 5 HOSP. 60 CLINICS 360 C.M. AND LAB. UNINSURED POPULATION FORMALLABOR SECTOR FORMAL LABOR SECTORRETIREES MILI- TARY POLICE UNINSURED POP. UNINSURED POPULATION

29 THE PROBLEM OF ACCESS TO HEALTH SERVICES IN QUITO PUBLIC SUBSECTOR PUBLIC (OTHERS) PRIVATE

30 ESTABLISHMENT PREFERRED BY THE GENERAL PUBLIC OF QUITO FOR MORBIDITY CONSULTATION IN THE DMQ SOURCE: Baseline of the Proyecto Salud de Altura (“High- Altitude Health Project). Quito, 2007

31 ESTABLISHMENT PREFERRED BY THE POOR POPULATION FROM QUITO (Q1-Q2), FOR MORBIDITY CONSULTATION IN THE DMQ SOURCE: Baseline of the Proyecto Salud de Altura (“High- Altitude Health Project). Quito, % FFAA 0.34 SOLCA 0.1 MSP. HOSP 7.04 PRIVATE CFL MIDWIFE 1.22 MSP. SCS. CS PRIVATE SFL 1.94 MUNICIPIO QUITO 1.56 IESS 3.11

32 A view of downtown …

33 PROPOSAL FOR CONSTRUCTING THE NATIONAL HEALTH SYSTEM

34 PROPOSED SCENARIO 2nd 3rd 1st 2nd 3rd 1st PUBLIC FINANCING Q1-Q2. SALE OF SERVICES (Comparison of accounts) USERS ORGANIZATION LEADERSHIP HEALTH AREAS PRIORITY EXCLUDED POPULATION Q1 - Q2 PRIORITY SUBSCRIBERS AND RELATIVES STATE FINANCING AND CONTRIBUTIONS. SALE OF SERVICES (Comparison of accounts) ORGANIZATION LEADERSHIP INSURER AND DISPENSARIES USERS MPHSTEERING CLOSING THE COVERAGE GAP

35 Proposal for the development of Ecuador’s National Health System Vision By 2012, the NHS will guarantee the right to health for all citizens through equitable and universal access to free public health services Mission Extend social protection in health in Ecuador by constructing the National Health System under the following principles: – Universal equitable access to health services for the entire population – Organization of a network of integrated services starting with Ministry of Health units and the IESS/SSC – Integrated care model – Decentralized participatory management model – Ministry of Health governance

36 Cornerstones of the Proposal Expected Results 1.Strengthen the Ministry of Public Health ’ s steering role 2.Construction of integrated public health service networks (MPH-SSC-IESS) based on primary care and organized to serve “ geographical areas-population ” 3.Implementation of the participatory and intercultural Integrated Health Care Model in family and community health 4.Guarantee the financial viability and sustainability of the NHS by allocating sufficient resources (6-8% of GDP *) 5.Establishment of a decentralized participatory management model 6.Formulation of a human resources management and development policy, ensuring sustainability, skills and a commitment to values by human resources 7.Strengthen the spaces and mechanisms for social participation in the NHS, with special emphasis on Health Councils *Roemer, Milton. Medical care in integrated health programmes of Latin America

37 Scenario I Creation of a pluralistic coordinated public network of health services for integrated care of the population with the substantive participation of two stakeholders: IESS and MPH, fulfilling the provisions of the MPH-IESS-CONASA Agreement Scenario II Creation of a single public network for health service delivery run by the MPH Scenario III Creation of a single public network for health service delivery, managed by the IESS, under MPH governance

38 Organization of an interinstitutional technical team (MPH, IESS-SSC, CONASA, PAHO/WHO and others) Strengthen the MPH services network through investments in physical infrastructure, equipment, and human resources Organization of health service delivery: participatory integrated care model, through the operational coordination of primary care Progressive extension of this coordination up to the second level for both Institutions Expansion of coordination up to the third level of care, including catastrophic diseases Assignment of the system’s operations: Governance, Care Delivery, Financing, and Insurance

39 Strategies Position the construction of the NHS as the government’s and the MPH’s “principal political project in the field of health” Lobby government officials to ensure that the NHS’ values, principles and main characteristics are adequately manifested in the new Constitution Negotiation and partnership building with key stakeholders to lend visibility, viability and legitimacy to the NHS project, giving priority to CONASA as a forum for consensus-building Institutional strengthening of the MPH to exercise the Health Authority, Steering Role, and as the principal provider of NHS services Develop international agreements

40 THANK YOU


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