1. .`. SOCIAL PROTECTION IN HEALTH CONTINUUM OF LIFE DR. HORACIO TORO OCAMPO TEGUCIGALPA 2006

2. VISION A continent that is united in order to reach the highest possible level of health for all of its inhabitants Governments that exert leadership and the responsibility to summon society as a whole to improve people’s health Individuals, families, communities and institutions that are empowered to seek social justice through the promotion of health and the protection of life Dr. Mirta Roses Director, PAHO

3. Family and Community Health Area - PAHO Joins all of the efforts of the different technical units in order to ensure a more integrated, effective and efficient technical cooperation response One of it central axes is to strengthen the cooperation between countries, supporting the documentation of experiences and the synthesis of lessons learned Ensure that the achievements reached by countries and by the Region are sustained Promote the scaling up of successful experiences

4. 22,000 AVOIDABLE MATERNAL DEATHS EACH YEAR l Child malnutrition / Poverty / Illiteracy l Early pregnancies l Unnecessary and harmful practices l Indirect causes (HIV/AIDS, Malaria, Violence) l Non evidence-based practices l Access to maternal-neonatal services and FP is still deficient l Deficient quality of care l Skilled care is not provided in high proportions 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 Labor 6.9% Hypertensive Disorders 12.9% DETERMINANT IMPACT

5. Dominican Republic (1996) Prenatal care according to area of residence Large differences between women in urban areas and rural areas persist Guatemala (1999) Bolivia (1998) Peru (1996) Haiti (1994) Source: AbouZahr and Wardlaw, 2002 % of women that report 4+ prenatal visits Nicaragua (1998) Latin America / Caribbean urbanrural

6. Pregnancy and delivery – crucial moments in the health of women, children and families Before, during and after birth 70% of maternal deaths 57% foeto-neonatal deaths PP

7. Infant Mortality Rates in the Region of the Americas per 1,000 live births. Estimates by FCH/CA. WHO/PAHO, 2005 > 30< 10

8. Main causes of mortality in children under-five in the Region of the Americas 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). 2004. 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%) Infectious 58,150 11.8% Respiratory 59,600 12.1% Malnutrition 14,444 2.9% Peri-Neonatal 186,700 38.0% Accidents 28,750 5.9% Others (congenital anomalies, cardiovascular diseases, etc.) 143,100 29.2% 132,194 annual deaths 26.9% of all deaths

9. Infant mortality at the national level and among indigenous populations in selected countries of the Americas Infant mortality per 1,000 live births Source: PAHO/WHO 2000 NATIONAL POPULATION INDIGENOUS POPULATION

10. Favorable scenarios on the International and Regional agendas I. Favorable scenarios on the International and Regional agendas Strategic alliances: USAID-UNICEF-UNFPA- PAHO/WHO-NGOs

11. Revitalization of Primary Health Care Revitalization of Primary Health Care Integrated health models Integrated health models The countries have national plans and policies to attain the MDGs in Maternal-Infant Health The countries have national plans and policies to attain the MDGs in Maternal-Infant Health The expansion process for the AIEPI strategy, both the community and neonatal components The expansion process for the AIEPI strategy, both the community and neonatal components Epidemiological Surveillance Systems in MNH under development Epidemiological Surveillance Systems in MNH under development More universal health systems. More universal health systems. OPPORTUNITIES IN LAC

12. The “New Delhi” Declaration, World Health Day, April 7, 2005 The “New Delhi” Declaration, World Health Day, April 7, 2005 WHO Resolution on the continuum of maternal, newborn and child care WHO Resolution on the continuum of maternal, newborn and child care Global Alliance for maternal-newborn-child health Global Alliance for maternal-newborn-child health Regional Agreement in support of the maternal, newborn and child component Regional Agreement in support of the maternal, newborn and child component Presentation of the Regional Strategy for reducing neonatal morbi-mortality to the PAHO Directive Council - 2006 Presentation of the Regional Strategy for reducing neonatal morbi-mortality to the PAHO Directive Council - 2006 Presentation of the Regional Strategy and Plan of Action on Nutrition and Development (SPP 2006) Presentation of the Regional Strategy and Plan of Action on Nutrition and Development (SPP 2006) OPPORTUNITIES

13. III. Challenges

14. Challenge I: Advances toward Action EFFECTIVE INTERVENTIONS PRIORITY AREAS / VULNERABLE POPULATIONS IMPACT

15. Challenge 2: Political will translated into national investment –Creation of consensus –Maintenance and support of working teams –Adoption of State policies –More rapid movement toward the reduction of health inequities and access to basic services –Extend social protection in health, providing fundamental interventions for the most needy populations

16. Challenge 3: Ensure a sustainable focus: Continuum of care –A continuum that considers the life cycle: Focus on sexual and reproductive health that includes pregnancy, delivery and the postnatal period through childhood –A continuum that extends: From the home; Through the primary level (ensuring appropriate care at each level according to people’s needs); And, when necessary, at the referral level –A continuum that cuts across the programs: Maternal Health, Child Health, Reproductive Health, STIs/HIV, Malaria, Nutrition, Immunizations

17. Fuente: OMS, 2003 Interventions Self-care and newborn care Care-seeking Delivery and emergency plan Social support during delivery Involvement of males and other decision makers Awareness raising among families and individuals about maternal-newborn health needs and rights Interventions Community awareness about maternal- newborn health needs and rights Community actions to support maternal- newborn health Links between the community and the health services Interventions Care for normal pregnancies that focuses on newborn care Delivery care (use of the partogram and active management of the third stage) Exclusive early breastfeeding Early detection and timely referral of women and children with pregnancy complications Family Planning, control of malaria, STI/RTI Prevention of HIV in mothers, including vertical transmission Interventions Management of complications during pregnancy, delivery and in the post-partum period Management of illnesses that affect pregnancy and delivery Management of newborn complications Interventions Blood transfusion Cesarean section Surgery Intensive care - women Intensive care - newborns A continuum of care and care practices under construction The Home: Women and Families The Community Level of primary care: Skilled personnel Referral level: Skilled personnel, including other doctors, nurses, others EmOC Surgeons, nurses, others Referral system Source: WHO, 2003

18. CHALLENGES Challenge 4: Guarantee the human resources to provide skilled care for women, their children and families under the framework of the continuum Challenge 5: Re-orient health care services based on the renewed Primary Health Care strategy that recognizes families and communities as the subjects of change

19. Challenge 6: SOCIAL PROTECTION IN HEALTH Mechanisms to increase financing in a sustainable manner Maternal, Newborn and Child Health is at the center of the right to health debate Evidence-based interventions form part of the insurance packages at the level of home/family/community and services Insurance packages that contribute to a decrease in gaps (socio-economic level; urban/rural; ethnicity) Establishment of responsibility mechanisms (territory- population) Accelerate the growth toward universal coverage and improvement in the quality of care

20. HFA & MDG Information and knowledge management Health as a human right Primary health care Health promotion Social protection Continue Moving Forward Instruments

21. SOCIAL PROTECTION IN MATERNAL-CHILD HEALTH

22. What is a social protection in health scheme ? Organized set of public interventions aimed at guaranteeing that groups and individuals are able to meet their health needs and demands through access to health services under adequate conditions of quality, dignity and timeliness, without ability to pay serving as a restrictive factor

23. There are three strategies to operationalize the idea of social protection Universal protection (for all citizens or residents) Protection for low-income people or groups in specific situations Protection for people that contribute or have contributed to a scheme (fund) or insurance (health, unemployment, pension, other) (especially workers)

24. And they use diverse mechanisms or instruments … Universal protection mechanisms: Benefits determined by the citizenship credential or by simple individual identification Protection mechanisms targeted at low-income people or groups in specific conditions: Assistance or benefits determined according to a means-test (means-tested assistance) Contribution-based protection mechanisms: Benefits determined by method of affiliation and actuarial calculation

25. Premises of the analysis Equity is a central issue in the health of mothers, newborns, boys and girls M-C health is strongly linked to the macro social determinants of health Access to health goods and the quality of the services provided are key factors in M-C health outcomes The situation of the M-C population improves when there is a social protection in health scheme

26. Analytical framework: Questions to answer How will it be financed? Who will have the right (to benefits)? What are the benefits? How is this right guaranteed?

27. Analytical framework: how will it be financed? General taxes: tributary pressure – collection – allocation of health resources – alternative sources of financing – consumption taxes –Tributary reform? Contributions: method of contributions (obligatory/voluntary monthly installments based on salary/willingness to pay/co-payments) –Who contributes? Employer/employee/State Extension of guaranteed social insurance: for temporary/informal workers –How to collect their contribution? Extension of employer responsibility: transnational companies Anticorruption measures: the administrator of the contributions should not have access to the fund of collected contributions Co-responsibility of national States: Cross-border agreements –Portability of guarantee? THE FINANCING OF PUBLIC HEALTH ACTIVITICES SHOULD BE CARRIED OUT BY THE STATE AND DISTINCT CHANNELS

28. Analytical framework: What are the benefits? Explicit set of guaranteed services (Insurance-based systems) vs. Non-explicit services (National health services) Design of the guaranteed package: intensive in terms of technology of generation, analysis and transfer of information (identification of beneficiaries-accreditation of service providers-identification and costing of services) Definition of the contents of the guaranteed package: by disease / by diagnosis-intervention/ by cost-effectiveness criteria/ by demographic-epidemiological criteria / by political pressures

29. EXPERIENCES IN THE REGION Bolivia: Universal Maternal and Child Insurance Brazil: Family Health Program Chile: Maternal-Child Health Protection Ecuador: Free Maternity and Child Care Law Honduras: Mother and Child Voucher Mexico: Education, Health and Nutrition Program Peru: Maternal-Child Insurance

30. OBJECTIVES OF THE SCHEME Reduce the maternal mortality and child mortality rates by 50% Improve access and increase use of services, reducing economic barriers The program focuses on free services for the population The financing comes from the tributary co- participation resources (municipal funds)

31. POSSIBLE IMPACTS a)Increase equity in access to/use of services? b)Control, eliminate or decrease the negative effects of social determinants? (demand or state of affairs) c)Increase access by eliminating a source of exclusion from the health system? d)Improve health outcomes?

32. Increase equity in access to/use of services Access to and use of health services covered by the program should increase with the implementation of the different schemes that they decide to implement Increase the quality of institutional care for pregnant women during pregnancy, delivery and in the postpartum period Decrease the gaps in inequity between rich-poor, urban-rural and indigenous-non-indigenous

33. Increase access, by eliminating barriers of exclusion from the health system By removing the economic barrier, there will be an increase in coverage Households continue to be a source of financing for the sector, 30% of total health spending (purchase of prescription drugs) Health insurance should be an element that increases demand in rural areas

34. Millennium Development Goals and Targets 1.Eradicate extreme poverty and hunger 4.Reduce child mortality 5.Improve maternal health 6.Fight HIV/AIDS, malaria and other diseases 1.Halve the proportion of people living on less than a dollar a day (PPA), between 1990 and 2015 2.Halve the proportion of people who suffer from hunger, between 1990 and 2015 3.Reduce by two thirds the mortality rate among children under five 4.Reduce by three quarters the maternal mortality ratio, between 1990 and 2015 7.Halt and begin to reverse the spread of HIV/AIDS by 2015 8.Halt and begin to reverse the incidence of malaria and other major diseases by 2015 9.Reduce by half the proportion of people without sustainable access to safe drinking water by 2015

35. 1- improve prenatal, delivery, postpartum and newborn care; 2- provide high quality family planning services, including infertility services; 3- eliminate unsafe abortion; 4- combat sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other gynecological pathologies; 5- promote healthy sexual health and responsible reproduction. STRATEGY TO ACCELERATE ACHIEVEMENT OF MDGs FOCUSES ON THE 5 SRH PRIORITY ASPECTS WHA 57, 2004

36. Potential Reduction in Maternal Mortality for Latin America and the Caribbean. Countries with Populations Over 2.5 Million People. 2003 Basic Indicators 2005 PAHO / SHA / 02.01 Update of: Maternal Mortality in Latin America and the Caribbean. Schwarcz & Fescina The Lancet 356.December 2000 255075100 C. Rica 30.0 Uruguay 38.0 Cuba 38.5 Argentina 42.5 Venezuela 57.8 Mexico 65.2 Panama 68.0 Brazil 73.1 Dom. Rep. 75.3 Ecuador 77.8 Nicaragua 82.8 Colombia 84.4 Jamaica 95.0 Honduras 108 Guatemala 153 El Salvador 173 Paraguay 174.1 Peru 185 Bolivia 230 Haiti 523 255075100 Potential Reduction % Desirable Potential: ref. Canada Rate 7.4 %ooo Possible Potential: ref. Chile Rate 13.4 %ooo Countries (Mat. Mort. %ooo)

37. REGIONAL AGREEMENTS MATERNAL MORTALITY Resolutions 13 and 14 of the 26 th Panamerican Sanitary Conference (PASC 2002) Interagency Strategic Consensus for the Reduction of MM CHILD HEALTH AIEPI Resolutions from the 23 rd and 26 th PASC Strategy and Plan of Action for Newborn Health on the MRN continuum (2006) HIV AIDS-STIs Strategic Regional Plan for the Health Sector (2005) ADOLESCENTS: Strategy under development, AISA NUTRITION, HEALTH AND DEVELOPMENT: E. R. Plan (2006) IMMUNIZATIONS: Regional Strategy (2006) Elimination of Rubella and CRS

38. CHALLENGE - Political will translated into national investment –Creation of consensus –Maintenance and support of working teams –Adoption of State policies –More rapid movement toward the reduction of health inequities and access to basic services –Extend social protection in health, providing fundamental interventions for the most needy populations

39. CHALLENGE - Ensure a sustainable focus: Continuum of care –A continuum that considers the life cycle: Focus on sexual and reproductive health that includes pregnancy, delivery and the postnatal period through childhood –A continuum that extends: From the home; Through the primary level (insuring the appropriate care at each level according to people’s needs); And, when necessary, to the referral level –A continuum that cuts across the programs : Maternal Health, Child Health, Reproductive Health, STIs/HIV, Malaria, Nutrition, Immunizations

40. Fuente: OMS, 2003 A continuum of evidence-based care and care practices within the framework of the Primary Health Care strategy 1) A continuum whose coverage begins with the start of life Newborn Pregnancy Childhood Some complications cannot be predicted, Therefore all mothers need to receive Check-ups Some complications cannot be predicted, Therefore all mothers need to receive Check-ups The Home Female Empowerment The Home Female Empowerment The Community Families Community workers, Self-taught The Community Families Community workers, Self-taught 1 st Level of Care Health Centers Skilled personnel, Nurses, Obstetricians, Midwives 1 st Level of Care Health Centers Skilled personnel, Nurses, Obstetricians, Midwives Level of Referral Hospital, Skilled pers., Obstetricians, Neonatologists, Nurses Level of Referral Hospital, Skilled pers., Obstetricians, Neonatologists, Nurses 2) A continuum that extends from Preconception Source: WHO, 2003

41. CHALLENGE – Social Protection in Health Maternal, Newborn and Child Health is the center of the rights to health Evidence-based interventions as part of the insurance packages at the level of the home/family/community and services Mechanisms to increase financing in a sustainable manner Insurance packages that contribute to a decrease in gaps (socio-economic level; urban/rural; ethnicity) Establishment of responsibility mechanisms (territory- population) Accelerate the growth toward universal coverage and improvement in the quality of care

42. CARE THROUGHOUT THE CONTINUUM OF LIFE “CARE FOR PEOPLE’S NEEDS, ASPIRATIONS AND PROBLEMS, ENSURING THAT THEY ENJOY COMPLETE PHYSICAL AND MENTAL WELL-BEING AND SOCIAL DEVELOPMENT DURING THE “CONTINUUM OF THEIR LIFE,” AS WELL AS MONITOR THE BIOLOGICAL AND SOCIAL DETERMINANTS THAT CAN AFFECT THEM AT ANY STAGE OF LIFE” ANTONIO HORACIO TORO OCAMPO 2006

43. Working Framework Family and Community Health Primary Health Care Social Protection in Health Human Resource Development Healthy Spaces HIV/AIDS - STIs Immunization Nutrition Women’s, Maternal, Reproductive Health Priority Countries Groups Newborns Infants Youth Children Adults Older adult Adolescents MDG 6 Fight HIV/AIDS, malaria and other diseases MDG 4 Reduce child mortality MDG 5 Improve maternal health MDG 1 Eradicate hunger and extreme poverty MDG 8 Establish alliances MDG 3 Promote gender equality and empower women Child / Adolescent Health Healthy life styles Pregnant women