1. Health Service Provision José Ruales Regional Advisor in Health Systems PAHO/WHO

2. Content The function of service provision Challenges of supply and demand Determinants of access Model of Care Model of Organization and Management Fragmentation vs. Integration of networks

3. Functions and Objectives of the Health System Health System Values Needs Resources Stewardship Financing Insurance Provision Maintain and improve health Access – Quality - Efficiency Protect financial risks Satisfaction of expectations Participation

4. Health Services: Definition Services delivered by health personnel in a direct manner, or by other people under the supervision of these personnel, with the goal of: –Promoting, maintaining and/or recovering health –Minimizing disparities both in access to health services and in the level of population health (PAHO/WHO 2003; Modification of the IOM 1996)

5. Health Service Provision Public or Collective Health Services – Disease prevention and control –Protection against environmental risks –Injury prevention –Promotion of healthy behaviors and mental health –Quality assurance and accessibility of health services Individual or Personal Health Services –Individual prevention –Diagnosis –Recovery –Rehabilitation –Palliative care

6. Challenges for Health Services in the Americas Access to health services is not available for large segments of the population, The supply of health services does not always adjust to expectations, social values and cultural preferences, The provision of health services, for certain population groups, is of poor effectiveness and technical quality, There is fragmentation, duplication, concentration in urban areas, weak information and referral systems, with inefficiency and inequity in the supply.

7. Health Services in Social Protection Schemes 7/7 aim to extend coverage and increase access by reducing exclusion and economic barriers 4/7 increased equity in terms of access and use, but 3/7 increased inequity 2/7 the elimination of economic barriers was insufficient among the dispersed and indigenous populations 3/7 increased the demand without expanding the supply of resources or the infrastructure, which leads to overload and reduction of quality

8. Needs, expectations, demand and use of health services by people, families and communities Response Model of care Model of organization & management Challenge Other systemic variables that are determinants of health services SUPPLY DEMAND ACCESS

9. Concrete existence of services aimed at promoting, preventing, recovering and rehabilitating the target population’s health, both at the individual and collective level, under the conditions of the people and the environment. Human Resources Physical Resources Technological Resources Health Service Supply

10. Health Service Demand –Formal (explicit) requirements for health services. –Utilization: Demand that is met through the supply of services to a target population in a specific time period. –Access: Probability of obtaining health care when needed.

11. Comprehensive access Conditions of effective coverage: –Availability –Elimination of barriers (geographic, cultural, economic and social) –Timeliness (moment and time) –Acceptability (satisfaction and respect) –Contact and real use (first contact or other) –Appropriate, effective services (procedures and levels) Ex. Maternal-Newborn Care: Contraceptives, Skilled delivery care, Emergency obstetric and newborn care –Based on social protection

12. Social Protection - Adequate access: –Timeliness –Quality –Dignity –Independent of ability to pay –Includes Health service coverage Coverage for the entire population Financial solidarity

13. Determinants of Access Prior to using health services: –The need for care should exist (pain, convincing, risk of death) –Should believe in services’ efficacy (confidence in the provider) –Should have the ability to access services (availability of income or insurance, time, transport) Source: Restrepo, JH, 2006

14. Barriers to access: supply side Initial contact: Travel time Means of transport Distance to service Hours of operation Obtaining the service Bureaucracy for the appointment Waiting times Continuity Regular source Hours Source: Restrepo, JH, 2006

15. Barriers to access: demand side Predisposition Demographic Social structure Culture, ethnicity and religion Ability Resources for demanding services: Income or Health Insurance, Recognition of Rights Needs Illness episodes or preventive actions, which in their opinion warrant health care Utilization Characteristics of the resources themselves: Type of service, Purpose, Concentration Satisfaction Provider perceptions: Information and attitude of professionals, Length of doctor’s visit Quality of waiting rooms, Size of exam rooms, Waiting times Cure / Solution Source: Restrepo, JH, 2006

16. Factors that influence access Provision / Use of Services Socio-economic development Health situation Health needs and care Socio-cultural aspects Geographic, environ- mental, road access Resources, organization and management of services Social protection in health Policies, plans and resources related to health Biological – demographic characteristics Cultural access Geographic access Economic access

17. Social determinants of health Need for health Perceived Unperceived Expressed Unmet Repressed Access How the factors interact Demand for health Met Equitable Inequitable Social protection in health scheme Health outcomes Supply of Services

18. Health Care Model Content of health care and principal characteristics of the interaction between the service provider and service user. Includes: Pertinence of the supply of services to users’ needs and demands, Accessibility and acceptability of services, Services oriented to people, families and communities, Role of people, families and the community in self-care, Level of integration of services.

19. Trends in the model of care Balance between personal services and public health services; curative, promotion and prevention services Services oriented to families and the community Promotion of self-care for the health of people, families and the community Search for the integrality of services: –Comprehensive –Continuous –Longitudinal

20. Model of organization and management The manner in which the components of the health system are organized and managed with the goal of achieving the objectives proposed and facilitating its collective function.

21. Trends in the models of organization and management Organization of services based on primary care Definition of a population base Prioritization of the most vulnerable population groups Emphasis on ambulatory care and care beyond traditional clinical environments Decentralization of services Management focused on quality and results Organization and management of integrated health systems

22. Fragmentation Coexistence of many units or entities that are not integrated into the health service network. does not allow the standardization of contents, quality, cost and provision leads to providers not working in a coordinated or synergetic manner generates increases in the costs of care promotes inefficient allocation of resources in the system.

23. Segmentation of the system and Fragmentation of services Tertiary Care Primary Care Social Security Private, high complexity MOH Professional Risks Private, low complexity NGOs Municipalities Universities Secondary Care Traditional Medicine

24. STRATEGIES FOR CONFRONTING SEGMENTATION AND FRAGMENTATION INTER-INSTITUTIONAL COORDINATION OPERATIONAL INTEGRATION Strengthening of the STEWARDSHIP / MANAGEMENT of the Sectoral Policy Leadership, Alignment and Harmonization of International Cooperation Management of Integrated Service NETWORKS Integration of the Programs in the System

25. Integration of the Population Involves the availability and the timeliness of access Guarantees the flow of users through all levels of care and complexity in order to ensure the continuity of care, Develops referral and counter-referral mechanisms, between different health services and, when required, other social services.

26. INTEGRATED HEALTH SERVICE SYSTEM ESTABLISHMENT OF AN INTEGRATED NETWORK OF HEALTH CARE DELIVERY THAT –ALLOWS THE PROVISION OF CONTINUOUS CARE TO A SPECIFIC POPULATION –AT A SPECIFIC TIME AND PLACE AND WITH DEFINED COST AND QUALITY –IS RESPONSIBLE FOR THE HEALTH AND ECONOMIC OUTCOMES OF THIS POPULATION. Source: MENDES (2001)

27. COMPONENTS OF INTEGRATED HEALTH SERVICE SYSTEMS COLLABORATIVE MANAGEMENT OF CARE MANAGEMENT OF POPULATION RISKS MANAGEMENT OF POINTS OF HEALTH CARE DELIVERY CLINICAL MANAGEMENT SOURCE: MENDES (2001)

28. Levels of construction of networks LevelActionsValue at play 5 th Floor Associate Share objectives and projects Confidence 4 th Floor Cooperate Share activities and/or resources Solidarity 3 rd Floor Collaborate Provide intermittent help Reciprocity 2 nd Floor Gain knowledge Knowledge of what the other is or does Interest 1 st Floor Recognize Recognize that the other exists as a peer or collaborator Acceptance Source: Rovere, M. 2004

29. Organization and management of networked services Segmentation of the resources, supply and population ORGANIZATION INTO A NETWORK PHC Primary Care Social Security Private, high complexity MOH Professional Risks Private, low complexity NGOs Municipalities Universities Secondary Care Traditional Medicine Tertiary Care

30. HOSPITAL DAY HOSPITAL NURSING CENTER HOME-BASED CARE BASIC HEALTH UNIT SPECIALIZED AMBULATORY CARE HOSPITAL DAY HOSPITAL NURSING CENTER HOME- BASED CARE SPECIALIZED AMBULATORY CARE BASIC HEALTH UNIT HOSPITAL A AMBULA- TÓRY B AMBULA- TÓRY A HOSPITAL B From fragmentation to integration in a network 1 2 3 SOURCE: MENDES (2001)

31. From the INTEGRATION OF SOCIAL PROTECTION to INTER-SECTORAL INTEGRATION HEALTH SERVICE SYSTEM SOCIAL PROTECTION SYSTEM HEALTH CULTURE SOCIAL PROTECTION EDUCATION HOUSING EMPLOY- MENT SOURCE: MENDES (2001)

32. José Ruales Regional Advisor in Health Systems PAHO/WHO rualesjo2@paho.org