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Perspectives on the Health Sector: challenges and opportunities

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1 Perspectives on the Health Sector: challenges and opportunities
José Gomes Temporão, MD, PhD Former Minister of Health ( ) South American Institute of Government in Health (Isags)

2 THE PRESENTATION 1-BACKGROUND 2- THE TRANSITIONS 3- HEALTH AND DEVELOPMENT 4-THE NEW SOUTH AMERICAN HEALTH CONTEXT

3 Brazil - Economic and Institutional Scenario
Macroeconomic stability (inflation, fiscal and monetary policies, etc.) Institutional strength (democracy, state organization) Stable growth trajectory GDP growth: 7,5 % Long Term Perspective: sustainable growth Perspective: 5th position in world Economy

4 Brazil: Social, Demographic and Health System Changes
Substantive improvement in social inclusion and income distribution Social assistance programs Expansion of middle class GINI index decrease: 9% from to 2009 (Ipeadata, 2010) Universal health system consolidation (Datasus, 2009) The primary “ Family health care program”: universal access Infant mortality rate: the biggest decrease in the last 10 years worldwide - 5,2%/year Life expectancy improvement (from 67 years in 1990 to 73 years in 2009)

5 The New Middle Class and Mass Market
5 The New Middle Class and Mass Market Distribution by social class % of population Fonte: IBGE Elaboração: Ministério da Fazenda 5

6 The Brazilian Health Reform and The SUS – Unified Health System

7 Democratic Constitution
1980’s: After dictatorship’s end a new Democratic Constitution is proclaimed Democratic Constitution National (Unified) Health System Fragmented system Health as Universal Right Health as State duty Decentralized to states and municipalities Public/Private mix Social participation at all levels Private services for those who could afford Social Security for sectors formally employed Public health for endemics and epidemic hazards 1988 1960 1970 1980 1990 2000 2010 7

8 SUS – Unified Health System
SUS Indicators 75% of the Brazilian population depend on SUS 6,000 hospitals 64,000 primary care units 30,000 family health care teams 2,3 billion ambulatory appointments 12 million hospital admissions 9 million chemo- and radiotherapy procedures 19 thousand transplants sponsored by SUS 1 million CT scans and 160,000 Magnetic Ressonance 8 million hemodialyses procedures SUS Characteristics Universality: SUS, as the Brazilian public system, provides healthcare for all, regardless of distinctions and restrictions; Unity: one system composed of decentralized unities managed by different governmental levels (Federal, State and Local/Municipal)

9 NATIONAL HEALTH SYSTEM (SUS)
More than 75% of the Brazilian population depends exclusively on SUS (150 million people) for its health needs The other 25% has private coverture but uses also the SUS (transplants, high cost drugs, emergency care, vaccines, Aids etc) 9

10 Private System: Insurance Health Plans Revenue (Brazil, 2000 to 2009)
Balança Comercial 2007 – Igual ao feito para a Índia Note: revenue growth is also the result of improved collection of information by ANS, expressing only partly real growth.

11 Targeting equity BRAZIL: an unequal country that chose to build a universal health system
This picture is “worth a thousand words”, as the saying goes. It is a graphic example of the social contrasts we face, where the upper classes coexist literally wall to wall with the less favored segments of our society. It is in this context of social and economics contrasts, as this picture well illustrates, which pose enormous challenges to the progress of our society, that Brazil was able to implant a universal Health System where all, no exceptions, have the right to integral and free care. 11 11

12 2- THE TRANSITIONS

13 The Transitions Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases. Demografic Diet Transition Technological (Cultural, organizational, economic)

14 Trends in deaths patterns according to causes, Brazil 1930-2007

15 Diabetes Mortality Rates 1996 - 2007 Legenda (Óbitos/100000)
Schmidt MI, et al Lancet, 2011

16 The Transitions Demografic – Increasing elderly population
Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases. Demografic – Increasing elderly population Diet Transition Technological

17 Ramos, Veras e Kalache, 1987 RSP
Demographic Transition: a Secular Trend 30 ANOS 60 ANOS 100 ANOS 80 ANOS 1750 1800 1850 1900 1950 2000 2050 Fecundidade Fecundidade EUROPA BRASIL Mortalidade Mortalidade Ramos, Veras e Kalache, 1987 RSP

18 Ramos, Veras e Kalache, 1987 RSP
2 6.2 1950 13.9 1975 31.8 2000 ‘BOOM’ OF ELDERLY IN BRASIL 2025 ( millions of inhabitants 60 +) Ramos, Veras e Kalache, 1987 RSP

19 The Transitions Diet Transition
Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases. Demografic – Increasing elderly population Diet Transition overweight : de 12% (1975) para 43% (2008) obesity: de 3% (1975) para 13% (2008). Technological

20 Height deficit in under 5 ys. according to family income, 1974/5-2006/7
3 4 Poorest 20

21 Obesity and overweight – How long will take to be at the same level as USA today?
MEN 64.2% OBESITY + OVERWEIGHT: 12 YEARS! % 27.1% OBESITY: 16 YEARS! VIGITEL (http://portal.saude.gov.br/) BRFSS para EUA NUPENS/USP

22 The Transitions Technological
Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases. Demografic – Increasing elderly population Diet Transition- overweight, obesity Technological

23

24 3-Health and Development: General Perspective From Brasil

25 Health and Development (The Duality of Health)
Health as a citizenship condition and a proeminent area of development 25

26 The Duality of Health Articulation of economic logic with health logic Development of production base combined with health needs Health Sector In Brasil About 8% GDP 10% of qualified work of the country 12 million direct and indirect jobs Platform for new technological paradigms (fine chemicals, biotechnology, eletronics, nanotechnology, new materials, etc) 26

27 Perspective of demand explosion and a strong pressure on the productive base: a challenge and an opportunity

28 BRAZIL: Health Industrial Complex (HIC)
S T A T E .. P R O M O T I O N + R E G U L A T I O Industrial Sectors Chemical and Biotechnology industries Mechanic, Electronic and Materials Industries Pharmaceuticals APIs Vaccines Blood Products Diagnostic Reagents Mechanical equipments Electronic equipments Prothesis and orthosis Materials Health Services Diagnosis and Therapeutic Services Hospitals Ambulatories Source: Gadelha, 2003

29 Informações Selecionadas
Health within a Development Context: Panorama of the Pharmaceutical Productive Chain (1) Informações Selecionadas Maior base industrial da América Latina Mercado farmacêutico de US$ 20 billion (alta tx de crescimento) Posição no ranking: entre os 9 maiores mercados mundiais Estrutura internacionalizada, porém com um significativo fortalecimento do capital nacional com base nos genéricos Elevado dinamismo nas vendas de medicamentos no período recente (todos segmentos) Produção de vacinas com elevado dinamismo (PNI e produtores públicos): R$ 900 milhões Estratégia nacional para Hemoderivados: Hemobrás Produção de reagentes limitada e de baixo conteúdo tecnológico Especialização em atividades de menor conteúdo tecnológico Papel destacado do Estado nas compras de todos segmentos

30 Informações Selecionadas
Health within a Development Context: Panorama of the Pharmaceutical Productive Chain (3) Indústria de Equipamentos e Materiais Informações Selecionadas Dinamismo do segmento no período recente Mercado em torno de R$ 8 bilhões Predomínio de empresas de pequeno e médio porte Estrutura empresarial fragmentada Afastamento da fronteira tecnológica Perda de competitividade nos segmentos mais dinâmicos Papel destacado do Estado nas vendas do setor (50%)

31 Health within a Development Context: Panorama of the Pharmaceutical Productive Chain (4)
Reagents for Diagnosis Industry – Selected Information Market domain for the international leaders Specialization of the local companies in activities of smaller technological content Permanent commercial deficit even after the depreciation Significant role of the government purchases (politics of blood and attendance in general)

32 HIC 2009 – Evolution of Brazilian Health Trade Balance: General Overview (values in US$ Billions, updated by USA Inflation) 32

33 HIC 2009 - Brazilian Health Trade Deficit by Sector
33

34 Health, Innovation and Development: policy perspectives
Institutionalization of an integrated policy

35 Productive Development Policy (PDP-2008)
Mobilization Programmes in Strategic Areas Health Industrial Complex Information and Communication Technologies Nuclear Energy Defense Industrial Complex Nanotechnology Biotechnology Programmes to Consolidate and Expand Leadership Aeronautics Complex Petroleum, Natural Gas and Petro chemistry Bio ethanol Mining Steel Cellulose and Paper Meat Programmes to Strengthen Competitivity Automobile Complex Capital Goods Textile Woods and Furniture Hygiene, Perfumery and Cosmetics Civil Construction Services Complex Naval Industry and Cabotage Leathers, Footwear and Artifacts Agro industry Biodiesel Plastics OTHER 35

36 PDP: The Context - Public Policies
Programme of Growth Acceleration (PAC): in expansion and oriented to overcoming structural bottlenecks Plan of Science, Technology and Innovation: programmes oriented to the promotion of scientific and technological development and innovation in the country Plan for the Development of Education: quality investments applied to overcoming the greatest restriction to long-term development – training of the Brazilian people “Mais Saúde”*: directly responds to immediate needs and builds on future capacity in the field of public health in Brazil Structural and convergent projects are currently under way in Brazil *Plus Health

37 HIC: Actions and Measures (1)
Use of the state purchasing power to stimulate domestic production Revision of regulation for governmental purchases Pre-qualification, competitive isonomy, taxes waving and orders of strategic products for health innovation Governmental Purchases - US$ 7,5 billion/year between 2008 and 2011 Financial support for increased production capacity New Profarma: Supporting Programmes for the Development of the Health Industrial Complex Objective: to increase the competitiveness of the HIC, by means of disseminating innovative activities and increasing the production of devices, materials, medicines and related products, contributing to the international insertion of national firms Resources: US$ 2 billion between 2008 and 2012 Budgetary Resources of the Ministry of Health: - US$ 582 million between 2008 and 2011

38 HIC: Actions and Measures (2)
Expansion of available resources for R&D in strategic areas Research and Technological Development in Health Priority and the Establishment of National Centres of Toxicology and Clinical and Pre-Clinical Research (at least two networks) - US$ 700 million between 2008 and 2013 New Profarma: Sub-Programme Innovation - Objective: to support projects of firms, the construction and consolidation of infrastructure for health innovation, as well as the internalization of competences and R&D&I activities in Brazil FUNTEC – Technological Fund: Non-reimbursable resources Strategic Areas 2008: Health, Renewable energies and Environment Active Principles and Medicines for Neglected Diseases; drugs that use of the technique of recombining DNA; construction of infrastructure for health innovation that includes bioteries, pre-clinical and clinical research

39 HIC: Strategic Areas for R&D&I
Productive and Scientific-Technological Challenges 1 2 Domestic production of hemoderivatives (factors 8 and 9, albumine and globulines) Development of Vaccines for the National Immunization Programme 3 4 Production of devices and materials used in health as a response to the National Health Policy Reactives and Diagnostic Devices for Blood Control based on Moderns Biotechnologies Regulatory landmark 5 6 Production of medicines and active principles for pharmochemicals Production of Biotechnological Products for Health

40 Health R&D – The MoH’s Role (2)
Some relevant projects in course National Network on Cell Therapy (RNTC). National Network on Clinical Research (RNPC). National Network on Health Technology Assessment HTA (REBRATS). National Cohort on Adult’s Health – CV diseases, diabetes, mental conditions (ELSA). National Cancer Research Network. Research on Neglected Diseases (~ 460 projects on Chagas Disease, Malaria, Leishmaniasis, Schistosomiasis, etc.) .

41 The Brazilian Policy for the Health Industrial Complex: recent trends
Articulation between health, industrial and S&T policy Intergovernmental Group involving 15 ministries and agencies Production Development Partnership 20 public-private partnership to produce strategic products Use of the public purchase power to stimulate innovation in health Regulatory System Evolution

42 Executive Group of the Health Industrial Complex - GECIS
WG Tributary exemption WG Transversal Actions WG government purchase WG Biopharmaceutical regulation Articulation Forum: 22 represents of the civil society, and from the entrepreneur sector. Participants: MS (coordinator), MCT, MDIC, MPOG, MF, MRE, Casa Civil, ANVISA, FIOCRUZ, FINEP, BNDES, INMETRO, INPI and ABDI.

43 The Brazilian Policy for the Health Industrial Complex: recent trends
Articulation between health, industrial and S&T policy Intergovernmental Group involving 15 ministries and agencies Convergence of incentives (investment, market, innovation) Production Development Partnership 30 public-private partnership to produce strategic products Use of the public purchase power to stimulate innovation in health Regulatory System Evolution Arrange a good balance between health access and innovation

44 Public and Private Development Partnership (PPDPs)
NINE PARTNERSHIP AGREEMENTS WERE ALREADY ESTABLISHED INVOLVING : 9 public companies; 20 private companies ; Local development and production of 28 active principles (API`s). The public purchases with these API’s currently reach around R$ 1,5 billion per year. After full implementation, these partnerships will be able to save an estimated amount of R$ 390 million per year.

45 PPP’s em Andamento

46 The Brazilian Policy for the Health Industrial Complex: recent trends
Articulation between health, industrial and S&T policy Intergovernmental Group involving 15 ministries and agencies Convergence of incentives (investment, market, innovation) Production Development Partnership 20 public-private partnership to produce strategic products Use of the public purchase power to stimulate innovation in health Regulatory System Evolution

47 Industrial Policy – MoH (2)
Reforming the Health Regulatory Framework. Building a special status for the health government purchasings (“Buy Brazilian” Act for the health products). Improving the purchasing processes in the health public sector (quality guarantee). Improving the Sanitary Surveillance regulations, together with ANVISA

48 A New Agenda of Cooperation in The New National Context
From simple trade and production relationship to: Benefits in terms of universal access Investment in higher technological products and process Cooperative R&D in Brazil Partnership with local private and public producers Enhancement of trade balance results

49 Main innitiatives to expand rational access to medicines and vaccines in Brazil.
Pharmaceutical Assistance Programs (strategic and high costs medicines) Popular Pharmacies Program. Generic Drugs Consumption Program. The National Immunization Program.

50 Expenditure in Medicines – Ministry of Health Budget
24/03/2017 Expenditure in Medicines – Ministry of Health Budget (%) Source: SCTIE/MS 50

51 Health and Development in Brazil Political Context
For the first time, Brasil has na industrial policy in health, to strengthen its pharmaceutical industry, having production capacity and reduce its dependence on this area 51

52 Health as a Window of Opportunity
Dimension of the national market (SUS and Private Sector) and high demand Existence in Brazil of a productive tradition (the most developed in Latin America) Scientific structure and human resources A well structured sanitary regulatory system organized on a national basis Macroeconomic stability (investment grade) Projected Industrial GDP growth (yearly): 5% (2008/11) Reduction of income inequalities (high market impact) Priority of Health Economic-Industrial Complex within national policy 52

53 4- The Growing Importance of Health in the Globalization Context
Health as a central issue in the international relations: South-south cooperation Latin America Portuguese-Speaking African Countries Haiti The Union of South American Nations (UNASUR)

54 Global Health: The South American Institute of Government
Global Health: The South American Institute of Government in Health (Isags)

55 Governance for Health ISAGS is a public, intergovernmental entity within the South American Health Council of the Union of South American Nations (UNASUR); with permanent headquarters in Rio de Janeiro

56 Governance for Health Its activities will be closely articulated with the Ministries of Health of UNASUR countries in: knowledge management and generating innovation in policy and governance for health, offering the best available practices and evidence to guide health management; developing leadership on systems, services, organizations and programs on health-related areas, providing technical support to government institutions in the health sector.

57 Networking ISAGS will collaborate with other institutions of national, regional and global scope. South America Network of National Institutes of Health (RINS); South America Network of National Public Health Schools (REGS); South America Network of Technical Health Schools (RETS); South America Network of Workshops on International Relations in Health (ORIS); Latin-America Network of National Institutes of Cancer (RINC).

58 The Unasur Strategic Agenda
Health Quinquennial Plan Health Surveillance and Response; Universal Health Systems; Universal Access to Drugs; Health Promotion and Action on Social Determinants of Health; Human Resources for Health.

59 Cooperação Sul-Sul e CIS
Saúde e Desenvolvimento Cooperação não pode olhar apenas para a oferta de insumos, tecnologias Compreensão mais ampla do processo de desenvolvimento das sociedades e como a saúde se insere nele Inclui a gestão de tecnologias, desenvolvimento e inovação, visando a redução da dependencia

60 OBRIGADO! jtemporao@isags-unasur.org


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