URUGUAY: HEALTH SECTOR REFORM Dr. Silvia Melgar Quito, October 2007

Health Reform in Uruguay: CHANGE IN THE CARE MODEL CHANGE IN THE MANAGEMENT MODEL CHANGE IN THE FINANCING MODEL INTEGRATED NATIONAL HEALTH SYSTEM (SNIS) NATIONAL HEALTH INSURANCE (SNS)

Arrangement of the National Health System FONASA (National Health Fund) Contributions from the state Contributions from households Contributions from businesses Public and private institutions Users Payment by capitation, age, gender, and service delivery goals Payment by income Provide comprehensive care

INTEGRATED NATIONAL HEALTH SYSTEM (SNIS)

PROPOSAL FOR THE HEALTH SECTOR BASED ON: Retaining the best values and foundational legacy of the system in Uruguay and putting them at the service of the Government’s health objectives Recognizing that the old policies are no longer appropriate for a society that has changed substantially over the past 30 years

…AND WHOSE GENERAL OBJECTIVE IS: To achieve universal access to health care for the entire population with uniform levels of coverage and quality, with distributive justice in terms of the economic burden that health expenditure represents for each citizen.

SOCIAL PROTECTION MATRIX State reform Educational reform Health reform Tax reform Housing policy Employment policy Plan for equal rights and opportunities

LEGAL FRAMEWORK

A Health Fund is created that brings together all the social security funds designed to finance health services (FONASA). The State Health Services Administration (ASSE) is added as a new care option. FONASA will pay risk-adjusted health premiums (age and gender). A bonus is paid for meeting service delivery goals in program implementation. This will improve access to health promotion and disease prevention, especially for children, the age group in which poverty is concentrated in the country. SOCIAL SECURITY EXPANSION LAW

SERVICE DELIVERY GOALS HEALTH OF CHILDREN UP TO 14 MONTHS OLD  Health promotion  Breast-feeding  Monitoring of growth and development HEALTH OF WOMEN  Health promotion  Adequate care during pregnancy  Sexual and reproductive health  Cancer prevention

SERVICE DELIVERY GOALS MATERNAL AND CHILD PROGRAM Providing care for newborns Monitoring during the first year of life Health of pregnant women Prevention and early detection of pathologies during pregnancy Providing care for pregnant women and newborns on a geographical basis

ASSE DECENTRALIZATION LAW Governance and health service delivery functions are separated. ASSE will organize and manage, in a decentralized manner, the health services currently provided by the Ministry of Public Health for health care in its preventive and curative modes. ASSE will be directed and administered by a five-member board, and when the Executive Branch proposes directors, it will take it into account that two of the five members must represent ASSE users and workers, respectively. With Executive Branch approval, ASSE can set rates and fees for its services.

THE INTEGRATED NATIONAL HEALTH SYSTEM LAW CHAPTER I: GENERAL PROVISIONS Guarantee the right of all inhabitants residing in the country to health protection. Create the Integrated National Health System, which will coordinate public and private providers of comprehensive health services.

THE SNIS LAW CHAPTER II: INTEGRATION OF THE SNIS ASSE and other health services in charge of public institutions. Public medical institutions. Private nonprofit medical institutions. Other comprehensive insurance in force when the law is approved.

CHAPTER III: NATIONAL HEALTH BOARD Duties: Plan, organize, direct, and control SNIS operations pursuant to the policies and standards set by the Ministry of Public Health. Administer National Health Insurance Ensure compliance with the regulatory principles and objectives of the SNIS. In coordination with the Ministry of Public Health, promote the adoption of measures that help improve public health and the quality of life of the population. THE SNIS LAW

CHAPTER IV: HEALTH CARE NETWORK Levels of care: The SNIS will be organized by levels of care, depending on the complexity of the benefits. The National Health Board will establish and ensure that there are referral and back- referral mechanisms between the different levels of care. The SNIS will employ primary health care as a strategy and will give priority to the first level of care. THE SNIS LAW

CHAPTER IV: CONTRACTS BETWEEN PROVIDERS Participants in the SNIS can contract, among themselves and with third parties, the benefits included in the integrated health services programs approved by the Ministry of Public Health. The National Health Board will regulate relationships among Integrated National Health System providers and between them and others that are not part of the system. THE SNIS LAW

CHAPTER V: MEDICAL CARE COVERAGE Comprehensive Benefits Programs Will be approved by the Ministry of Public Health Should be offered to the users of health services by entities participating in the SNIS. Benefits included Will be strictly defined Will be described in terms of their components Will have quality indicators for processes and outcomes. THE SNIS LAW

CHAPTER VI: SNIS USERS All people who reside in the national territory according to registry in one of the institutional health service providers that are part of it. Providers can neither deny nor limit benefits to any SNIS beneficiary. Free selection of the provider, which can later be modified periodically according to the regulations. THE SNIS LAW

CHAPTER VII: FINANCING OF THE SNIS National Health Insurance Will have a single mandatory public fund known as the National Health Fund. Will be made up of public and private funds, which will be used to reimburse the health premiums Reimbursement of health premiums Will be made to the public and private entities that make up the SNIS The health premium will be set by the Executive Branch, with the participation of the Ministry of Economy and Finance and the Ministry of Public Health, and with input from the National Health Board. Will take into account cost differentials by specific population groups and the achievement of health care goals. Contributions to FONASA The state and private enterprises will contribute to FONASA 5% of the total pensionable amount paid to their workers and, when applicable, surplus funds from health premiums. Public and private workers who are FONASA beneficiaries will contribute 6% of their eligible earnings to FONASA beginning in January Incomes lower than 2.5 CBB (contributions and benefits base) do not contribute the additional 3%. THE SNIS LAW

Per Capita Adjusted by Age and Sex ___ Women ________ Men

STRENGTHENING GOVERNANCE Participation of health actors in the Advisory Committee for change (companies, trade associations, professional schools, health service users, public sector, municipal governments). Consensus-based health programs in this Committee. Consensus-based prioritization of service delivery goals. Public-private complement at the micro, middle, and macro levels in geographical agreement with private providers.

STRENGTHENING GOVERNANCE FUNCTIONS Starts with the Ministry of Public Health’s obligations under the organic law of 1934 and successive laws. Health indicators to ensure that benefits are provided as indicated. Financial indicators of the solvency of the institutions. Monitoring of the rational use of technology, registries, and qualifications of health services in relation to the needs of society.

STRENGTHENING DRUG POLICY Improve the population’s access to drugs: Development of protocols for all pathologies, particularly those with low prevalence and high cost. Improve the dispensing of drugs through agreements with community pharmacies. Agreements with ROU University, MERCOSUR, and PAHO. Ongoing dialogue with the legislature. Guarantee the quality of drugs, increasing controls: Improve the technical and administrative processes of the Department of Drugs and the Quality Control Lab. Rational use of drugs: – Unit for the monitoring of adverse reactions. – Discourage self-medication and inform the public about this issue. – Promote user participation. Coordinate with other actors in the sector on a policy for the rational and nonhazardous use of drugs.

Thank you very much