National Health Authority Republic of Colombia

Who we are: A public institution An inspection, surveillance, and control agency Policymaker for inspection, control, and surveillance A technical agency with its own judicial authority, administrative autonomy, and budget. National Health Authority Republic of Colombia National Health Authority Republic of Colombia

National Health Authority Republic of Colombia INSPECTION, SURVEILLANCE, AND CONTROL FUNCTIONS

National Health Authority Republic of Colombia  Steering entity of the Health Inspection, Surveillance, and Control (ISC) System.  Sets inspection, surveillance, and control policies to be followed by the essential public health service.  Exercises ISC in the exempted and special systems. AREA

National Health Authority Republic of Colombia  Coordinates user advocacy services.  Exercises legal authority over the services monitored and provides mediation.  Enforces application of the beneficiary selection criteria (SISBEN) AREA

National Health Authority Republic of Colombia  Enforces compliance with the principles and fundamentals of the essential public service of the social security health system.  Protects the rights of users - Right to insurance - Right of individuals and groups to health services. AREA

National Health Authority Republic of Colombia  Health service delivery without pressure from or the imposition of conditions by doctors.  Exercises authority over the services monitored in terms of ISC. AREA

National Health Authority Republic of Colombia  Ensures that EPS and IPS adopt the CODE OF CONDUCT AND GOOD GOVERNANCE that regulates the delivery of the services they provide  Authorizes the creation and accreditation of EPS AREA

National Health Authority Republic of Colombia INSPECTION, SURVEILLANCE, AND CONTROL system

National Health Authority Republic of Colombia Thematic Areas of the ISC System ISC SYSTEM Financing Efficiency, effectiveness, and efficacy in the generation, flow, and administration of resources Insurance Guarantee of members’ rights Service Delivery Accessible individual and collective health services that adhere to quality standards Health promotion and disease prevention Diagnosis, treatment, and rehabilitation Information Ensure that the actors involved guarantee the production of transparent, quality data

National Health Authority Republic of Colombia Thematic Areas of the ISC System ISC SYSTEM Care for users and social participation Actions and special measures Targeting of health subsidies Guarantee respect for users’ rights and actors’ fulfillment of their responsibilities and promote citizen participation Application of criteria for determining, identifying, and selecting beneficiaries Forcible administrative intervention to administer or close entities monitored Technical and administrative intervention in territorial health bureaus Oversight of voluntary closures Closure after revocation of operating license

National Health Authority Republic of Colombia DEFINITIONS FOR THE EXERCISE OF AUTHORITY by THE NHS

National Health Authority Republic of Colombia Definitions ISC SYSTEM Inspection Surveillance Control Ascertaining the situation with respect to the health services and their resources Determining compliance with standards in entities responsible for financing, insurance, and service delivery Order corrective measures for critical or irregular situations and sanction activities of entities monitored Follow-up, monitoring, evaluation Warn, prevent, guide, assist, and encourage Correct and sanction

National Health Authority Republic of Colombia UNIVERSE OF ENTITIES MONITORED ENTITIES MONITORED ENTITIES MONITOREDContributory,Subsidized, Exempted, and Special Systems Public and Private IPS Departmental and Municipal Secretariats Fosyga,Etesa, Idumil State-owned Social Enterprises Public and private EPS Entities that generate resources Entities that generate resources Special and Exempted Systems Special and Exempted Systems

National Health Authority Republic of Colombia Entities subject to Inspection, Surveillance, and Control Insurance Entities of the System (EPS, ARS, CCF, ARS, EAS, EMP, and SAP) 83 Public and Private Institutional Health Service Providers3,920 Entities that generate resources (Lotteries, Apuestas Permanentes, Gaming, liquor, and beers) 500 Territorial Entities (Departments and Municipalities) 1,129 Other Monitored Entities (CCF, Etesa, Fosyga, Fondo Cuenta, Indumil, special and exempted systems) 47 Subtotal5,677 Employers750,000 Total755,681

National Health Authority Republic of Colombia ORGANIZATION CHART

National Health Authority Republic of Colombia SUPERINTENDENCY FOR THE GENERATION AND MANAGEMENT OF FINANCIAL HEALTH RESOURCES

National Health Authority Republic of Colombia Guarantee the efficient generation, collection, flow, administration, custody, and use of resources for health service delivery. OBJECTIVE

National Health Authority Republic of Colombia SUPERINTENDENCY FOR HEALTH CARE

National Health Authority Republic of Colombia Perform inspection, surveillance, and control of the entities under its jurisdiction, ensuring compliance with the standards set for the management of health risk within the Social Security Health System. OBJECTIVE

National Health Authority Republic of Colombia INSURANCE BUREAU SUPERINTENDENCY FOR HEALTH CARE BUREAU FOR QUALITY AND HEALTH SERVICE DELIVERY PUBLIC HEALTH GROUP HEALTH RISK INSURANCE GROUP INSURER OPERATIONS GROUP QUALITY IMPROVEMENT GROUP ADVISERS HEALTH CARE GROUP INTERNAL STRUCTURE

National Health Authority Republic of Colombia SUPERINTENdency FOR user PROTECTION AND CITIZEN PaRTICIPAtion

National Health Authority Republic of Colombia POLICY OBJECTIVE Ensure respect for users’ rights in the SGSSS through inspection, surveillance, and control, and promote citizen participation and social control following the orientations provided in the participatory mechanisms established by law.

National Health Authority Republic of Colombia WORKING GROUPS: USER CARE GROUP CITIZEN PARTICIPATION GROUP INSPECTION AND SURVEILLANCE GROUP USER ADVOCACY GROUP SUPERINTENDENCY FOR USER PROTECTION AND CITIZEN PARTICIPATION

National Health Authority Republic of Colombia SUPERINTENDENCY FOR SPECIAL MEASURES

National Health Authority Republic of Colombia 1.Perform inspection, surveillance, and control of entities subject to corrective measures. 2.By order of the National Health Authority, take over and implement the respective interventions in the entities monitored to administer or close them. DECREE 1018 /07

National Health Authority Republic of Colombia Take over Forcible intervention Administer Close Technical and administrative intervention Territorial entities DECREE 1018 /07

National Health Authority Republic of Colombia Superintendency for legal affairs and mediation

National Health Authority Republic of Colombia JUDICIAL AUTHORITY Hear and issue a definitive ruling, with the legal authority of a judge, on matters specified in the law; in addition, serve as a mediator in any disputes that arise among the entities monitored and/or between these and users that adversely affect the latter’s access to the health services.

National Health Authority Republic of Colombia NHS LEGAL FUNCTIONS Law 1122/07, Art. 41 COVERAGE: 1. Activities, Procedures, Interventions - POS REFUNDS: 2. Beneficiaries x emergency care Unjustified denial or negligence of EPS 3. CONFLICTS Multiple coverage - Free Choice - Mobility--within the SGSSS

National Health Authority Republic of Colombia MEDIATION IN NHS Law 1122/07, Art. 38 CONFLICTS THAT ARISE BETWEEN:  MONITORED ENTITIES AND USERS  MONITORED ENTITIES  (EPS, EPS-IPS, P.E.) STEMMING FROM PROBLEMS THAT PREVENT THEM FROM MEETING THEIR OBLIGATIONS IN THE SGSSS, ADVERSELY AFFECTING USERS’ ACCESS TO THE HEALTH SERVICES.

National Health Authority Republic of Colombia

National Health Authority Republic of Colombia POLICY OBJECTIVE

National Health Authority Republic of Colombia USER CARE GROUP

National Health Authority Republic of Colombia THANK YOU! Ana Milena Rizo