1. Mandates and Regional Frameworks for Strengthening Health Systems TECHNICAL WORKSHOP Economic Dimensions of NCDs in Latin America and the Caribbean Region Disease Control Priorities Project Dr. Reynaldo Holder Regional Advisor on Hospitals and Integrated Healthcare Delivery June 24, 2013

2. Overview Fragmentation and NCDs The response: Integrated People Centered Care Mandates and Strategic Framework o Integrated Health Service Delivery Networks (IHSDNs) o Universal Health Coverage (UHC) o Primary Health Care-Based Systems & Systems Thinking

3. PHC based Health Systems: Evolution of the Strategic Framework Alma Ata 1977 PHC Renewal 2005 IHSDNs 2008 The Path to Universal Coverage WHR 2010 PHC Reforms WHR 2008 PHC based Health Systems

4. Fragmentation of Healthcare Delivery Services Social Security Private Practice (High Technology) Other Providers Private Non-profit (NGOs) Local Govs Universities HIV-AIDS Malaria & Others Maternal-Child Health Ministry of Health Traditional Medicine

5. Fragmentation of Healthcare Delivery Services

6. The Model of Care Acute, episodic, curative care Disease/organ centered Highly dependent on expensive technologies Mostly provided by medical specialist Delivered mostly in hospitals With poor or no coordination between providers (particularly at the first level of care and social services).

7. The patient “vanishes” The patient “shows up” The patient is “treated” The patient is discharged The current model of care and the radar phenomenon

8. Source:Medicare Standard Analytic File,2004

9. “ “Las personas con condiciones crónicas intentan obtener un continuo de servicios en un sistema de financiamiento y provisión de servicios de salud orientado a la provisión episódica de cuidados”. “People with chronic conditions attempt to obtain continuous care in a systems where healthcare services and financial mechanisms are oriented to the delivery of episodic care”. Jesús María Fernández Dep. de Sanidad y Consumo Basque Country, Spain. The Model of Care

10. Integrated People Centered Care “ the management and delivery of health services such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health systems, and according to their needs throughout the life course ” PAHO, 2010

11. Integrated Health Service Delivery Networks (IHSDNs)

12. “Recognizing that integrated health services delivery networks are one of the principal operational expressions of the PHC approach in health service delivery, helping to make several of its essential elements a reality, namely universal coverage and access; the first contact; comprehensive care; appropriate health care; optimal organization and management; and intersectoral action… “ Integrated Health Service Delivery Networks (IHSDNs) PAHO, CD49.R22, 2009

13. Integrated Health Service Delivery Networks (IHSDNs)

14. Progress in Country Implementation Countries with on-going reforms based on PAHO’s IHSDNs framework: o Brazil Ordinance 4.279 (2010) on organization of IHSDNs in the SUS Ordinance 7.508 (2011) on integration and coordination of care between states (Federal Regulation) National consultation on a new policy for Hospital Care (2012) The experience of Minas Gerais o Chile The experiences in Ñuble and the Western Metropolitan Regions o Colombia New legislation (Act 1438 of January 19, 2011) o El Salvador National Heatlh Policy (“Building Hope”) o New Model of Care (People Centred integrated care) o Strengthening of the First Level of Care (ECOS) Intersectorial Health Commission o Others: Panamá, Perú, Paraguay, Uruguay, Trinidad and Tobago o Regional Level: PHC Collaborative Network Guidelines for implementation of IHSDNs Development of a Regional Agenda for Hospitals in IHSDNs

15. THE WORLD HEALTH REPORT 2010

16. Gerard Anderson, Analysis of the Medical Expenditure Panel Survey, 2004.

17. Dimensions to Universal Coverage

18. Three fundamental tenets of Universal Health Coverage. “First, it means that every individual and community has access to health services for prevention, promotion, treatment and rehabilitation. Second, it means putting in place the financial mechanisms and policies to ensure that people are protected from falling into poverty because of sickness. And third, universal health care means universal access to well-trained and motivated health care professionals, to safe and effective medical products and technologies, and to well- organized delivery networks. It means building and maintaining strong health systems based on primary health care.” Dr. Carissa Etienne Director of the Pan American Health Organization

19. Right to the highest attainable level of health Equity Solidarity Responsiveness to peoples’ health needs Quality-oriented Government accountability Social justice Sustainability Participation Intersectoriality First Contact Comprehensive, integrated and continuing care Family and community based Emphasis on promotion and prevention Appropriate care Active participation mechanisms Sound policy, legal & institutional framework Pro-equity policies & programs Optimal organization & management Appropriate human resources Adequate and Sustainable resources Intersectorial actions Universal coverage and access PHC-Based Health Systems Core Values, Principles and Elements

20. SYSTEMS THINKING

21. Thank you.