1. Office of the Assistant Director Health Systems Strengthening Area DYNAMICS OF HEALTH POLICIES AND CHALLENGES FOR HEALTH SYSTEMS STRENGTHENING IN LATIN AMERICA AND THE CARIBBEAN Eduardo Levcovitz, MD, MSC, Ph.D Unit Chief, Health Policies and Systems Development Pan-American Health Organization - PAHO/WHO Health Systems Strengthening Workshop Belize, May/June2006

2. Office of the Assistant Director Health Systems Strengthening Area OUTLINE DYNAMICS OF HEALTH POLICIES HEALTH SYSTEMS CHANGES/ REFORMS IN LAC Monitoring and Evaluation General Trends THE WAY AHEAD Challenges for health systems strengthening Health Systems Strengthening Workshop Belize, May/June2006

3. Office of the Assistant Director Health Systems Strengthening Area EVOLUTION OF THE ETHICS/IDEOLOGIES/VALUES IMBEDDED IN HEALTH POLICIES 20s/40s 80s/90s50s/70s XXIst Century Formal Social Security for industrial workers Public assistance and charity for the poor and indigent XXth Century Welfare state Segmented systems according to ability to pay UNIVERSAL SOCIAL PROTECTION AS CITIZENSHIP RIGHTS

4. Office of the Assistant Director Health Systems Strengthening Area Resolutions PAHO-CSP26/12- 2002 and WHA58.33 – 2005 UNIVERSAL SOCIAL PROTECTION AS CITIZENSHIP RIGHTS Ensure to all citizens the UNIVERSAL SOCIAL PROTECTION IN HEALTH, eliminating or reducing the avoidable inequities in coverage, access and utilization of services and stimulating that everyone receives care according to its needs and contributes to the financing of the system according to its possibilities.

5. Office of the Assistant Director Health Systems Strengthening Area INTRINSIC ELEMENTS OF HEALTH AND SOCIAL POLICIES IDEAS VALUES PRINCIPLES INTERESTS INFORMATION KNOWLEDGE

6. Office of the Assistant Director Health Systems Strengthening Area Politics (Power, Gobernability) HEALTH SECTOR Industrial (economic interest) Social Protection (citizenship right) Ethics (respect to life) DIMENSIONS OF THE HEALTH SECTOR

7. Office of the Assistant Director Health Systems Strengthening Area Social Protection : Subsystem of the Welfare State Politics: Subsystem of the Democratic Pluralist State Industrial: Subsystem of the Industrial Capitalist State Ethics: Subsystem of the Code of Global, Regional and National Values/Commitments of each Country/Society DIMENSIONS OF THE HEALTH SECTOR

8. Office of the Assistant Director Health Systems Strengthening Area HEALTH SYSTEMS IN LAC NATIONAL HEALTH SERVICE SOCIAL HEALTH INSURANCE ENTREPRENEURIAL SEGMENTED Although the classical types of health systems influenced the development of the health sector in the Americas, neither of those models were fully implemented in the Region, where most of the countries have highly SEGMENTED HEALTH CARE SYSTEMS PRIVATE SOCIAL INSURANCE PUBLIC

9. Office of the Assistant Director Health Systems Strengthening Area ….. any other typology or classification is arbitrary. TYPOLOGIES OF HEALTH SYSTEMS With the exception of the MENDELEYEVs PERIODIC TABLE OF ELEMENTS…

10. Office of the Assistant Director Health Systems Strengthening Area HEALTH SYSTEMS REFORMS IN LAC: MONITORING AND EVALUATION www.lachsr.org

11. Office of the Assistant Director Health Systems Strengthening Area HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS It looks like deregulation reached even the diseases Look doctor, my glucose raised until 250 than went down to 85 and than raised again to 170 Health Systems Reforms has followed the processes of fiscal adjustment, reduction of the size and role of the State and market deregulation that happened throughout the Region during the 1980´s and 1990´s HEALTH REFORMS PUBLIC SECTOR REFORMS

12. Office of the Assistant Director Health Systems Strengthening Area HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS HSR did not respect the unique characteristics of each country related to their history, political culture and health systems organization, and with few exceptions adopted the fashion patterns and general receipts dictated the International Financial Institutions – IFIs

13. Office of the Assistant Director Health Systems Strengthening Area HSR did not increase INVESTMENT IN HEALTH, even within a context of some increase in social expenditures Health HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS

14. Office of the Assistant Director Health Systems Strengthening Area HSR has produced LOW IMPACT ON THE SIGNIFICANT DIFFERENCES in ensured rights, levels of percapita expenditure and degree of access to services between the various groups of population HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS

15. Office of the Assistant Director Health Systems Strengthening Area HSR were NOT CONVERGENT WITH THE SOCIAL SECURITY REFORMS in a way to generate synergistic actions to expand coverage of social protection HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS (5)

16. Office of the Assistant Director Health Systems Strengthening Area Few countries have faced the challenge of HUMAN RESOURCES DEVELOPMENT to adapt to the new reality of the public sector and to cope with the demands generated by the Health Sector Reforms HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS

17. Office of the Assistant Director Health Systems Strengthening Area Matters related to PUBLIC HEALTH, quality and continuity of care and integration between prevention, promotion and treatment in a comprehensive approach have remained marginal subjects in the debates on HSR HEALTH SYSTEMS REFORMS IN LAC : GENERAL TRENDS EPHF in the Americas

18. Office of the Assistant Director Health Systems Strengthening Area There has been little or no progress in the improvement of the overall systems performance and general effectiveness, nor in overcoming the inequity and segmentation/fragmentation of health systems, as HSR has focused on MICROECONOMIC EFFICIENCY, decentralization, separation of functions of financing/provision and hospital autonomy. HEALTH SYSTEMS REFORMS IN LAC: GENERAL TRENDS

19. Office of the Assistant Director Health Systems Strengthening Area REFORMS LAC (80s & 90s) : CHANGES IN HEALTH CARE SYSTEMS SEGMENTED SYSTEMS

20. Office of the Assistant Director Health Systems Strengthening Area Inequities in access to and utilization of resources LIMITATIONS/RISKS OF SEGMENTED SYSTEMS Stratification of the population causing huge differences in access to services, goods and opportunities in health, and levels of per capita expenditure

21. Office of the Assistant Director Health Systems Strengthening Area Example: Per capita health spending El Salvador 2004 Institution Population covered (% of total population) Per capita spending US$ Ministry of Health80%48.00 Social Security (ISSS)17%283.00 Military health services1%247.00 Teachers health services1%417.00 Inequities in access to and utilization of resources LIMITATIONS/RISKS OF SEGMENTED SYSTEMS

22. Office of the Assistant Director Health Systems Strengthening Area SOCIAL INSURANCE CONTRIBUTIONS INTERNATIONAL GRANTS AND LOANS GENERAL TAXES PRIVATE PAYMENTS CONTRIBUTIONS FROM HOUSEHOLDS TO COMMUNITY FUNDS PUBLIC PRIVATE EXTERNAL Segmentation of financial contributions/ risk pools SOURCES LIMITATIONS/RISKS OF SEGMENTED SYSTEMS

23. Office of the Assistant Director Health Systems Strengthening Area Example: MEXICO LIMITATIONS/RISKS OF SEGMENTED SYSTEMS Segmentation of financial contributions/ risk pools

24. Office of the Assistant Director Health Systems Strengthening Area Example: Chile LIMITATIONS/RISKS OF SEGMENTED SYSTEMS Segmentation of financial contributions/ risk pools

25. Office of the Assistant Director Health Systems Strengthening Area MEXICO Segmentation of financial contributions/ risk pools LIMITATIONS/RISKS OF SEGMENTED SYSTEMS

26. Office of the Assistant Director Health Systems Strengthening Area SEGMENTED SYSTEMS FROM THE USERS POINT OF VIEW: OUT-OF-POCKET PAYMENTS

27. Office of the Assistant Director Health Systems Strengthening Area NGO MOHs Health Center Social Security Clinic Hospital Municipal Ambulatory Operational fragmentation SEGMENTED SYSTEMS FROM THE USERS POINT OF VIEW: FRAGMENTED DELIVERY NETWORKS

28. Office of the Assistant Director Health Systems Strengthening Area Health Systems in LAC EQUITY EFFICIENCY LIMITATIONS/RISKS OF SEGMENTED SYSTEMS Mainstream economics: Trade Off: Equity X Efficiency

29. Office of the Assistant Director Health Systems Strengthening Area Segmentation according to ability to pay Fragmentation of the services delivery network A GHOST THREATENS HEALTH CARE SYSTEMS IN LAC

30. Office of the Assistant Director Health Systems Strengthening Area CHALLENGES FOR HEALTH SYSTEMS STRENGTHENING INTER- INSTITUTIONAL COORDINATION + OPERATIONAL INTEGRATION

31. Office of the Assistant Director Health Systems Strengthening Area INTER-INSTITUTIONAL COORDINATION OPERATIONAL INTEGRATION Strengthening the STEERING ROLE of National Health Authorities ALIGNMENT AND HARMONIZATION of International Cooperation INTEGRATED health care delivery networks Reorganization of health systems based on PHC STRATEGIES Incorporating scientific KNOWLEDGE from public health programs into the scaling up of health systems STRATEGIES TO REDUCE/ELIMINATE SEGMENTATION AND FRAGMENTATION SOCIAL/POLICY DIALOGUE among multiple stakeholders Harmonization and integration of FINANCING mechanisms CHALLENGES FOR HEALTH SYSTEMS STRENGTHENING

32. Office of the Assistant Director Health Systems Strengthening Area FRAMEWORK FOR HEALTH ACTION IN THE AMERICAS FOR THE XXI CENTURY Addressingtheunfinishedagenda Protecting the achievementsFacingthenewChallenges

33. Office of the Assistant Director Health Systems Strengthening Area POLICY FRAMEWORK FOR HEALTH SYSTEMS STRENGTHENING primary health care health promotion social protection in health health as a human right information and knowledge management Health For All

34. Office of the Assistant Director Health Systems Strengthening Area LEADERSHIP AND INSTITUTIONAL CAPACITY BUILDING INFORMATION, KNOWLEDGE AND INNOVATION PLANNING AND COORDINATION INTELLIGENCE, CREATIVITY, OPEN DEBATE AND COMMITMENT CHALLENGES FOR HEALTH SYSTEMS STRENGTHENING