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Eduardo Levcovitz, MD, MSC, Ph.D Chief, Health Policies and Systems Unit

Regional Forum 2006 Tegucigalpa, Honduras. “SOCIAL PROTECTION IN HEALTH FOR WOMEN, NEWBORNS AND CHILDREN IN LAC”. Eduardo Levcovitz, MD, MSC, Ph.D Chief, Health Policies and Systems Unit. EXPANSION OF DISPARITIES GROWTH OF EXCLUSION. GLOBALIZATION

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Eduardo Levcovitz, MD, MSC, Ph.D Chief, Health Policies and Systems Unit

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  1. Regional Forum 2006 Tegucigalpa, Honduras “SOCIAL PROTECTION IN HEALTH FOR WOMEN, NEWBORNS AND CHILDREN IN LAC” Eduardo Levcovitz, MD, MSC, Ph.D Chief, Health Policies and Systems Unit

  2. EXPANSION OF DISPARITIES GROWTH OF EXCLUSION GLOBALIZATION and a new economic order DEMOCRATIZATION and decentralization Economic reforms and State reforms Health sector reforms Crisis of the welfare state and social security MDG HFA 2000 1975 1990 2015 Political panorama of population health in the Americas bipolar world cold war capitalism vs. socialism anti-colonialist movement Third World multilateralism unipolar world war against terrorism hegemony of capitalism globalization unilateralism human insecurity and vulnerability DEMOGRAPHIC TRANSITION : population growth, urbanization and aging EPIDEMIOLOGICAL POLARIZATION: coexistence of opposing risk and disease profiles Overwhelming ENVIRONMENTAL and ECOLOGICAL impact

  3. Evolution of the regional demographic profile PAHO; Health of the Americas, 2002 edition

  4. Epidemiological polarization of the mortality burden all other causes external perinatal cardiovascular cancer infectious external expected years of life lost up to 85 years of age, 2000 PAHO; Health of the Americas, 2002 edition

  5. Evolution of theethics/ideology/values that guide social protection systems Public Assistance and Charity for the poor and indigent UNIVERSAL SOCIAL PROTECTION AS A CITIZEN RIGHT WELFARESTATE Segmented systems according to ability to pay Formal Social Security for industrial workers MDG XXI Century 50s/70s 80s/90s XX Century 20s/40s

  6. Main causes of mortality in children under five in the Americas 132,194 annual deaths 26.9% of all deaths Malnutrition 14,444 2.9% Respiratory 59,600 12.1% Others, 36,960 (19.8%) Sepsis, 11,200 (6%) Low Weight, 22,590 (12.1%) Peri-Neonatal 186,700 38.0% Infectious Diseases 58,150 11.8% Asphyxia, 39,200 (21.0%) Problems during Pregnancy and Delivery, 76,750 (41.1%) Perinatales Others (congenital anomalies, cardiovascular diseases, etc.) 143,100 29.2% 38.0% Accidents 28,750 5.9% 2003 Estimates Source: Estimates by the Child and Adolescent Health Unit (FCH/CA), using a database from the Health Analysis and Information Systems Area (AIS). Pan American Health Organization (PAHO). 2004.

  7. Observed 1990-2000 2.4% Required according to Summit Goals 1990-2000 4.0% Observed 2000-2003 2.6% Required Increase: 142% Required according to the MDGs1990-2015 4.3% Required to meet the MDGs starting in 2003 6.3% Percentage of average annual decline in the under-5 mortality rate in the Region of the Americas Comparison of values observed and values proposed at International Summits Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

  8. Percentage of average annual decline Registered in 2000-2003 Needed between 2003 and 2015 in order to meet MDG 4 10.1% 7.8% 6.4% 6.3% 6.3% 6.3% 5.3% 5.1% 5.0% 4.5% 3.1% 2.9% 2.6% 2.4% 1.8% 1.8% 1.2% -0.4 Regional Total Haiti Bolivia Guyana Honduras Nicaragua Peru Brazil Mexico Percentage of average annual decline in the under-5 mortality rate in the Region of the Americas Comparison of observed values and values proposed at International Summits

  9. Hemorrhages 24.8% Sepsis 14.9% Indirect causes 19.8% Hypertensive disorders 12.9% Other direct causes Obstructed delivery Complications of abortion 7.9% 6.9% 12.9% 22,000 avoidable maternal deaths each year • Unnecessary, harmful practices • Indirect causes (HIV/AIDS, Malaria, Violence) • Child malnutrition / Poverty / Illiteracy • Lack of access to health services • Deficient quality of care • Provision of unqualified services • Early pregnancies • Under-registration of maternal deaths Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

  10. Social exclusion in health LAC, 2003 • 230 million inhabitants (46%) do not have health insurance • 125 million (25%) do not have permanent access to basic health services • 17% of births are without a skilled attendant • 680,000 children do not complete their DPT3 vaccination program • 152 million people do not have access to potable water and basic sanitation Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

  11. Regional strategic framework: PAHO mandates and commitments by the Member States (Resolutions CSP 26/13 and 14, 2002) • Development of public policies at the national and local levels • Improve quality of care • Guarantee access: ensure the provision of essential obstetric care, access to family planning, prenatal care and newborn care • Skilled delivery care • Empower women, families and communities • Monitoring systems for the reduction of maternal mortality • Epidemiological surveillance of maternal morbi-mortality • Financing mechanisms for ensuring equity, solidarity and sustainability.

  12. Extension of social protection in health PAN AMERICAN SANITARY CONFERENCE - 2002 WORLD HEALTH ASSEMBLY – 2005 Resolution WHA58.33

  13. Extension of social protection in health The fundamental challenge confronting the health systems of the countries in the Region is …… “Guarantee all citizens with UNIVERSAL SOCIAL PROTECTION in health, eliminating or reducing to the greatest degree possible the avoidable inequalities in coverage, access and use of services and ensuring that every person receives care according to his or her need and contributes to the financing of the system according to his or her possibilities”

  14. Strategies for the extension of social protection in health • GUARANTEE EQUITABLE ACCESS AND UTILIZATIONwith the objective of providing social groups, that until today have been excluded with the opportunity to receive integral care, independent of their ability to pay DISTRIBUTION OF CHILD MORTALITY BY INCOME QUINTILES IN SELECTED COUNTRIES – LATIN AMERICA, 1999 Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Source: PAHO/WHO, Health of the Americas, Volume 1 - 2002

  15. Fundamental elements of social protection systems IDEAS PRINCIPLES VALUES INTERESTS INFORMATION KNOWLEDGE

  16. Conditions for the extension of social protection in health • SOLIDARIDATY IN FINANCING: intergenerational, among different occupational categories, among diverse income groups, and among populations exposed to health risks. • FINANCIAL SECURITY OF THE HOUSEHOLD: that the financing of health services not represent a threat to the economic stability of families or the development of their members.

  17. Conditions for the extension of social protection in health • ACCESS TO SERVICES: availability of the necessary, timely supply for the provision of services and the elimination of physical, geographic and economic barriers. • DIGNITY IN CARE: provision of care with quality, warmth and opportunity and under conditions that respect ethnicity, culture, gender, age and sexual orientation.

  18. Country-based initiatives for the extension of social protection in health • Integrated Health Insurance - SIS (Peru) • Universal Maternal and Child Insurance - SUMI (Bolivia) • Popular Health Insurance (Mexico) • Free and universal health care (Mexico DF) • SGSSS Subsidized Scheme (Dominican Republic) • Free Maternity Law (Ecuador) • Community Insurance in Caazapá (Paraguay)

  19. Country-based initiatives for the extension of social protection in health • Unified Health System - SUS (Brazil) • National Health Insurance (Bahamas, Trinidad & Tobago, Aruba) • Subsidized affiliation by the State to the Costa Rican Social Security System - CCSS (Costa Rica) • Revision and expansion of the Obligatory Medical Program (Argentina) • Legislative review of Law 100 (Colombia) • Extension of benefits to dependent family members in the Social Security system (El Salvador) • Extension of PHC Coverage in rural areas (Guatemala) • Explicit Health Guarantees (Chile) • Universal Basic Insurance (Massachusetts, USA) • Inside the Neighborhood (Misión Barrio Adentro) (Venezuela)

  20. Strategies for the extension of social protection in health: SYNERGY AND COHERENCE Expansion of classic social insurance schemes, including the incorporation of informal workers Expansion of the mechanisms and projects for the extension of health systems coverage EXTENSION OF SOCIAL PROTECTION IN HEALTH Establishment of links between previous mechanisms and other protection mechanisms and public initiatives (overcome fragmentation and segmentation and improve equity) Promotion and development of innovative protection strategies, including community-based initiatives

  21. HEALTH SYSTEMS IN LAC NATIONAL HEALTH SERVICE HEALTH SECTOR REFORMS SOCIAL SECURITY IN HEALTH “BUSINESS”

  22. A GHOST TRAVERSES THE HEALTH SYSTEMS OF LAC ….. Segmentation according to ability to pay Operational fragmentation

  23. Limitations of segmented systems Inequities in access and utilization • Large differences in guaranteed rights, per capita spending levels, and the degree of access to health services, benefits and opportunities across different population strata BIRTHS ATTENDED BY SKILLED PERSONNEL, AROUND 2002 Poorest Quintile 2 Quintile 3 Quintile 4 Richest Source: World Bank, Socio-Economic Differences in Health, Nutrition, and Population, Washington, DC

  24. Limitations of segmented systems Segmentation of financial contributions / risk pools Sources FORMAL EMPLOYMENT CONTRIBUTIONS GENERAL AND SPECIFIC TAXES Public Private HOUSEHOLD CONTRIBUTIONS TO COMMUNITY FUNDS PRIVATE PREMIUMS External INTERNATIONAL LOANS AND DONATIONS

  25. Limitations of segmented systems Per capita spending on health, El Salvador 2004 Sub-System of Affiliation by Income, Chile, 1998

  26. Limitations of segmented systems • Regressivity and insufficient financing, with the predominance of out-of-pocket expenditures

  27. Limitations of segmented systems:out-of-pocket expenditures

  28. Limitations of segmented systems:catastrophic expenditures • At the global level: • Annually 150 million people and 44 million households confront financial catastrophes as a direct result of health expenditures. • 25 million households and 100 million people are pushed into poverty given the need to pay for health services. • In the Americas: • The family contribution, through out-of-pocket spending, represents 37% of total health expenditures and in several countries, exceeds 50%. • Family expenditures on health are considerably greater in families with lower incomes. • Out-of-pocket expenditures on health are 16% to 40% higher for women than men.

  29. Limitations of segmented systems • Weak stewardship: insufficient regulatory framework and inadequate fiscalization • High transaction costs • Administration, propaganda, sales and intermediation • Absence of integrated planning and programming • Targeting and micro-insurances that constitute pools of reduced risks • Clientelism, corporativism and corruption • Insufficient capacity for developing contracts with providers and the use of payment mechanisms that generate perverse incentives

  30. Limitations of segmented systems Operational fragmentation NGO Hospital EFFICIENCY EQUITY Walk-In, Mayor’s Office Social Security Health Center

  31. Strengthening of the STEWARDSHIP / MANAGEMENT of Sectoral Policies POLITICAL / SOCIAL DIALOGUE among multiple actors INTERINSTITUTIONAL COORDINATION Harmonization and integration of FINANCING Alignment and harmonization of INTERNATIONAL COOPERATION STRATEGIES FOR CONFRONTING SEGMENTATION AND FRAGMENTATION Integrated and integral Service NETWORKS Incorporation of the knowledge from PROGRAMS into the organization of SYSTEMS OPERATIONAL INTEGRATION Health Systems based on PHC

  32. Final reflections …. and stimuli for the debate at our Regional Forum

  33. HEALTH FOR ALL Information and knowledge Human Rights FOUNDATIONS OF PUBLIC HEALTH POLICY AIMED AT HEALTH FOR ALL Primary Health Care Health Promotion Social Protection

  34. OPPORTUNITIES FOR INTERVENTION • INSTITUTIONAL LEADERSHIP AND CAPACITY • INFORMATION, KNOWLEDGE AND INNOVATION • INTELLIGENCE, CREATIVITY, DISCUSSION, COMMITMENT AND BOLDNESS • PLANNING AND COORDINATION

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