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Gloria Delfim Walker Health Services Architect Specialist in Health Care Management

Integration of Programs in the Organization of Systems and Health Services Networks Regional Consultation Meeting: Integrated Health Services Networks and Vertical Programs Cusco, Peru, 11-12 November 2009. Gloria Delfim Walker Health Services Architect Specialist in Health Care Management

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Gloria Delfim Walker Health Services Architect Specialist in Health Care Management

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  1. Integration of Programs in the Organization of Systems and Health Services Networks Regional Consultation Meeting: Integrated Health Services Networks and Vertical ProgramsCusco, Peru, 11-12 November 2009 Gloria Delfim Walker Health Services Architect Specialist in Health Care Management Technical Adviser to Directorate of Health Care Networks, DARAS/SAS-MS 1

  2. Unified Health System (SUS): The Brazilian Experience 1. Brief Description of the SUS 2. Challenges Facing the SUS 3. The Integrated Health Networks Concept 4. Guidelines for the Implementation of IHNs 5. Ongoing Activities 2

  3. 1. BRIEF DESCRIPTION OF THE HEALTH SITUATIONAND THE UNIFIED HEALTH SYSTEM (SUS) 3

  4. Demographic Aspects National territory: 8.5 million km2 26 states, 1 Federal District, and 5,564 municipalities, all with political, fiscal, and administrative autonomy and with no hierarchical links between them 184 million inhabitants 42.6% in the Southeastern Region 27.7% in the Northeastern Region 14.6% in the Southern Region 8.0% in the Northern Region 7.1% in the Midwestern Region Regions Northern Northern Northeast Central/Western Southwest Southern 4 Source: IBGE

  5. Macroregions AMAZON REGION NORTHEAST REGION • Great diversity • Economic • Social • Cultural • Epidemiological CENTRAL/ SOUTHERN REGION 5

  6. BRAZIL Social Context The challenge: Formulatenational policies that allow for marked regional differences HDI over 0.801 HDI between 0.751 and 0.800 HDI between 0.701 and 0.750 HDI between 0.651 and 0.700 HDI under 0.650 Source: UNDP, 2000 6

  7. FEDERAL CONSTITUTION - LAW CREATING THE SUS • Article 196: “Health is a right of all and a duty of the State and shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other threats and at the universal, equal access to actions and services for its promotion, protection and recovery.” • Article 198: “Health actions and public services make up a regionalized hierarchical network and constitute a single system, organizedaccording to theprinciples …” of decentralization, regionalization, comprehensive care, and community participation. Law 8,080 (Art. 2, par. 3): Health determinants include food, basic sanitation, environment, work, income, education, transportation, leisure, and access to goods and social services; a population’s level of health is a reflection of the social and economic organization of the country. INTERSECTORAL APPROACH 7

  8. Technical and Political Pillars of Brazilian Health Sector Reform • Health as a right of all and a duty of the State • Decentralization with independent management in each sphere of government: municipal, state, and federal • Organization of health services based on universal care, equity in the delivery of services, and comprehensive care • Participation of the population in monitoring of the system • Responsibility for financing the system shared among the three levels of government 8

  9. Brazilian Health System Unified Health System (SUS): public, free, universal access Health expenditure as % of GDP: 7.4% (total) 3.6% (public) SupplementaryHealth System: private, benefi-ciaries subscribe to private health plans and insurance Direct pay: access throughdirect payment from beneficiary to provider 9 SOURCE: MS-SPO - MS-SIOPS - STUDIES QA. Year of Reference: 2007

  10. Integration of Health Careand SUS Services Law 8080/90 Article 7, paragraph II: (...) comprehensive health care, defined as acontinuous articulated set of individual and collective actions and preventive and curative services (...) Article 10 refers to organizational arrangements for local and regional networks operating through intermunicipal consortia and health districts tointegrate and articulate resources and increase the coverage of actions. 10

  11. National Programs 1. National Program for Reproductive Health 2. National Program for Health Promotion in Children and Youth 3. National Program for Oral Health Promotion 4. National Program for Health in Schools 5. National Program for People’s Health 6. National Program for Prevention of HIV/AIDS Infection and other Sexually Transmitted Diseases 7. National Vaccination Program 8. National Program for Polio Eradication: Post-Elimination Phase 9. National Program for Measles Elimination and Prevention of Congenital Rubella 10. National Program to Combat Tuberculosis 11. Integrated National Program for Clinical and Laboratory Surveillance of Flu - Information about the disease 12. National Program for Prevention of Antimicrobial Drug Resistance 13. National Program for Prevention of Hospital Infections 14. National Program for Prevention and Control of Oncological Diseases 15. National Program for Prevention and Control of Cardiovascular Disease 16. National Program for Control of Asthma 17. National Program for the Prevention and Control of Chronic Obstructive Pulmonary Disease 18. National Program for Control of Diabetes 19. National Program to Combat Obesity 20. National Program to Combat Rheumatic Diseases 21. National Program for Eye Health 22. National Program for Control of Hemoglobinopathies 23. National Program to Combat Depression 24. National Program on Post-Traumatic Stress Disorder 25. National Program for Prevention of Alcohol-Associated Problems 26. National Program on Prevention/Consumption of Illegal Drugs 27. National Program on Pain Management 28. National Program on Palliative Care  29.  National Program for Accident Prevention 30. National Program to Fight Inequalities in Health 31. National Program for Integrated Intervention in the Determinants of Health-Lifestyles 32. National Program for Environmental Health 33. National Program on Food Hygiene and Control 34. National Program for Health Promotion and Protection in the Workplace 35. National Program for Development of Health Human Resources 36.  National Program for Information and Knowledge Management 37. National Program for Development of Organ Transplantation 38. National Program on Accreditation of Hospitals 39. National Program on Accreditation of Health Centers 40. National Program for Laboratory External Quality Assessment

  12. Critical Reflection20 years later ... Challenges remain • Marked fragmentation of care and management • Gaps in care and barriers to access • Poor-quality services, lack of commitment on the part of health care and teams • “Treat ‘em and street ‘em” and physician-centered approaches to care (patients not taking a proactive role) • Focus on hospital and physician (peoplegoing where they know they will be served); • User dissatisfaction • Insufficient financial resources (rising production costs) 12

  13. Facing the Challenge: HEALTH PACT Integration Strategy PACT FOR LIFE Health Situation of the Population PACT TO UPHOLD THE SUS Basic Principles SUS Stakeholders PACT FOR MANAGEMENT Decentralization Regionalization Financing, Planning, Social Monitoring, Health Education New Format for Intergovernmental Relationships: Coalitions for Regional Management Integration of Actions In Terms of Service contracts of Municipios, States, and Ministry of Health • Regional: • Joint Action in the 3 Spheres • Integrated Approach • Recognition of Relationships of Interdependency and Cooperation Basic Principles Responsibilities under the Pact 13

  14. Facing the Challenge!(current Government proposal) 22 Points from Inaugural Address Plurianual Plan National Health Plan Pact for Life Strategic Approach BETTER HEALTH Strategy for Strengthening Regionalized Health 14

  15. Planning: Evidence x Results(rescue of SUS planning) 15

  16. Where does integration begin? Regionalization of Health Care Health Regions -spaces for sharing actions and health services.... Adequate secondary care and health surveillance actions (prevention, promotion) These can be: • Intramunicipal: Joinville-Santa Catarina • Intermunicipal: Piauí(Floriano region) • Interstate: Juazeiro(Bahia) and Petrolina (Pernambuco) • Border area • Governance of IHNs ~ 390 coalitions involved in Regional Management 16

  17. Strengthening Regional Planning • Health macroregions bring together two or more Health Regions to organize actions and share among themselves such services in this area as specialized outpatient care, third-level hospital facilities, and health surveillance. “The criteria of scale, scope, subsidiarity, and flexibility are important in this process.” Agency responsible for governance: • Regional Management Coalition, a co-managing entity in the Regionalized Health Care Network 17

  18. National Health Plan (PNS) 2007-2010 – General Lines of Action • Step up the strategy calling for regionalization, social participation, and federative relationsin keeping with the lines of action approved in the Pact for Health, seeking a decisive improvement in the systematic and organizational efficiency of the health services,revitalizing the role of the Federal Government in organizing regional integrated health networks throughout Brazil. • Technical support for states and cities in implementing Integrated Health Care Territories (TEIAS) as the organizational model for health care networks. 18

  19. 2. CHALLENGES FACING THE SUS 19

  20. Challenges x Opportunities forImprovement Double burden of disease(triple, if external causes are considered) Weak institutional capacity (managers and technical teams) Underfunding of health(resources for health promotion, increased costs); Poor quality of the health services offered User dissatisfaction (services and access) Minimal use of clinical management tools by the health services (clinical directives, clinical protocols, case management, treatment plan...) Lack of coordination of PHC 20

  21. Challenges (2) Demographic Transition THE AGING POPULATION 6 older adults for every 12 children under 5 years 6 older adults for every 5 children under 5 years MORTALITY RATE from chronic diseases: Brazil ~ 600/100,000 United Kingdom ~ 300/100,000 Life expectancyat birth: 72 years 21

  22. Challenges (3) Production of Health Production of Subjects • Recognition of the interdependencebetween theneed to enlist technology convergencefor health production in construction/activation of the intra- and interinstitutional Human Relations Network, on the one hand, and high accountability, connectivity, and friendly, compassionate, complementary care, on the other. Rollo (2007) • Evaluation of SUS professionals: • Leaders • Management • Teams 22

  23. Challenges (4) Health Management in the Territories THE GREATEST CHALLENGE: TRANSFORM THE CURRENT HEALTH REGIONS INTO TEIAS! 23

  24. Reorganizing UHS Management Organizing Management TEIAS Integrated Health Care Territories Organizing Management 24

  25. Organization of Integrated Health Care Territories 25

  26. Organization of Integrated Health Care Territories 26

  27. Organization of Integrated Health Care Territories 27

  28. Organization of Integrated Health Care Territories 28

  29. Agenda for Implementing IHNs Resources needed Unit Public health commitments/ responsibilities Assignment of responsibility (management/goals) GEN. HOSP 29

  30. Agenda for implementation of IHS Assignment of responsibility (unit and manager) Public health commitments Unit Resources needed 30

  31. What kind of NETWORKSare we talking about? 3. THE INTEGRATED NETWORKS CONCEPT 31

  32. Building a New Care ModelNational Policy on Basic Care (PNAB) (PHC) (Decree 648/GM of 28 March 2006) Focused on care of acute and chronic cases, surveillance, and health promotion PHC as the preferred gateway for the coordination of end-user health care, providing support for the case and following up throughout its course in the system – in other words, a longitudinal approach to care over time and appropriate use of the technologies available in the health services network With these goals in mind, the best first step: development of a Plan for Strengthening PHC (FAPS) 32

  33. Systemic View Health Services Networks (RISS) The networks should be built on the presence of horizontal spaces that connect to form a POLYARCHY in which decisions are made by consensus. They should be capable of generating partnerships based on mutual trust, strengthening the meaning of networks as spaces for complementarity and creativity. The bases for co-management and the elements that hold the network together are: clear definition of common objectives and shared resources coupled with monitoring of outcomes. 33

  34. Definition of Networks Health Care Networks areorganizational arrangements of health units and actions of different technological densities, integrated through diagnostic, logistic, and management support systems, designed to guarantee an integrated approach to care in a given territory/population(....) 34

  35. Technical & Political Implications -Promoting Synergies(Feasibility Strategy) • Key ISSUE: In terms of resources, this means • Compensating for gaps and deficits in investments • Working toward unifying the transfer of per capita resources • Providing incentives to implement regional management tools to promote health production, as well as logistic and administrative support tools,especially • Optimizing, integrating, promoting synergies, and making resources already allocated under national SUS structural policies more efficient 35

  36. Ministry of Health Integrated Health Care Networks Articulation with other policies Strengthening the constitutional foundation for the organization of health policy, including the expansion of integration through regionalized health care networks based on a public policy that is inclusive and also promotes citizen participation 36

  37. Implementation of the BRAZIL IHS/Ministry of Health Program Secretariat of Health Care: 1. Department of Basic Care 2. Department of Specialized Care 3. Department of Strategic Programming Actions 4. Department of Regulation, Appraisal, and System Monitoring 5. Department of Hospital Management for the State of Rio de Janeiro 6. National Cancer Institute 7. National Institute of Cardiology 8. National Institute of Traumatology and Orthopedics Article 14. The Secretariat of Health Care is responsible for: I – Participating in the formulation and implementation of health care policy based on UHS principles and guidelines II – Defining and coordinating integrated health actions and services networks; (DARAS, established in 05/2007) III - Establishing standards, criteria, parameters, and methods formonitoring quality and evaluating health care (...) 37

  38. DARAS: Directorate of Health Care Networks • Goal: Provide technical assistance to states and municipalities to build integrated health care networks • Internal articulation through groups supporting Proposed Networks (UF) as well as experts in regionalization (SE), specialized care (SAS), urgent and emergency care (SAS), regulation and Information processing and retrieval (SE), participatory management (SGEP), health surveillance, promotion, and disease prevention (SVS), National Health Fund (SE), management of health education and the health professions (SGTES), among other areas; • External articulation,once the project is formalized, establishment of collegiate management (via decree) for the Project through government agencies (CONASS, CONASEMS at the national level and COSEMS, CES, CMS, IES (institutions of higher education), providers (those operating under agreements, philanthropic, private, Ministries of Justice, Education, Agriculture, Armed Forces...) • Development of educational strategies for training local and regional facilitators in the process of building health care networks 38

  39. 4. GUIDELINES FOR THE IMPLEMENTATIONOF IHNs 39

  40. FUNDAMENTAL ISSUES Starting point for building health systems in a given regional space (identifying health needs) Health care focused on the individual, family, and community Definition of a set of actions and services (public health services map) to be provided to a given population through health care delivery sites or functional units of different technological densities Broad application of the directive that the primary care level is the gateway to the system of integrated and coordinated care, which has to capacity to meet most of the healthneeds of the population 40

  41. FUNDAMENTAL ISSUES Organization of care based on criteria of scale and scope Development of tools for clinical and managerial coordination Institutional integration throughcommitments to outcomes Efficiency and transparency in management of resources Integrated structures for the provision of health actions and services with institutionalization through public policies Collective and planned construction process Emphasis on the interdependencies between the stakeholders involved 41

  42. FUNDAMENTAL ISSUES • Support for rapid, unified geoinformation systems, as well as logistic, diagnostic, therapeutic support, and management systems • Accountability for costs and health outcomes in the subscriber population • Focus on continuity and quality of care through coordination and gains in effectiveness • Unique participatory system of governance with broad intersectoral action • Adequate financing and financial incentives in alignment with system goals 42

  43. Expanded Integration of HealthProduction: A New Paradigm 1.Needs-based organization of health services and actions, in tandem with implementation of a policy on Health Promotion and Monitoring 2. Implementationof SUS structural policies (PNAB, U/E, Mental Health, Workers Health, STD/AIDS...) and Clinical Guidelines (Pregnant Women and Newborns, Systemic Hypertension, Mental Disorders, Cancers of the Breast and Colon, Tuberculosis, Hansen’s Disease, etc. …) starting with PHC and taking into account the epidemiological profile of the region 43

  44. Integration of Care 3. Building the Regional Health Monitoring Nucleus (clinical support and collective health) • Expansion of the clinical and collective effectiveness of the health team either through the direct action of other professionals or through the integration of basic care with environmental, public health, and epidemiological monitoring in the territory • Directives on Care Delivery, Care Protocols, Pathology Management, and Case Management • Peer review, discussion of cases • Collective Health Projects based on Sentinel Events and tracers 44

  45. Integration of Care • 4. Implementation of devices and tools for Clinical Management (Directives on Care, Individual Treatment Plan (ITP), Case Management ...) and the National National Humanization Policy (shelter, support for mothers ...) 5. Implementation of Family Health Support Nuclei (NASF) 45

  46. IntegratedHealth Care Territories (TEIAS) • Objective of the strategy:stimulate the initiative to turn the current Health Regions, which today are fragmented, intoIntegrated Health Care Territories, or TEIAS – an acronym that spells the word for ‘webs’ in Portuguese With the awareness that it will be a gradual and complex process thatwill require constant input of knowledge and resources Rollo (2009) 46

  47. 5. ONGOING ACTIVITIES 47

  48. Issues under Discussion • How to expand the PHC-level investment to strengthen its role as coordinator of care and of the implementation of TEIAS • How to implement Lines of Care (Pact for Life) and the Policy on Regulation: ensure new contractual agreements, reduce fragmentation, guarantee connectivity, manage the waiting list • How to restructure Diagnostic Support Services and Specialized and Hospital Care while taking into account: Access, • Regionalization, Trends in Density, Responsibility for Resolving Problems, Continuity of Care, • Economies of Scale, Scope, and Quality of Care • How to implement actions under the Health Promotion Policy while at the same time focusing on the social determinants of health in the regions, acting both intersectorally and comprehensively with respect to other public policies 48

  49. Issues under Discussion • How to improve logistical support for the networks: identification card, electronic messaging, patient transportation, maintenance, supplies • How to strengthen the governance of IHNs (Regional Coalition Managers - CGRs) with a view to improving their performance with such network management tools and strategies as: • Review of Master Regionalization Plans • Preparation of Regional Health Plans • Investment Master Plans • Integrated Pact related Programming • Contracts for Management and Setting Targets • Monitoring and Evaluation 49

  50. Issues under Discussion • How to implement the provisions of the National Humanization Policy (PNH) in terms of: Reception, including risk classification, clinical management, safety of patients and health production environments • How to operationalize the start of the Investment Project for SUS Qualification “QualiSUS-NETWORKS: Lending Agreement with the World Bank,”which will support 15/27 states in the organization of integrated health care networks in Brazil 50

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