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VII Regional Forum Strengthening Health Systems Based on PHC

VII Regional Forum Strengthening Health Systems Based on PHC. Health Systems Responses Programmatic- and Population-Based Approaches. Ministry of Health Costa Rica. Quito, Ecuador 29-31 October 2007. Table of Contents. Background of Health Sector Reforms National Quality Assurance Program

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VII Regional Forum Strengthening Health Systems Based on PHC

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  1. VII Regional Forum Strengthening Health Systems Based on PHC Health Systems Responses Programmatic- and Population-Based Approaches Ministry of Health Costa Rica Quito, Ecuador 29-31 October 2007

  2. Table of Contents • Background of Health Sector Reforms • National Quality Assurance Program • Results • Conclusions

  3. Guatemala Honduras El Salvador Nicaragua Costa Rica Panama Costa Rica 52,000 Km2

  4. History of a Transformation Transforming the Role of the State Development Model Crisis Rethinking of State’s Role • Phase I: • Beginning of State’s Role • Health Secretariat • Ministry of Health • Social Security Phase II: Expanding Coverage Phase III & IV: Integrating Services & New Models Phase V Steering Role Adjusting Model of Care • Programs to expand coverage • Universal SS Coverage • Epidemiological transition • Increase in the cost of care • Separation of preventive-curative care • Aging population • New models of care • Integrated Care • Health Promotion • Breaking up concentrated areas • Assessing systems & services • Epidemiological Accumulation ‘30-’40s ‘70s ‘80s ‘90s 1998 …21st Century.....

  5. FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF LIFE AND BETWEEN THE AGES OF 20 TO 59 COSTA RICA 1912-2002 FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF LIFE AND BETWEEN THE AGES OF 20 TO 59 COSTA RICA 1912-2002 Life expectancy (years) Probability of dying (logarithms) CCSS

  6. Health Sector Reform 1994-2007 … • Substantive Functions of Ministry of Health Governance (2006) • Health Policy Bureau • Marketing the health promotion strategy and the culture of nonexclusion • Health Surveillance • Strategic Health Planning • Modularization of health financing • Harmonization of health service delivery • Health Regulations • Assessment of impact of actions in health • Scientific research • Integrated Care Model in Social Security • Universality • Solidarity • Equity • Unity and Efficiency • Adjusting Supply • Health Areas and sectors (EBAIS) • Program titled Integrated Health Services for the Public • Outsourcing contracts • 88% of population insured 2006

  7. SUPPORT TEAM 40,000-60,000 Inhabitants Fields: Medical specialties Nursing Social Work Laboratory Dentistry Diagnostic Imaging Health Records Population Sector EBAIS 4,000 Inhabitants GENERAL PRACTITIONER NURSING AUXILIARY PRIMARY CARE TECHNICIAN MEDICAL RECORDS TECHNICIAN INTEGRATED HEALTH CARE: HOME VISIT CARE IN FACILITIES AND THE COMMUNITY

  8. CCSS Hospitals, Health Areas & EBAIS by Region 2006 & 2007 2006 2007 Ratio of Ratio of EBAIS/ Health Areas Health Areas, 2007 EBAIS/Health Areas Health Areas 2007 Region Hospitals EBAIS EBAIS Total 29 103 903 8,8 104 944 9.1 8 H. Nacionales 3 Brunca 6 68 11.3 6 69 11.5 4 Central Norte 32 258 8.1 32 264 8.3 3 Central Sur 27 266 9.9 28 297 10.6 5 Chorotega 13 95 7.3 13 94 7.2 2 Huetar Atlántica 8 105 13.1 8 107 13.4 2 Huetar Norte 8 45 5.6 8 46 5.8 2 Pacífico Central 9 66 7.3 9 67 7.4 Source: CCSS, . Office of Executive President, Planning Unit, 2006 & 2007 ,

  9. Historical Evolution Health Insurance Coverage, Costa Rica1944-2005 %

  10. Health Insurance Coverage by Insurance Modality, Costa Rica, 1960,1970,1984,1994, 2000 & 2005 Indicator 1960 1970 1984 1994 2000 2005 Coverage of services 15.4 62.6 100 100 100 100 Contribution-based coverage 15.4 62.6 71.1 86.2 81.7 87.6 National population by type of coverage (%) Directly insured 7.6 11.7 19.2 19 18.7 19.6 Voluntary 4.5 5 6.6 3.4 Pension Recipients 8 8.6 6.3 Insured's Family 7.7 35.1 44.6 45 41.5 44.4 State & Family Account 7 11 12.2 Other type 0.1 0.4 2.8 2 1.1 1.7 Uninsured 84.6 52.8 28.9 14 12.5 12.4 Source: Office of the Actuary, CCSS & Census Bureau

  11. Life Expectancy at Birth 2005 Source: INEC Source: State of the Nation and State of the Region

  12. Infant Mortality Rate for Quintiles of Cantons Grouped according to Social Lag Index for the Quadrenniums 1994-1997, 1998-2001 & 2003-2006 Costa Rica 8.95 Quintile 5 11.68 9.48 Quintile 4 12.65 9.64 Quintile 3 2003-2006 12.21 98-2001 10.12 Quintile 2 94-97 13.85 11.08 Quintile 1 16.35 0 5 10 15 20 Rates per 1,000 births Average: 9.78 per 1,000 births in 2006

  13. Strategies • Standardization of integrated care for people in Level I and care for priority health problems of public health interest • Evaluation of coverage in participating population areas • Evaluation of quality of care based on meeting basic quality standards • Household Survey

  14. Total Coverage and Quality Coverage Level I – Health Care Programs CCSS, 2005 120.0 100.0 % Total Coverage 80.0 60.0 % Quality Coverage 40.0 20.0 0.0 Prenatal Postpartum Cytology Diabetics 1 to 6 yrs. Hypertensive < 1 yr. old Elderly Adolescents

  15. Ministry of Health: Quality Assurancewith a Systemic Approach • Qualification: Structure - basic level • Accreditation: Structure - Processes - Outcomes • Evaluation of Health Systems and Services: Structure, Process, and Outcomes in the EEP service network • Tracer Events: • Infant/Maternal Mortality • Other health problems of public health interest (hypertension, diabetes mellitus, screening for cervical cancer) • Care Programs for the public (prenatal check-ups, integrated care for children under 2 years)

  16. Outcomes Structure Processes Accreditation of Facilities Evaluationof Systems in EEP P u b l i c & P r i v a t e Quality Assurance Certification of Facilities

  17. Assessment of Level I integrated Care, EBAIS Headquarters Costa Rica, 2000-2006 CATEGORY  2000 2006 TOTAL 74 80 I. Physical Plant 74 73 II. Material Resources 87 94 III. Human Resources 61 67 IV. Standards & Procedures 66 86 Boys & Girls 71 90 Adolescents 45 80 Prenatal 69 94 Postpartum & Post-abortion nd 83 Women aged 20-49 69 74 Elderly 64 78 V. Programming & Management 77 62 VI. Supplies 83 95 VII. Education for Health 81 89 VIII. Social Participation 57 61 Source: Office of Health Services and Regional Offices, Ministry of Health

  18. Results of the Standards and Procedures Assessment for the Integrated Care Program for the Public, 1st Level of Care; Costa Rica 2000-2004 Elderly Integrated care for women aged 20 to 59 Postpartum and Post-abortion Prenatal Adolescents Boys & Girls 2000 2001 2002 2003 0 10 20 30 40 50 60 70 80 90 100 % 2004

  19. Graph 1. Assessment of Level I Care at the Homes Visited as part of the Survey on Family Health Needs, Costa Rica 2000-2005 2500 55 2100 45 1700 2120 Nº 45 1917 35 1900 1300 39 1555 35 25 33 900 1300 1000 500 15 20 19 2000 2001 2002 2003* 2004 2005 Year * Only 2nd Semester Source: Regional Offices and Office of Health Services, Ministry of Health, 2006 Evaluation of Level I Integrated Care Household Survey, Costa Rica, 2000-2005

  20. Graph 3. Assessment of Level I Integrated Care Household Survey: Distribution of type of insurance by Satisfaction of Basic Needs, Costa Rica 2005 65.0 Total 13.0 22.0 75.4 Met 7.7 16.9 58.5 Unmet 15.9 25.6 0 10 20 30 40 50 60 70 80 Percentage Uninsured State Insured All other types of insurance Source: Regional Offices and Office of Health Services, Ministry of Health, 2006 Insurance Average 88%

  21. The poorest and even the uninsured population gained access to Level I health services in 2006

  22. Assessment of Level I Comprehensive Care. Household Survey: Quality of Morbidity Care, Costa Rica 2005 8.7% 11.5% Good Fair Poor 79.9% • 14% required a medical visit at EBAIS in the past 15days • 10% of requests for care from EBAIS are rejected: • The main reasons were: • “There wasn’t enough space and they were told to return the next day.” (44%) • “Were not insured, so they were charged.” (41%) Source: Ministry of Health, Household Survey, 2006

  23. Graph 4. Household Survey on Family Health Needs: Opinions on the quality of health care received by group of migrants, Costa Rica 2005 5.7% 17.7% Good Fair Poor 76.6%

  24. Hypertension Tracer: Screening 5% Yes No 95% Clinical file of level I and II facilities: Individuals 20 years and older with hypertension value recorded in the last year. Costa Rica, 2005. Range: 65-70% fulfillment Files Reviewed: 1073 Source: Interinstitutional Commission of Hypertension Tracer, Ministry of Health.

  25. Hypertension Drugs Available* 5 3 to 4 Total Level of care No. % No. % No. % First - - 14 100 14 100 Second 16 50 16 50 32 100 Third 8 44 10 56 18 100 Table 22. Hypertension drugs available at health facilities, by level of care.Costa Rica, 2004. * By level of care Established Range: 100%. Source: Interinstitutional Commission of HT Tracer. Regional Offices, Ministry of Health.

  26. Reached optimal treatment goal Yes No Total Level of care % % Number First 58 42 174 Second 30 70 263 Third 65 35 131 National total 46 54 568 File: Hypertensive individuals reaching optimal treatment goal (<140/<90), by level of care. Costa Rica, 2005. Established Range: 40%

  27. Care Coverage for Costa Rican and Immigrant Women Costa Rica, 2000 Coverage, by type of care Immigrant CR Insurance 48 78 Prevalence of birth control 70 80 Childbirth % % Care during CCSS Hospital delivery 84 96 Care during home birth 15 2 Professional care during delivery (physician or nurse) 91 96 Has had a PAP test at least once 75 79 Medical visit CCSS Medical visit in the past year 79 71 Private medical visit in the past year 8 22 Immunization of children ages 1 to 4 yrs. 95 80 Basic system Source: CCEP. National Survey on Sexual and Reproductive Health, 1999

  28. Health Care Challenges MAIS Forum, 2005 DEMAND CURRENT SUPPLY • Control of risk factors beyond the scope of medical care and environmental health determinants • Emphasis on health promotion and disease prevention • Long-term care • Care for complex problems • Sexual & reproductive health care • Mental health care • Communication & education skills • Pain management, and death and grief counseling services • Interdisciplinary approach & communication between the different levels of complexity • Knowledge of bioethics • Persistence of a biology-based, individualistic model of care. • Weak teamwork • Normative approach to planning centered on productivity and not on health needs • Incongruity between education of HR for health and the requirements of the model • Lack of coordination between levels and institutions • Reactive environmental protective action • Lack of clarity in defining the functions of health sector institutions • Activistic and utilitarian concept of social participation in health Source: DSS, Ministry of Health

  29. CONCLUSIONS • The integrated care model was applied on a geographical-population basis, thus incorporating the concepts of public health and conceiving Level I as the gateway to the health system. • The service package tends to unify the entire insured population, since it includes first-level and highly specialized services for all. • The public system de-commercializes the system to a high degree.

  30. CHALLENGE • Financial sustainability and preserving a universal, collective health system that ensures the delivery of equitable quality services

  31. Thank You Very Much !!! Osa Peninsula, channels of Río Sierpe, Costa Rica

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