Health Sector Projects in Region 3

1. Health Sector Projects in Region 3 Amanda Glassman Health Specialist Social Programs Division – Regional Operations Department 3 Washington DC, 15 July 2004

2. Region 3 Countries • Andean countries: Colombia, Ecuador, Peru, and Venezuela • Caribbean countries: Barbados, Bahamas, Guyana, Jamaica, Suriname and Trinidad and Tobago.

3. Different Health Systems and Challenges • Different level of economic development, demographic and epidemiological profiles • Andean Countries: • Fragmented health system: MOH, social security, private sector • Large inequalities in access to health care • Caribbean Countries: • NHS type system: universal access, financed by general taxation • Increasing cost pressure on public budget • Limited human resources: out-migration

4. IDB Added Value • Share international experiences • Provide technical assistance from international experts • Promote transparent decision making and procurement practices • Enable collaboration of various actors: national agencies, international donors, NGOs, etc. • Provide grant and low interest rate loans • Technical Cooperation, Investment Loan, Policy Based Loan, Performance Driven Loan

5. Health Sector Reform Projects in Jamaica, Trinidad & Tobago (and Venezuela) • Strengthening the institutional capacity of the MoH • Decentralization: creation of RHA • Health Financing: creation of NHI • Rationalization and upgrading of services provision (hospitals and primary care centers)

6. 5 years later… • The process took longer than expected • The importance of political support • Decentralization process is very problematic, requiring support from the professional associations and unions • The physical infrastructure components were easier and less controversial, but distracted from the reforms • Macroeconomic and budget constraints may limit the capacity to implement the project

7. HSR in Colombia • Expand health insurance coverage to all population • Subsidized health insurance to the poor (“transform” supply-side into demand-side subsidies) • Managed competition among both insurers and providers • Responsibility for health service delivery decentralized to local entities • Hospital financing move from block transfers to services sale

8. 11 years after… 1993-2004 • Importance of macroeconomic constraints • Effect of HSR on fiscal equilibrium of local entities and macroeconomic stability • Structural deficit in public hospitals • Crisis of the ISS: incomplete reform • Danger of being overly ambitious

9. Recent Health Projects in Colombia

10. Health Care and Social Security Reform Program (PBL) • Objective: improve coverage, quality, equity and financial sustainability of the health system • Loan resources are disbursed in compliance with the policy actions in the following areas: • macroeconomic stability • extension of the subsidized health insurance • financial sustainability and reform of the Instituto de Seguros Sociales • efficiency, transparency, and equity in the Cajas de Compensación Familiar

11. Reorganization, redesignand modernization of health services networks • Objective: raise efficiency and quality of service provided by public hospitals • TA to public hospitals: improve administrative, financial and capacity to sell services • TA to local entities and MOH/MPS: improve capacity to monitor and evaluate health services provision • Functional integration of public hospitals in health service networks • Implementation of human resource rationalization measures

12. Peru: Maternal-Child Health Care Insurance • Expand MCH health insurance • Change payment system: from historical budget to incentive-based provider payments • Improved regulatory capacity and quality control • Rationalize and upgrade services

13. MC Health Insurance • Change in payment system have a large impact on activity rates, but limited impact on health outcomes • Importance of combining demand side and supply side interventions: • rationalize and upgrade services • assure quality of care • Importance of focusing on the poor

14. Suriname’s HSR Program • Strengthening institutional capacity of the MoH • Improve primary care, public health and preventive care at community level • New health provider payment methods to promote productivity and quality of care • Improve pharmaceutical management • SZF and MSA as active purchasers • Improve targeting and subsidies to the poor • Improve quality assurance

15. IDB Health Projects in Guyana • Health Care I 1978: construction of health posts, heath centers and district hospitals in rural areas • Health Care II 1988: rehabilitation of outpatient, diagnostic and surgical services at the Georgetown Public Hospital • Health Sector Policy and Institutional Development Program 1998: studies and technical assistance

16. Guyana Health Sector Program • Objective / Component 1 : improve the organizational and institutional capacity of the health sector • Institutional strengthening support organizational reforms • Human resource development • Health management information system • Strengthening of the pharmaceutical system • Objective / Component 2 : Improve the health services delivery system • Civil work: rehabilitation and upgrade of key health facilities

17. Other Countries • Ecuador: Strengthening the Seguro Social Campesinos capacity to deliver preventive and primary health care • Barbados: strengthen the institutional capacity of the MOH, upgrade of the Queen Elizabeth Hospital • The Bahamas: strengthen the institutional capacity of the health system and general re-development of the Princess Margaret Hospital

18. Conclusion • Health reforms fix problems, but can also produce new challenges • Importance of seeking consensus among key stakeholders • Setting realistic objectives and time frames • Pool national and external resources in order to maximize national capacity • Strengthening the institutional capacity of the public sector agencies