Eduardo Levcovitz, MD, MSC, Ph.DChief, Health Policies

and Systems Unit

“SOCIAL

PROTECTION IN

HEALTH FOR

WOMEN, NEWBORNS

AND CHILDREN IN

LAC”

Regional Forum 2006Tegucigalpa, Honduras

DEMOCRATIZATION and

decentralization

1975 1990 2000 2015

MDGHF

A

Crisis of the welfare state and social

security

Economic reforms and State reforms Health sector reforms

GLOBALIZATIONand a new economic order

DEMOGRAPHIC TRANSITION : population growth, urbanization and aging

EPIDEMIOLOGICAL POLARIZATION: coexistence of opposing risk and disease profiles

Overwhelming ENVIRONMENTAL and ECOLOGICAL impact

bipolar world

cold war

capitalism vs. socialism

anti-colonialistmovement

Third World

multilateralism

unipolar world

war against terrorism

hegemony of capitalism

globalization

unilateralism

human insecurity and vulnerability

Political panorama of population health in the Americas

EXPANSION OF DISPARITIESGROWTH OF EXCLUSION

02468101214 0 2 4 6 8 10 12 1402468101214 0 2 4 6 8 10 12 14

Evolution of the regional demographic profile

20

30

40

50

60

70

80

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

popu

lation

pro

porti

on (%

) Latin America & The Caribbean

Latin America & The Caribbean

Northern America

Northern America

URBAN

RURAL

PAHO; Health of the Americas, 2002 edition

Epidemiological polarization of the mortality burden

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

todas las demás

externas

perinatales

cardiovasculares

cancer

infecciosas

PAHO; Health of the Americas, 2002 edition

all other causes

external

perinatal

cardiovascular

cancer

infectious

external

exp

ect

ed

ye

ars

of

life

lost

up

to

85

ye

ars

of

ag

e,

20

00

Evolution of theethics/ideology/values that

guide social protection systems

20s/40s 80s/90s50s/70s XXI Century

Formal Social Security

for industrial workers

Public Assistanceand Charity for the poor and indigent

XX Century

WELFARESTATE

Segm

ente

d

syst

ems

acco

rdin

g to

abili

ty to

pay

UNIVERSAL SOCIAL

PROTECTION AS A CITIZEN

RIGHT

MDG

Main causes of mortality in children under five in the Americas

Infectious Diseases

58,15011.8%

Respiratory59,60012.1%

Malnutrition14,4442.9%

Peri-Neonatal186,70038.0%

Accidents28,7505.9%

Others (congenital anomalies, cardiovascular

diseases, etc.)143,10029.2%

132,194 annual deaths26.9% of all deaths

Perinatales

38.0%

Problems during

Pregnancy and Delivery,

76,750 (41.1%)

Asphyxia, 39,200 (21.0%)

Low Weight, 22,590 (12.1%)

Sepsis, 11,200 (6%)

Others, 36,960 (19.8%)

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.

2003 Estimates

Percentage of average annual decline in the under-5 mortality rate in the Region of the

Americas

2.4%

4.0%

Observed 1990-2000

Required according to Summit Goals 1990-2000

2.6%

4.3%

6.3%

Observed 2000-2003

Required according to the MDGs1990-2015

Required to meet the MDGs starting in 2003

Required Increase:

142%

Comparison of values observed and values proposed at International Summits

Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

2.6%

-0.4

4.5%

1.8%

2.9%2.4%

5.0%

1.2%1.8%

6.3%

7.8%

5.3%

10.1%

6.3%

3.1%

5.1%

6.4% 6.3%

RegionalTotal

Haiti Bolivia Guyana Honduras Nicaragua Peru Brazil Mexico

Percentage of average annual decline

Registered in 2000-2003

Needed between 2003 and 2015 in order to meet MDG 4

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

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

Sepsis14.9%

Hemorrhages24.8%

Indirect causes

19.8%

Other directcauses

7.9% Complications of abortion

12.9%

Obstructed delivery 6.9%

Hypertensive disorders

12.9%

Millennium Development Goals and Health Targets, PAHO/WHO Resolution - CD45/8, 2004

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

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.

WORLD HEALTH ASSEMBLY – 2005

PAN AMERICAN SANITARY CONFERENCE - 2002

Resolution WHA58.33

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”

Extension of social protection in health

Strategies for the extension of social protection in health

• GUARANTEE EQUITABLE ACCESS AND UTILIZATION with 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

DISTRIBUCION MORTALIDAD INFANTIL POR QUINTILES DE INGRESOS EN PAISES SELECCIONADOS - AMERICA LATINA, 1999

0

20

40

60

80

100

120

Quintil I Quintil 2 Quintil 3 Quintil 4 Quintil 5

Brasil

Bolivia

Colombia

Guatemala

Haití

Fuente: OPS/OMS La Salud en las Américas- Volumen I – 2002

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

Fundamental elements of social protection systems

IDEAS PRINCIPLES

VALUES

INTERESTSINFORMATION KNOWLEDGE

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.

• 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.

Conditions 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)

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)

Country-based initiatives for the extension of social protection in health

Strategies for the extension of social protection in health: SYNERGY AND COHERENCE

EXTENSION OF SOCIAL

PROTECTION IN HEALTH

Expansion of classic social insurance

schemes, including the incorporation of informal workers

Promotion and development of innovative protection

strategies, including community-based initiatives

Expansion of the mechanisms and projects for the extension of health

systems coverage

Establishment of links between previous mechanisms and other

protection mechanisms and public initiatives (overcome

fragmentation and segmentation and improve equity)

NATIONAL HEALTH SERVICE

SOCIAL SECURITY IN HEALTH

“BUSINESS”

HEALTH

SYSTEMS IN LAC

HEALTH SECTOR

REFORMS

A GHOST TRAVERSES THE HEALTH SYSTEMS OF

LAC …..Se

gmen

tatio

n

acco

rdin

g to

abili

ty to

pay

Ope

ratio

nal

frag

men

tatio

n

Inequities in access and utilization

Limitations of segmented systems

• 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 Richest

Source: World Bank, Socio-Economic Differences in Health, Nutrition, and Population, Washington, DC

Quintile 3 Quintile 4

FORMAL EMPLOYMENT

CONTRIBUTIONS

INTERNATIONAL LOANS AND DONATIONS

GENERAL AND SPECIFIC TAXES

PRIVATE PREMIUMS

HOUSEHOLD CONTRIBUTIONS TO COMMUNITY

FUNDS

Public

Private

External

Segmentation of financial contributions / risk pools

Sources

Limitations of segmented systems

Per capita spending on health, El Salvador 2004

Sub-System of Affiliation by Income, Chile, 1998

InstitutionPopulation covered (% of

total population)Per capita

spending, US$

Ministry of Health 80% 48.00

Social Security (ISSS) 17% 283.00

Military Health Services 1% 247.00

Teacher Health Insurance 1% 417.00

Limitations of segmented systems

• Regressivity and insufficient financing, with the predominance of out-of-pocket expenditures

Public and Private Spending as a percentage of GDP: Latin America and the Caribbean, 2000-2004

0%

20%

40%

60%

80%

100%

Percentage of GDPSource: HP/HSS Basic Indicators 2005

Public Private

Limitations of segmented systems

Limitations of segmented systems: out-of-pocket expenditures

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.

• 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

• Weak stewardship: insufficient regulatory framework and

inadequate fiscalization

Limitations of segmented systems

NGO

Health Center

Social Security

HospitalWalk-In, Mayor’s Office

EFFICIENCY EQUITY

Operational fragmentation

Limitations of segmented systems

INTERINSTITUTIONALCOORDINATION

OPERATIONAL INTEGRATION

Strengthening of the STEWARDSHIP / MANAGEMENT of Sectoral Policies

Alignment and harmonization of INTERNATIONALCOOPERATION

Integrated and integral Service NETWORKS

Health Systems based on PHC

Incorporation of the knowledge from PROGRAMS

into the organization of SYSTEMS

POLITICAL / SOCIAL DIALOGUE among multiple actors

Harmonization and integration of FINANCING

STRATEGIES FOR CONFRONTING

SEGMENTATION AND FRAGMENTATION

Final

reflections

…. and

stimuli for

the debate

at our

Regional

Forum

HEALTH FOR ALL

Information and knowledgeInformation and knowledge

Human RightsHuman Rights

Primary Primary Health Health CareCare

Social Social ProtectionProtection

Health Health PromotionPromotion

FOUNDATIONS OF PUBLIC HEALTH FOUNDATIONS OF PUBLIC HEALTH POLICY AIMED AT POLICY AIMED AT

HEALTH FOR ALLHEALTH FOR ALL

• INSTITUTIONAL LEADERSHIP AND CAPACITY

• INFORMATION, KNOWLEDGE AND

INNOVATION

• PLANNING AND COORDINATION

• INTELLIGENCE, CREATIVITY,

DISCUSSION, COMMITMENT

AND BOLDNESS

OPPORTUNITIES FOR INTERVENTION