Experiences and Lessons Learned from the Region of the Americas:

Case StudiesRegional Consultation Meeting:

Integrated Health Services Networks and Vertical ProgramsCusco, Peru11 and 12 November 2009

Hernán Montenegro and Caroline RamagemArea of Health Systems and Services

PAHO/WHO

Content

• Background

• Summary of case studies

• Lessons learned

• Facilitating factors and barriers

• Future PAHO work

Why Integrate Service Networks and Vertical Programs?

Health Services Fragmentation

Poor performance of health services

• Access problems• Poor technical quality of services• Inefficient use of resources• Increased production costs• Low levels of user satisfaction

Other causes of poor system performance

(For example, insufficient financing,weak governance of the health authority, lack of qualified human resources, etc.)

Integration Initiatives in LAC

Country Initiative

Argentina Law creating the Integrated Federal Health System

Bolivia Municipal Intercultural Family and Community Health Networks and Network of Services

Brazil Better Health: The Right of All 2008-2011

Chile Health Care Networks Based on Primary Care

El Salvador Law creating the National Health System

Guatemala Coordinated Health Care Model

Mexico Functional Integration of the Health System

Peru Guidelines for forming networks

Dominican Republic Regional Health Services Network Model

Trinidad and Tobago Experience of the Eastern Regional Health Authority

Uruguay Integrated National Health System

Venezuela Health Network of the Metropolitan District of Caracas

Progress of PAHO Technical Cooperation on Services Integration

Degree of Progress Integrated Health Services

Networks

Integration of Vertical Programs *

Review of literature and case studies

+++ +

Preparation of analytical framework, including definitions

+++

Position paper ++

Resolution of PAHO/WHO Governing Body

+++ +++

Implementation strategy +++

Regional technical cooperation platform

+

*Link with Global Health Initiatives.

Summary of Case Studies Lima Workshop, 9 November 2009

Country Type of Case

Integrated health services networks (2 topical + 3 general = 5)

Integration of vertical programs (6)

Brazil • Care for women and children: “Mãe Curitibana” (Curitiba, Paraná)

• Urgent/emergency care (Northern

Macroregion, Minas Gerais)

• HIV/AIDS (National)

Chile • Ñuble Health Service• Metropolitan Health Services

• Children: “Chile Grows With You”

(National) Guatemala • Ministry of Public Health and Social

Welfare and Guatemalan Social Security Institute (Department of Escuintla)

Colombia • Tuberculosis (National) Peru • HIV/AIDS (National) Dominican Republic

• HIV/AIDS (National)

Trinidad and Tobago

• HIV/AIDS (National)

Some General Observations

On cases:

- Diversity of experiences reflect the regional reality

- Of the 11 cases: • 4-5 cases: exemplify fragmentation or have had little success in

terms of integration, including sustainability

• 6 cases: varied success in terms of integration and improvements in access, quality, efficiency, social participation, and impact on health*

On the dynamic of the discussion:

- Issue that arouses passions

- Positions were identified

- Confusion in managing basic concepts of integration (what is understood as a vertical program)

Framework to Analyze the Implementation of Health Policies

Contents Processes

Context

ActorsAs individuals

As members of groups

Walt and Gibson (1994)

Lessons Learned

Context:

• Diversity of contexts

• Most successful experiences - framework of broad health services reforms consistent with integration

• Evaluate the consistency of the legal and administrative framework with integration efforts

• Most successful experiences in countries that

already have strong health systems

Content:

• People-centered solutions adapted to local conditions and consistent among themselves

• Clarity of objectives and roles

• 1st level of care: multidisciplinary with family/community orientation

• Assistance, managerial, and institutional coordination

• Results-based management

• Use of the intersectoral approach Processes:

• Gradual development of processes

• Vision of a long-term stable policy

• Ensure early demonstration successes

• High levels of commitment and strong leadership

• Transparency of processes

Actors:

• Measures that promote mutual trust and knowledge (opportunities for dialogue)

• Cultivate commitment and a sense of belonging

• Close the gap between policymakers, managers, clinicians, and researchers

• Citizen participation: self-care; social control

Facilitating Factors and BarriersFacilitators: • Political commitment and backing

• Availability of financial resources

• Leadership of health authorities and service managers

• Decentralization and flexibility of local management

• Alignment of financial and nonfinancial incentives

• Culture of collaboration and teamwork

• Active participation of stakeholders

Structural barriers: • Segmentation and weakness of health systems• Reforms of the 1980s and 1990s:

– Privatization of insurance– Differentiated service portfolios– Provider competition– Diversification and instability of labor

regimes– Regressive cost-recovery schemes

• Powerful opposing Interest groups: – Specialists and super-specialists*– Private insurers and social security– Pharmaceutical industry, supply industry ,

etc. • External financing modalities (Global Health Initiatives)

Nonstructural barriers: • Deficiencies in information, monitoring, and

evaluation systems*

• Management weaknesses

Future Work for PAHO

• Integrated Health Services Networks: – Consolidate work on integrated health services networks

• Integration of Vertical Programs: – Produce a position paper that addresses:

• Definitions and analytical framework• Indications for vertical programs, being the exception• Strategy for integrating programs into health systems

– Develop technical cooperation that provides:• Instruments• Direct technical assistance• Educational programs• Research