Challenges and opportunities of running a public hospital in Argentina

Cdra. Teresita Cecilia Durañona SanabriaLic. Ariel Mario Goldman

2014

Ramos Mejía Hospital

EconomicsEvolution of the poverty and indigence. 1988 – 2010

Source: U.C.A. and INDEC graphicshttp://noelmaurer.typepad.com/aab/2013/04/-observatorio-argentino-19-poverty-in-argentina.html

EconomicsInequality. Distribution of family labor income equivalent. Share of deciles and income ratios. 2004-2010

                       

2004 1,0 2,2 3,4 4,6 6,0 7,6 9,7 12,5 17,7 35,2   36,7

2005 1,1 2,4 3,6 4,8 6,0 7,6 9,6 12,4 17,2 35,4   33,2

2006 1,1 2,5 3,7 4,9 6,3 7,9 9,8 12,7 17,4 33,9   31,7

2007 1,2 2,6 3,8 5,1 6,3 7,8 10,0 12,9 17,5 32,9   27,8

2008 1,3 2,8 4,0 5,2 6,5 8,1 10,1 12,9 17,3 31,8   24,7

2009 1,3 2,8 4,0 5,2 6,6 8,1 10,1 12,9 17,4 31,6   24,6

2010 1,3 2,8 4,1 5,4 6,7 8,2 10,1 12,8 17,2 31,3   24,5

        Share of deciles         Deciles

  1 2 3 4 5 6 7 8 9 10   10/1

Source: CEDLAS and World Bank. http://cedlas.econo.unlp.edu.ar/esp/pantalla.php?seccion=estudios_especiales&idP=88

Demographics Population pyramid. Argentina Republic 2010

Source: INDEC. Censo Nacional de población. Hogares y viviendas 2010

Population pyramid. Buenos Aires City 2010

Health

Source: INDEC, Dirección de Estadísticas Sectoriales en base a información suministrada por el Ministerio de Salud de la Nación, Dirección de Estadísticas e Información de Salud (DEIS).

Age group (years)Mortality rate per thousand population

1980 1990 2000 2006 2007 2008 2009 2010 2011

Total country 8,6 8,0 7,5 7,5 8,0 7,6 7,6 7,9 7,8

Under one year 33,2 25,6 16,6 12,9 13,3 12,5 12,1 11,9 11,7

1 to 4 1,5 1,1 0,7 0,6 0,6 0,6 0,5 0,5 0,5

5 to 14 0,5 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3

15 to 24 1,0 0,9 0,9 0,8 0,8 0,9 0,9 0,9 0,9

25 to 34 1,5 1,2 1,2 1,0 1,1 1,1 1,1 1,1 1,1

35 to 44 3,1 2,5 2,2 1,9 1,9 1,9 1,9 1,8 1,8

45 to 54 7,1 6,0 5,2 4,7 4,8 4,7 4,7 4,4 4,4

55 to 64 15,2 13,8 11,9 11,4 11,8 11,2 11,2 11,1 10,8

65 to 74 34,6 29,5 26,5 24,8 26,2 24,6 24,2 24,9 24,5

75 and over 102,8 100,8 91,5 88,0 95,4 87,6 86,5 92,2 90,6

Mortality rate per thousand population, by age group and sex. Total country. Years 1980, 1990, 2000, 2006-2011

MOTHER´S RESIDENCE

JURISDICTION

 

1990 2003 2004 2005 2006 2007 2008 2009 2010 2011

 

Argentina 25,6 16,5 14,4 13,3 12,9 13,3 12,5 12,1 11,9 11,7

C. de Buenos Aires 16,8 10,3 8,7 8,0 8,3 8,4 7,7 8,5 7,0 8,8

Buenos Aires 24,2 16,3 13,0 13,0 12,5 13,6 12,4 12,5 12,0 11,8

Catamarca 34,6 20,1 21,8 16,8 15,4 14,9 15,3 14,5 15,4 14,0

Córdoba 22,2 14,3 12,7 11,9 11,6 12,7 12,1 10,7 11,1 10,8

Corrientes 31,7 21,1 19,3 18,2 17,5 15,6 17,1 15,3 16,8 15,7

Chaco 35,8 27,7 21,3 19,9 18,9 21,2 18,0 17,8 14,7 11,4

Chubut 20,6 15,1 11,8 11,7 11,5 11,0 10,4 9,4 9,8 10,2

Entre Ríos 24,3 17,2 15,5 13,2 12,6 11,9 13,5 11,8 11,6 11,0

Formosa 33,2 25,0 25,1 22,9 24,2 22,9 19,2 20,5 17,8 21,2

La Pampa 22.2 12,7 14,6 11,4 10,0 11,8 14,9 13,7 7,0 10,4

Jujuy 35.8 19,2 17,8 16,1 17,0 15,2 14,0 11,5 13,4 12,9

HealthInfant mortality rate by jurisdiction

Source: Secretaria de Políticas, Regulación e Institutos. Dirección de Estadísticas e Información de Salud. http://www.deis.gov.ar/Publicaciones/Archivos/Serie5Nro55.pdf

Health

MOTHER´S RESIDENCE

JURISDICTION

 

1990 2003 2004 2005 2006 2007 2008 2009 2010 2011

 

La Rioja 28,8 17,3 18,2 13,8 14,1 12,9 15,0 14,6 12,6 16,5

Mendoza 21,1 11,1 13,5 11,3 11,9 11,3 10,8 9,9 11,7 9,7

Misiones 31,8 20,2 16,6 14,6 17,1 14,6 13,9 13,0 13,2 13,7

Neuquén 16,9 10,8 11,1 9,9 9,8 9,6 7,4 7,6 9,2 7,5

Río Negro 23,1 15,9 14,1 9,4 9,3 9,8 11,7 8,8 9,4 9,6

Salta 32,3 16,9 15,4 14,3 14,9 15,4 14,4 14,0 12,8 14,0

San Juan 24,4 19,6 16,4 16,7 14,0 13,2 14,4 11,0 11,0 9,9

San Luis 29,7 17,4 15,2 16,0 12,8 15,7 13,1 12,9 10,7 12,3

Santa Cruz 20,7 15,5 11,9 11,0 15,4 12,9 10,6 10,3 9,7 9,7

Santa Fe 28,3 13,9 12,0 12,4 11,0 11,6 11,5 11,1 10,3 10,8

Santiago del Estero 28,3 14,2 13,8 11,7 12,1 13,8 10,4 12,1 14,0 11,7

Tucumán 28,5 23,0 20,5 16,2 13,5 12,9 13,8 13,1 14,1 14,1

Tierra del Fuego 27,9 8,4 4,1 6,7 10,9 10,2 6,8 4,6 9,9 7,1Source: Secretaria de Políticas, Regulación e Institutos. Dirección de Estadísticas e Información de Salud. http://www.deis.gov.ar/Publicaciones/Archivos/Serie5Nro55.pdf

Health and Poverty

Health SystemSub - sector Public Social security Private

Funders Government + others funders

National Social Insurance + Province Social Insurance + other Law Social Insurances + I.N.S.S.J.P. + Work Risk Insurance

Private insurance

Providers Public hospitals + primary health care centers + GPs

Private health centers and public hospitals

Private health centers and public hospitals

Regulators Nation, provinces and municipalities

S.S.Salud + S. ART. S.S.Salud

Population in charge

100% Workers and their families

Clients

Others COFESA – COFELESASupportive Redistribution Fund

Health System Spending Spending

Exclusive public subsector: 2.75% of GDP (28.50%) Social security subsector : 3.6% of GDP (37,.31%) Private subsector: 3.3% of GDP (34,20%) includes private

insurance, drugs and direct services

Resources Resources Establishments with hospitalization : 3300 (1310 public subsector) Establishments without hospitalization: 14500 (6600 public

subsector) Beds: 153000 (80000 public subsector) Doctors: 120000 (1/1000) – nurses 82000

Estimated demandEstimated demand Exclusive public subsector: 42% Social security subsector: 47% Private subsector: 11%

Health System Emphasis on health recovery processes, instead of

promotion, prevention and rehabilitation. Lack of integration between sectors Unplanned incorporation and distribution of

technology. Emphasis on high complexity. Concentration of physicians, generating excess and

deficit depending on the region. Lack of nursery personnel Excessive spending on drugs

Public system Vs. Private system

Efficiency: More production with a fix budget.

Offer: Depending on “physician power”

Quality: Expectations of competence, bureaucracy and discomfort

Efficiency: Necessary production, saving money

Offer: Depending on the profit rate

Quality: High

expectations of competence, speed in the answer and comfort

USA - Argentina numbers   Argentina EEUU

Population (in thousands) total 2012 WHO 41087 318000

Population proportion under 15 (%) 2012 WHO 24,42% 19,63%

Population proportion over 60 (%) 2012 WHO 14,97% 19,61%

Per capita total expenditure on health (PPP int.$) 2011 WHO

U$S 1.433,70 U$S 8.607,90

Per capita government expenditure on health (PPP int. $) 2011 WHO U$S 869,40 U$S 3.954,20

General government expenditure on health as a percentage of total government expenditure 2011 WHO 20,40% 19,80%

Total health expenditure (% of GDP) 2011 World bank 8.10% 17.9%

Life expectancy 2011 WHO 76 79

Infant mortality rate (per 1.000 live births) 2011 WHO 11,7 5,98

Maternal mortality ratio (per 100 000 live births) - Interagency estimates 2011 WHO 77(67-87) 21 (18-23)

Public Hospital Health Management

Guarantee health right Principles Holistic health concept Universal coverage of the population Gratuity of the health services for everybody Development of the primary care strategy

FinancingState budget Billing to social security and private insurance

Mental Health Centres 2

Health Centres and Community Care 43

Neighbourhood Health Centres 35

Dental Centres 2

LevelsFirst Level: Cobertura porteña

Buenos Aires city public health system Law 153: Buenos Aires city basic health law

Second and third level

Acute Care hospital 13

Specialized Hospital 20

Zoonosis Prevention and treatment Institute 1

Public Hospital Health ManagementHospital General de Agudos J.M. Ramos Mejia

It was created in 1868 to give attention to the cholera epidemic patients and give support to soldiers.

In 1914, the hospital was named in honor to Dr. Ramos Mejia as a recognition of his work as a doctor

Nowadays 404 beds 2200 employees (temporary and permanent staff). Allergy, Cardiology, Internal Medicine, Dermatology, Endocrinology, Physiotherapy, Phoniatrics, Speech Therapy, Gastroenterology, Gynecology, Nephrology, Pulmonology, Neurology, Obstetrics, Ophthalmology, Oncology, ENT, Proctology, Psychiatry, Rheumatology, Orthopedics, Urology, General Surgery, immunocompromised, Neurosurgery, Radiotherapy, Mental Health and pediatric medical specialties Allergy Clinic, Dermatology, Neonatology and Traumatology.

Public Hospital Health Management

Medical Management Clinical Management - Protocols for services Control through indicators

Administrative Management Human resources – Central Ministry Management

– Unique hospital function: control of personnel absenteeism

Buying Expenditure recovery

Buying Processes analyzed Virtues Deficiencies Observations

Competitive tendering or bid in the hospital

TransparencyBudget Control Opportunity

Efficiency Supply of common and normal inputs

Acquisition through emergency mechanisms

Efficiency Opportunity TransparencyBudget Control

Overuse

Purchases through the Health Ministry with stock

Budget ControlEfficiency

Opportunity Uncertainty

Purchases through the Health Ministry without stock

Efficiency Budget ControlOpportunity

Opportunity Problems for single supplier. Different results

Petty Cash Efficiency Transparency Limited in amount. Not always available

Buying It doesn't exist a single ideal process, considering that in the practice all of them show their virtues and deficiencies.

The causes of the deficiencies are multiple, they involve all the participants and the revision of the regulatory. It is necessary to have a specific set of purchases processes for health.

The health system is an "intensive labor system" where the 70% of the budget are salaries. The emphasis in the purchasing system is on the public expenditure control, suffering a lack of cost control per patient

There are necessary and relevant instruments to improve processes regardless the method chose. Ex: Registration of suppliers, supplies catalogs, etc.

There isn't a discussion on critical issues such as minimum quality standard or stock management.

New trends: - Green Purchases (included in the new National law since August 2012) - Electronic purchases

Expenditure recovery

Three Steps

Detection: The detection is done on guard, appointment and hospitalization areas. It is done through consulting at social security database or through voluntary statement from the patients having private insurance

Billing: We need the document of the beneficiary and the service. We can only bill what is included in the “Obligatory Medical Program”

collecting: Outsourced

Challenges Accelerated aging of the population - epidemiological transition Health judicialization The public structure has deteriorated and its technology is

outdated Lack of political consensus for a new Health Plan International economic crisis Transnational health problems - Migration and immigration Create consciousness in the society about the importance of

the hospital

MORE SERVICES

MORE MONEY

MORE EFFICIENCY

Opportunities

Development of Information Technology Excellent human resources with great

prestige Inclusion of professionals in health economy

and hospital management

Public Hospital Health Management

Mistakes

1) Financial Managers have the final decision of purchasing

2) The administrative work is wrongly consider less important than medical work.

3) Lack of information in the decision process