HEALTH SYSTEM REFORM IN FEDERATIONS: CURRENT SITUATION AND PERSPECTIVES

HEALTH SYSTEM REFORM IN FEDERATIONS: CURRENT SITUATION

AND PERSPECTIVES

THE MEXICAN EXPERIENCE

INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

DR. EDUARDO VELASCO

DR. ARMANDO ARREDONDO

HEALTH POLICY AND FEDERALISM

Presentado ante el Foro de Federaciones en Sao Paulo, Brasil, 15 de octubre de 2001

Forum of Federations / Forum des fédérations www.forumfed.org [email protected]


HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE

Diagram 2

Insured and uninsured population by income level

Insured UninsuredP

riva

te I

nsur

ence

Soc

ial S

ecur

ity

IMS

S &

IS

SS

TE

Min

istr

y of

hea

lth

IMS

S S

olid

arid

ad

No

acc

ess

to h

ealt

h se

rvic

es

47 26 9 10

High income Low income

Populationin millions

Institutions

Coverage

Source: Ministry of Health, 1995



Variable SSA IMSS-ISSSTE PRIVATE INST.

Funding type

Funding source

% total health expenditures

Population coverage

Basic principle

Decentralization

Invest in promotion

in preventive care

in curative care

in rehabilitation

in research

Unipartite

Federal & state govt.

15%

40%

Citizenship & poverty

Yes (1985)

High

High

Medium

Low

Medium

Tripartite

Federal govt. , eployrs & workers

43%

50%

Corporative

Yes (1995, 1999)

Medium

Medium

High

Medium

Low

Unipartite

Users

42%

10%

Purchasing power

No

Very low

Low

Medium

Very low

Very low

THE MEXICAN EXPERIENCE



Reform of the social security through pension reform to generate internal savings in the long run.

Financial restructuring to avoid bankruptcy of the social security system, including its health component.

Health reform formulation, legislation, and implementation is led by structural adjustment policies, through technocrats empowered to bring about policy change.

Efforts at reforming the IMSS health care provision have included decentralization and financial deconcentration to the local level.

Efforts to establish separation of the financing and provision functions.



1) Deconcentration to shift power from the central offices to peripheral offices

2) Delegation

3) Devolution shifts responsibility and authority from the central offices of the Ministry of Health to separate administrative structures still within the public administration

4) Privatization. Prospective payment health insurance with private providers; reversion of fees to companies who purchase health services elsewhere.

The center retains policy making and monitoring roles and the periphery takes operational responsibility for administration.



DECENTRALIZATION COMPONENTS:

-Competitional. Devolution to the states, of the direction, coordination, and operational implementation of medical care, public health, and sanitary control of concurrent general health services.

-Administrative. Creation of a structure to operate State Health Services.

-Patrimonial. The federal infrastructure was transferred at no cost to State Health Services.

-Occupational. Workers were protected under the labor and social security scheme and the employers’ individual faculties were delegated.

-Financial. A co-financing system was set up with federal and state contributions.

-Logistic. A mechanism was established to provide technical and logistic support required by decentralized services for their culmination and better development.



link health to economic and social development

reduce health system gaps that affect the poor.

deal with emerging problems by establishing priorities

launch a national crusade for improving the quality of services

build a new cooperative federalist health system

strengthen the leading role of Secretaria de Salud ( SSA)

advance towards an Integrated Healthcare Model

strengthen investments in human resources, research, and infrastructure.

promote community participation in health and the free choice of medical care provider.

provide financial protection against catastrophic expenditures.



IMSS

Financial restructuring

Deconcentration and rationalization of the IMSS

Institutional model for comprehensive health services (MIAIS)

Medical areas for deconcentrated management (AMGD)

Family health insurance (SSF)

Family doctor eligibility and performance incentives in family health care centers

Performance incentives

Costing according to diagnosis-related groups (DRGs)

Contracting-out of health servicesSSA

Extended Coverage Program (PAC)



Health PoliciesHealth Care

Reforms

Entrepreneurs

Federal Government

SSA

President

IMSS

PRI

PAN

PRD

State governments

States with high incomes

States with middle and low

incomes

Insured Population

Uninsured Population

Communication media

Health Institution Unions

Other Unions

Civil society: low incomes

Civil sociaty:

high and middle incomes

HIGH INFLUENCE on health policies

MEDIUM INFLUENCEon health policies

LOW INFLUENCEon health policies

Health Researchers

GUIDING FORCE: DEMOCRATIZATION

LEADING PRINCIPLE: CITIZENSHIP

VALUES: • JUSTICE• LIBERTY• REPRESENTATION OF CITIZENS’ INTERESTS• SOCIAL PARTICIPATION• ACCOUNTABILITY

HEALTH REFORM STRATEGIES


1. SUBSTANTIVE STRATEGIES

a) Linking health to economic developmentb) Decrease backlogs of disease and healthcarec) Respond to emerging problemsd) Crusade for qualitye) Financial protection

2. INSTRUMENTAL STRATEGIES

a) Federalizationb) Regulation (steering, stewardship)c) Universal Health Systemd) Freedom to choose provider and citizens

participatione) Advancement of knowledge




Linking health to development

- Healthy policies- Intersectoral cooperation- Healthy communities- Women and health- Healthy fiscal policies (15% tax to medications)




Decreasing backlogs of disease

- Improving the package of basic interventions- Cost-effectiveness- Modernization of biotechnology, informatics and telecommunications- 100 essential medications for all




Responding to emerging problems

- cost-effective interventions for emerging or priority problems such as injuries, tobacco smoking, substance abuse, depression, diabetes, high blood pressure, obesity.




Crusade for quality

- Ethics codes- Patients’ rights- Ethics education and information- Performance appraisal of personnel- Standardized processes and monitoring outcomes- Certification of health personnel- Rationalization of regulatory structures




Financial Protection

- Improve financial equity and justice- Decrease catastrophic expenditure in

70-80%- Strengthen preventive care- Liberate resources for productive use- Incentives for formal work/employment- Six-year cumulative cost: 1.2% of GNP



• INSTRUMENTAL STRATEGIES

Federalization

- Complete decentralization- Explicit formulation of resource allocation to states- Interstate cooperation

-in public health services- in high specialty areas and

services




Stewardship

- Liaisons:• intersectoral (Consejo de Salud

General)• sectoral (Comisión Federal de

Políticas de Salud• territorial (Consejo Nacional de

Salud)• Through popular representatives

(through Oficina de Vinculación del Congreso de la Unión and citizen groups)




Universal Health System

- Gradual elimination of population selective access to health care services- Interinstitutional master plans for high technology investments- Compensation fund among federal and state institutions




Freedom to choose health provider and citizens’ participation

- Free choice of healthcare provider- Free choice of family physician- Citizen health committees at all levels of health care




Strengthening knowledge

- Promotion of mission-oriented research

- Information system for decision making

- Human resource development



HEALTH SYSTEM REFORM IN FEDERATIONS: CURRENT SITUATION AND PERSPECTIVES

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