Uruguayans’ healthcare coverage: analysis of presentacion ISEqH.pdf · 2011-11-16 ·...

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity

since the implementation of the National Integrated Health System

Ec. Juan Pablo Pagano Health Economics Division

Ministry of Public Health Uruguay

ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since the implementation of the National Integrated Health System 2

Uruguay: summary data Capital: Montevideo (40% pop.)

Pop.: 3.300.000 aprox. 94% urban Area: 176.065,00 km2

Climate: Mild (16º)

HDI: 42nd (high)

GDP: USD 14.000 (per captita, ppp)



Introduction • Law #18.211 of december 2007 creates the National Integrated Health System

• On the basis of the Human Right to Health • One of the main objectives of the Health System reform: achieve equity in access to health care between different groups regardless of capacity to pay


• Also to guarantee a homogeneous set of health care services that define “integral coverage”


Flashback • Until the year 2007 the uruguayan Health System was divided into two subsystems*: Public (basically for lowincome groups) Private (formal workers through social security and individual affiliates with capacity to pay)

• Each subsytem served approximately 50% of the population

• Public sector: 25% of total country health expenditure vs. 75% of private sector



Flashback (cont.) • Consecuence: expenditure percapita in the private sector was 2,5 times higher than that of the public sector

• Moreover: public sector users had higher needs for care taking into account their socioeconomic situacion

• Therefore, there was a high correlation between quality of health care coverage and income levels / laboral status



Creation of the SNIS • Homogenize health care quality and access with distributive justice that equals the economic burden of health care spending for each citizen

• Access to the private institutions of the SNIS formal workers and their sons/daughters in charge the retired (chronogram) sons/daughters of the unemployed individual affiliated

• Financial reform: general taxes, employers and employees* all contribute to the FONASA (National Health Fund)



6th international conference September 26, 27, 28 Cartagena de indias, Colombia

Sources

Funds

Supliers

Users

General taxes

Employees’ contributions

Employers contributions

Households

Militar, police, University hospital FONASA FNR OOP Private

insurance

Police, Militar and University hospitals

ASSE “Public”

IAMC “Private”

IMAE Private Clinics, etc

Policemen, Militars, some civil servants

Worstoff (income)

Formal workers, & family, and retired

Households with Capacity to pay

*Source: Aran D, Laca H. 2011


2006

2010*

Coverage by type of institution

Institution People PercentagePublic 1.253.256 41%Private 1.335.131 44%Other 393.931 13%Not covered 82.889 3%Total 3.065.207 100%

Institution People PercentagePublic 1.152.566 34%Private 1.797.073 53%Other 325.894 10%Not covered 93.065 3%Total 3.368.598 100%

Public Private

Private Public



Young people • In 26: 22% of people under 18 years had access to the private sector

• This proportion more than doubles for the year 2010 (50%), representing the entrance of more than 260.000 people of that age range to the private sector

• Consecuence: this group now represents 26% of total private sector* users, vs. 14% in the year 2006.

• Important changes in the risk profile of institutions



2006

2010

Institutions’ age structure

Age range Public P rivate Others<18 years 372.964 458.865 105.20418‐65 years 633.573 1.066.532 270.575>65 146.029 271.676 43.180Total 1.152.566 1.797.073 418.959

Age range Public P rivate Others<18 years 501.237 196.172 167.62418‐65 years 623.866 888.427 264.726>65 128.153 250.532 44.470Total 1.253.256 1.335.131 476.820



Public Private

1865 (55%) <18 (32%) <18 (26%)

1865 (59%)

1865 (50%) <18 (40%)

1865 (67%) 15 % 10%

13% 15%

19%

Grafically

2006

2010

* Risk structure becomes more even between public and private sector institutions



2006

2010

Labor condition

S ector Employed Unemployed R etir/pens E studiantesPublic 26% 57% 34% 33%P rivate 62% 24% 55% 53%Other 12% 19% 11% 14%Total 100% 100% 100% 100%

S ector Employed Unemployed R etir/pens E studiantesPublic 28% 60% 33% 46%P rivate 59% 20% 54% 36%Other 13% 20% 13% 18%Total 100% 100% 100% 100%



2006

2010

By income quintiles

S ector/quintile 1st 2nd 3rd 4th 5thPublic 74% 47% 30% 15% 4%P rivate 18% 41% 57% 72% 80%Other 4% 9% 10% 10% 14%No C overage 3% 3% 3% 3% 2%Total 100% 100% 100% 100% 100%

S ector/quintile 1st 2nd 3rd 4th 5thPublic 79% 60% 40% 20% 5%P rivate 6% 21% 42% 66% 83%Other 12% 16% 14% 11% 11%No C overage 2% 3% 4% 3% 1%Total 100% 100% 100% 100% 100%



By income quintiles • Noticeable increase in the percentage of people of the first two quintiles that gain access to the private sector

• Small proportion of richier families tend to move to another type of coverage such as private insurance like Blue Cross

• The mayority of people tend to move from the public to the private sector if possible



Grafically 2006 2010

Quintile

Public Private Other No coverage



From the institutions point of view, users profile changed considerably

2006 2010

Consecuence

Quintile Public P rivate1 39% 3%2 30% 10%3 20% 19%4 10% 30%5 2% 38%

Total 100% 100%

Quintile Public P rivate1 43% 7%2 27% 15%3 18% 21%4 9% 27%5 2% 30%

Total 100% 100%



2006 2010

1º 1º

1st 2nd

Private

5th

Public

1st 1st

2006 2010

Grafically



Per capita expenditure • Important reduction of Public sector users + important budget increase (social security contributions, general taxes)

Consecuence: important reduction of publicprivate gap in per capita expenditure

• Private/public ratio 2010: 1,30* (vs 2,7 2006)



FONASA coverage

• Now some facts about people included in the National Health Fund (FONASA)

• Those FONASA covered can choose where to be affiliated (with some restrictions)



Age <18 2645 4665 65 + 18 25

33% 9% 29% 23% 7%

Labor status <14y S R

25% 59% 7% 7%

2%

Income 1st 2nd 3rd 4th 5th

9% 19% 23% 25% 24%

2010: FONASA coverage

Employed

1% U



FONASA Covered

2010 by institution

Not FONASA Covered

People %Public 137.419 8%P rivate 1.408.786 87%Other 75.246 5%Total 1.621.451 100%

People %Public 1.015.147 58%P rivate 388.287 22%Not C overed 93.065 5%Other 250.648 14%Total 1.747.147 100%



The “not covered”

• Stable percentage in the period, of about 2,7%

• 38% of them are in the 2645 age range

• No other relevant characteristic of this group that distinguishes them from the entire population

• Equitable distribution by income quintiles



The “not covered” (cont.)

• 53% are employed

• 12% declare contributing to a retirement insurance (inconsistent)

• At least a part of this is a measurement error



Summary

• Equity in terms of age: people under 18 years of age gained access to the private sector

• Also inactive students gained access to the private sector

• Households of the first quintiles of the income distribution can choose

• One third of total FONASA covered are <18 years



Summary (cont.)

• Nevertheless Public sector users’ profile did not change dramatically

• Increasing entrance of the retired to the FONASA (before 2007 they had to pay, to gain access to the private sector)

• The mayority FONASA covered choose a private institution (87%)

• Important reduction in expenditure private/public gap



Forthcoming

• Reform still taking place until 2016 when all the retired will be included in the FONASA

• Extended assistance (mental health, reproductive health, etc).

• User satisfaction surveys (waiting time, etc.)

• Military and policmen


Uruguayans’ healthcare coverage: analysis of presentacion ISEqH.pdf · 2011-11-16 ·...

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