VII Regional Forum VII Regional Forum Strengthening Health Systems Strengthening Health Systems

Based on PHCBased on PHC

Health Systems Responses Health Systems Responses Programmatic- and Population-Programmatic- and Population-

Based ApproachesBased Approaches

Quito, Ecuador 29-31 October 2007 Ministry of HealthCosta Rica

Table of ContentsTable of Contents

Background of Health Sector ReformsBackground of Health Sector Reforms National Quality Assurance ProgramNational Quality Assurance Program ResultsResults ConclusionsConclusions

GuatemalaGuatemala

HondurasHonduras

El SalvadorEl Salvador

NicaraguaNicaragua

Costa RicaCosta Rica

PanamaPanama

Costa RicaCosta Rica

Total population:Total population: 4,501,8454,501,845

52,000Km2

History of a TransformationTransforming the Role of the State

Development Model Crisis

Rethinking of State’s Role

Phase II:

Expanding Coverage

Phase III & IV:

Integrating Services & New Models

Phase V

Steering Role

Adjusting Model of Care

• Programs to expand coverage

•Universal SS Coverage

•Epidemiological transition

•Increase in the cost of care

•Separation of preventive-curative care

•Aging population •New models of care

•Integrated Care

•Health Promotion

•Breaking up concentrated areas

•Assessing systems & services

•Epidemiological Accumulation

‘ ‘70s70s ‘‘80s80s ‘‘90s90s 1998 …21st Century.....

‘30-’40s

Phase I: Beginning of State’s Role

•Health SecretariatMinistry of Health•Social Security

CCSS

FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF LIFE AND BETWEEN THE AGES OF 20 TO 59LIFE AND BETWEEN THE AGES OF 20 TO 59

COSTA RICA 1912-2002COSTA RICA 1912-2002

FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF LIFE AND BETWEEN THE AGES OF 20 TO 59LIFE AND BETWEEN THE AGES OF 20 TO 59

COSTA RICA 1912-2002COSTA RICA 1912-2002

Pro

bab

ilit

y o

f d

yin

g (

log

ari

thm

s)P

rob

abil

ity

of

dyi

ng

(lo

ga

rith

ms) L

ife ex

pectan

cy (y

ears)L

ife ex

pectan

cy (y

ears)

• Integrated Care Model in Social Security– Universality– Solidarity– Equity– Unity and Efficiency

• Adjusting Supply– Health Areas and sectors

(EBAIS)– Program titled Integrated

Health Services for the Public

– Outsourcing contracts • 88% of population insured

2006

• Substantive Functions of Ministry of Health Governance (2006)

– Health Policy Bureau– Marketing the health

promotion strategy and the culture of nonexclusion

– Health Surveillance– Strategic Health Planning – Modularization of health

financing – Harmonization of health

service delivery– Health Regulations– Assessment of impact of

actions in health– Scientific research

Health Sector Reform1994-2007 …

4,000 Inhabitants

Population Sector

GENERAL PRACTITIONER

NURSING AUXILIARY

PRIMARY CARE TECHNICIAN

MEDICAL RECORDS TECHNICIAN

INTEGRATED HEALTH CARE: HOME VISITCARE IN FACILITIES AND THE COMMUNITY

40,000-60,000 Inhabitants

SUPPORT TEAM

EBAIS

Fields:Medical specialtiesNursingSocial WorkLaboratory DentistryDiagnostic ImagingHealth Records

Region Hospitals

Health Areas

EBAIS

Ratio of

EBAIS/HealthAreas

HealthAreas, 2007

EBAIS

Ratio of EBAIS/

Health Areas2007

Total 29 103 903 8,8 104 944 9.1

H. Nacionales 8

Brunca 3 6 68 11.3 6 69 11.5

Central Norte 4 32 258 8.1 32 264 8.3

Central Sur 3 27 266 9.9 28 297 10.6

Chorotega 5 13 95 7.3 13 94 7.2

Huetar Atlántica 2 8 105 13.1 8 107 13.4

Huetar Norte 2 8 45 5.6 8 46 5.8

Pacífico Central 2 9 66 7.3 9 67 7.4

Source: CCSS,. Office of Executive President, Planning Unit, 2006 & 2007,

2006 2007

CCSS Hospitals, Health Areas & EBAIS by Region

2006 & 2007

Historical Evolution Health Insurance Historical Evolution Health Insurance Coverage, Costa RicaCoverage, Costa Rica

1944-20051944-2005%%

Indicator 1960 1970 1984 1994 2000 2005Coverage of services 15.4 62.6 100 100 100 100Contribution-based coverage 15.4 62.6 71.1 86.2 81.7 87.6

National population by type of coverage (%)

Directly insured 7.6 11.7 19.2 19 18.7 19.6

Voluntary 4.5 5 6.6 3.4

Pension Recipients 8 8.6 6.3

Insured's Family 7.7 35.1 44.6 45 41.5 44.4State & Family Account 7 11 12.2

Other type 0.1 0.4 2.8 2 1.1 1.7Uninsured 84.6 52.8 28.9 14 12.5 12.4

Source: Office of the Actuary, CCSS & Census Bureau

Health Insurance Coverageby Insurance Modality, Costa Rica, 1960,1970,1984,1994, 2000 & 2005

Life Expectancy at BirthLife Expectancy at Birth

20

30

40

50

60

70

80

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

años

Costa Rica

El Salvador

Guatemala

Honduras

Nicaragua

Panamá

Source: State of the Nation and State of the Region

WomenWomen 81.0381.03

MenMen 76.576.5

2005

Source: INEC

Average: 9.78 per 1,000 births in 2006

Infant Mortality Rate for Quintiles of Cantons

Grouped according to Social Lag Index for theQuadrenniums 1994-1997, 1998-2001 & 2003-2006

Costa Rica

16.35

13.85

12.21

12.65

11.68

11.08

10.12

9.64

9.48

8.95

0 5 10 15 20

Quintile 1

Quintile 2

Quintile 3

Quintile 4

Quintile 5

Rates per 1,000 births

2003-2006

98-2001

94-97

StrategiesStrategies

Standardization of integrated care for Standardization of integrated care for people in Level I and care for priority people in Level I and care for priority health problems of public health interesthealth problems of public health interest

Evaluation of coverage in participating Evaluation of coverage in participating population areaspopulation areas

Evaluation of quality of care based on Evaluation of quality of care based on meeting basic quality standardsmeeting basic quality standards

Household SurveyHousehold Survey

Total Coverage and Quality CoverageLevel I – Health Care Programs CCSS, 2005

0.0

20.0

40.0

60.0

80.0

100.0

120.0 <

1 y

r. o

ld

1 to

6 y

rs.

Ado

lesc

ents

Pre

nata

l

Pos

tpar

tum

D

iabe

tics

Hyp

erte

nsiv

e

E

lder

ly

Cyt

olog

y

% Total Coverage

% Quality Coverage

Ministry of Health: Quality AssuranceMinistry of Health: Quality Assurance with a Systemic Approachwith a Systemic Approach

Qualification: Structure - basic levelQualification: Structure - basic level

Accreditation: Structure - Processes - OutcomesAccreditation: Structure - Processes - Outcomes

Evaluation of Health Systems and Services: Structure, Evaluation of Health Systems and Services: Structure, Process, and Outcomes in the EEP service network Process, and Outcomes in the EEP service network

Tracer Events: Tracer Events: Infant/Maternal Mortality Infant/Maternal Mortality Other health problems of public health interest (hypertension, Other health problems of public health interest (hypertension,

diabetes mellitus, screening for cervical cancer)diabetes mellitus, screening for cervical cancer) Care Programs for the public (prenatal check-ups, integrated Care Programs for the public (prenatal check-ups, integrated

care for children under 2 years)care for children under 2 years)

StructureStructure

OutcomesOutcomes

ProcessesProcesses

Certification of Facilities

Accreditationof Facilities

Quality Assurance

Evaluation of Systems in EEP

P u blic & P ri v ate

Assessment of Level I integrated Care, EBAIS HeadquartersCosta Rica, 2000-2006

CATEGORY  2000 2006TOTAL 74 80

I. Physical Plant 74 73II. Material Resources 87 94III. Human Resources 61 67IV. Standards & Procedures 66 86

Boys & Girls 71 90Adolescents 45 80

Prenatal 69 94Postpartum & Post-abortion nd 83Women aged 20-49 69 74

Elderly 64 78V. Programming & Management 77 62VI. Supplies 83 95VII. Education for Health 81 89VIII. Social Participation 57 61

Source: Office of Health Services and Regional Offices, Ministry of Health

Results of the Standards and Procedures Assessment for the Integrated Care Programfor the Public, 1st Level of Care; Costa Rica 2000-2004

0 10 20 30 40 50 60 70 80 90 100

Boys & Girls

Adolescents

Prenatal

Postpartum and Post-abortion

Integrated care for women aged 20 to 59

Elderly

%

2000 2001

2002 2003

2004

Evaluation of Level I Integrated Care Household Survey, Costa Rica, 2000-2005

1900

1000

15551300

2120191745

20

39

19

35 33500900

1300170021002500

2000 2001 2002 2003* 2004 2005Year

Nº

15

25

35

45

55

* Only 2nd SemesterSource: Regional Offices and Office of Health Services, Ministry of Health, 2006

Graph 1. Assessment of Level I Care at the Homes Visited as part of the Survey on Family Health Needs, Costa Rica 2000-2005

Household Survey: Assessment of Satisfaction Household Survey: Assessment of Satisfaction of Basic Needs by Country of Birth, Costa Rica 2005of Basic Needs by Country of Birth, Costa Rica 2005

Type of DeficiencyType of Deficiency

Non-MigrantsNon-Migrants MigrantsMigrants

%% (N)(N) %% (N) (N)

Total # of Homes Visited Total # of Homes Visited 100 (1,729)100 (1,729) 100 (188)100 (188)

No educational support for children under 15No educational support for children under 15 5.25.2 11 6.16.1 11

Have worked less than 12 yearsHave worked less than 12 years 0.90.9 22 0.00.0 22

Do not have water in homeDo not have water in home 8.68.6 13.313.3

Do not have waste disposal service Do not have waste disposal service 7.27.2 24.524.5

Deficient housingDeficient housing 14.514.5 34.634.6

High Economic DependencyHigh Economic Dependency 33.633.6 53.753.7

OvercrowdingOvercrowding 17.617.6 37.837.8

Homes with one or more Homes with one or more than onethan one basic need unmetbasic need unmet 50.750.7 78.778.7

11 Of the total # of homes with children under 15: 908 and 115 Of the total # of homes with children under 15: 908 and 115

22 Of the total # of homes with children under 12: 885 and 117 Of the total # of homes with children under 12: 885 and 117

Source: Regional Offices and Office of Health Services, Ministry of Health, 2006Source: Regional Offices and Office of Health Services, Ministry of Health, 2006

InsuranceAverage 88%

Graph 3. Assessment of Level I Integrated CareHousehold Survey: Distribution of type of insurance by

Satisfaction of Basic Needs, Costa Rica 2005

25.6

16.9

22.0

15.9

7.7

13.0

58.5

75.4

65.0

0 10 20 30 40 50 60 70 80

Unmet

Met

Total

Percentage

Uninsured State Insured All other types of insurance

Source: Regional Offices and Office of Health Services, Ministry of Health, 2006

Results of Household SurveyResults of Household Survey

Utilization and Access to Level I Health Services inUtilization and Access to Level I Health Services in Populations Living in Poverty, Household Survey, Ministry of Populations Living in Poverty, Household Survey, Ministry of Health, Costa Rica, 2006Health, Costa Rica, 2006

     

VariableVariable %%

Pregnant women with prenatal carePregnant women with prenatal care 9595

Women >49 yrs. with Pap test in 2 yearsWomen >49 yrs. with Pap test in 2 years 7878

Check up of boys and girls < 6 yearsCheck up of boys and girls < 6 years 7676

Complete vaccination series in children < 1Complete vaccination series in children < 1

9595

Medical monitoring of hypertension and Medical monitoring of hypertension and diabetes mellitusdiabetes mellitus 9393Source: DSS, Regional Offices, Ministry of HealthSource: DSS, Regional Offices, Ministry of Health

The poorest and even the uninsured population gained access to Level I health services in 2006

Household Survey: Perception of IllnessHousehold Survey: Perception of Illnessand Need for Medical Visit in the Past Year, Costa and Need for Medical Visit in the Past Year, Costa Rica 2005Rica 2005

  Non-MigrantsNon-Migrants MigrantsMigrants

No.No. %% No.No. %%

Total Households Total Households SurveyedSurveyed 1,7291,729 100.0100.0 188188 100.100. 00

Households seeking Households seeking care at public cliniccare at public clinic 1,1311,131 65.465.4 126126 67.067.0

Care actually Care actually providedprovided 1,0681,068 94.494.4 116116 92.192.1

Source: Regional Offices and Office of Health Services, Ministry of Health,Source: Regional Offices and Office of Health Services, Ministry of Health, 20062006

14% required a medical visit at EBAIS in the past 15 days

10% of requests for care from EBAIS are rejected: The main reasons were:

•“There wasn’t enough space and they were told to return the next day.” (44%)

•“Were not insured, so they were charged.” (41%)

Source: Ministry of Health, Household Survey, 2006

Assessment of Level I Comprehensive Care. Household Survey: Quality of Morbidity Care, Costa Rica 2005

79.9%

11.5%8.7%

Good

Fair

Poor

Graph 4. Household Survey on Family Health Needs: Opinions on the quality of health care received by group of migrants,

Costa Rica 2005

5.7%

76.6%

17.7%

GoodFairPoor

Hypertension Tracer: ScreeningHypertension Tracer: Screening

Clinical file of level I and II facilities: Individuals 20 years and older with hypertension value recorded in the last year. Costa Rica, 2005.

Range: 65-70% fulfillmentFiles Reviewed: 1073

Source: Interinstitutional Commission of Hypertension Tracer, Ministry of Health.

95%

5%

Yes No

Table 22. Hypertension drugs available at health Table 22. Hypertension drugs available at health facilities, by level of care.facilities, by level of care. Costa Rica, 2004. Costa Rica, 2004.

Total3 to 45

%No.%No.%No.Level of care

18

32

14

10

16

14

8

16

-

Hypertension Drugs Available*

1005644Third

1005050Second

100100-First

Source: Interinstitutional Commission of HT Tracer. Regional Offices, Ministry of Health.

Established Range: 100%.

* By level of care

File: Hypertensive individuals reaching optimal treatment goal(<140/<90), by level of care. Costa Rica, 2005.

TotalNoYes

Number%%Level of care

568

131

263

174

Reached optimal treatment goal

5446National total

3565Third

7030Second

4258First

Established Range: 40%

Care Coverage for Costa Rican and Immigrant WomenCosta Rica, 2000Coverage, by type of care CR Immigrant

Insurance 78 48

Prevalence of birth control 80 70

Childbirth % %Care during CCSS Hospital delivery 96 84Care during home birth 2 15Professional care during delivery (physician or nurse) 96 91

Has had a PAP test at least once 79 75

Medical visitCCSS Medical visit in the past year 71 79Private medical visit in the past year 22 8

Immunization of children ages 1 to 4 yrs. Basic system 95 80

Source: CCEP. National Survey on Sexual and Reproductive Health, 1999

Health Care Challenges Health Care Challenges MAIS Forum, 2005MAIS Forum, 2005

Control of risk factors beyond the Control of risk factors beyond the scope of medical care and scope of medical care and environmental health determinants environmental health determinants

Emphasis on health promotion Emphasis on health promotion and disease preventionand disease prevention

Long-term careLong-term care Care for complex problemsCare for complex problems Sexual & reproductive health careSexual & reproductive health care Mental health careMental health care Communication & education skillsCommunication & education skills Pain management, and death and Pain management, and death and

grief counseling servicesgrief counseling services Interdisciplinary approach & Interdisciplinary approach &

communication between the communication between the different levels of complexitydifferent levels of complexity

Knowledge of bioethics Knowledge of bioethics

Persistence of a biology-based, Persistence of a biology-based, individualistic model of care. individualistic model of care.

Weak teamworkWeak teamwork Normative approach to planning Normative approach to planning

centered on productivity and not on centered on productivity and not on health needshealth needs

Incongruity between education of HR Incongruity between education of HR for health and the requirements of for health and the requirements of the modelthe model

Lack of coordination between levels Lack of coordination between levels and institutionsand institutions

Reactive environmental protective Reactive environmental protective action action

Lack of clarity in defining the Lack of clarity in defining the functions of health sector functions of health sector institutionsinstitutions

Activistic and utilitarian concept of Activistic and utilitarian concept of social participation in healthsocial participation in health

DEMAND CURRENT SUPPLY

Source: DSS, Ministry of Health

CONCLUSIONSCONCLUSIONS The integrated care model was applied on a The integrated care model was applied on a

geographical-population basis, thus geographical-population basis, thus incorporating the concepts of public health and incorporating the concepts of public health and conceiving Level I as the gateway to the health conceiving Level I as the gateway to the health system.system.

The service package tends to unify the entire The service package tends to unify the entire insured population, since it includes first-level insured population, since it includes first-level and highly specialized services for all. and highly specialized services for all.

The public system de-commercializes the The public system de-commercializes the system to a high degree.system to a high degree.

CHALLENGECHALLENGE Financial sustainability and preserving a Financial sustainability and preserving a

universal, collective health system that universal, collective health system that ensures the delivery of equitable quality ensures the delivery of equitable quality

servicesservices

Osa Peninsula, channels of Río Sierpe, Costa Rica