Moving towards a more equitable health system: prospects

Moving
towards
a
more
equitable
health
system:
prospects
and
challenges
Janice Seinfeld
Agenda
  Introduction
 
 
 
Low budget allocated to health sector is a problem
Target spending is key
System fragmentation generates inefficiencies
  The challenge of the Universal Health
Insurance
 
 
Normative aspects
The case of cancer in the Universal Health
Insurance: lessons
  Conclusions
Introduc;on
  Peruvian health sector has had major advances in last
decades; however, it still presents high levels of
deficiency:
  Low budget allocated to health sector (5.9% of the total
budget; 1.6% of GDP). It is unsustainable when
implementing Universal Health Insurance.
  Important inequalities is a problem that health sector
faces. It is necessary to target spending to consolidate
poorest people improvements.
  Inefficiencies
in the sector should decrease.
Fragmentation leads to poor use of scarce-resources.
Executed
Budget
by
Health
Sector
1/
(Millions
of
current
US$)
Health
care
spending
2006
2007
2008
2009
2010
GDP
92
303.81
107
233.30
126
822.74
126
923.12
153
844.94
Health
expenditure
1
209.18
1
426.20
1
521.87
2
145.00
2
399.98
Health
expenditure
(%
of
GDP)
1.31
1.33
1.2
1.69
1.56
Source:
WDI,
MEF,
BCRP
1/
Includes
collec:ve
and
individual
health,
management,
planning,
science
and
technology
Health
Sector
Budget
2010
by
Level
of
Government
(Millions
of
US$
2/)
Health
Sector
Central
government
Regional
government
Local
government
Total
Budget
%
Execu;on
Budget
%
Execu;on
Budget
%
Execu;on
Budget
%
Execu;on
81
86,5
120
69
20
68,7
220
75,4
1036
89,9
1152
72
133
68,1
2321
79,7
Other
expenses
1/
114
92,1
158
95
2
56,5
282
91,1
Total
1
231
89,9
1
430
74,3
155
68,0
2
823
84,4
Collec&ve
health
Individual
health
1/
Includes
management,
planning,
science
and
technology
2/
2010
Average
US$‐PEN
exchange
rate:
2,826
Source:
MEF,
BCRP
Health
indicators
Indicators
Chronic
malnutri&on
(percent
of
children
under
5
years)
ENDES
2000
ENDES
2009
URBAN
RURAL
URBAN
RURAL
13
40
10
33
Source:
INEI
 Despite
the
marked
improvement
in
the
indicators
of
rural
areas,
the
gap
between
rural
and
urban
areas
is
still
quite
large.
Maternal
Mortality
Rate
and
Ins;tu;onal
Delivery
Ra;os,
by
poli;cal
regions
Institutional Delivery Ratios, by areas
Births
by
caregiver
and
area.
Peru:
2009
Caregiver
Births
by
health
establishment
and
area.
Peru:
2009
Urban
Rural
Establishment
Urban
Rural
Doctor
63.1
24.4
At
home
5.9
41.5
Nurse
18.3
20.7
Midwive's
home
0.2
0.3
Obstetri&an
12.9
15.9
MINSA
Hospital
48.3
23.2
Health
Especialist
0.1
1.7
Tradi&onal
Birth
AZendant
ESSALUD
Hospital
14.9
2.1
2.8
16.4
Other
2.7
20.3
FF.AA./PNP.
Hospital
0.6
0
None
0.1
0.6
MINSA
Health
Center
13.8
16.5
MINSA
Health
Post
2
13.5
ESSALUD
Post/Center
1.7
0.1
Private
Prac&ce
11.5
1.3
Other
1.2
1.6
Source:
ENDES
2000,
2009.
Source:
ENDES
2000,
2009.
Es;mated
User
Subsidy
for
2010
(Includes
dona;ons
from
public
ins;tu;ons
and
SIS)
Expenditure
quin;le
Served
(number
of
people)
Average
subsidy
per
user
(US$)
1/
Total
Subsidy
(%)
First
quin&le
2
389
495
7
12
Second
quin&le
1
935
124
13
20
Third
quin&le
1
524
138
20
23
Fourth
quin&le
1
081
921
23
19
Fi\h
quin&le
780
940
44
26
Total
SIS
7
711
618
17
100
1/
2010
Average
US$‐PEN
exchange
rate:
2,826
Source:
BCRP,
Enaho‐
INEI
Increased number of beneficiaries in the firsts quintiles.
Amount of subsidy is, however, 6 times higher in the fifth quintile.
Distribu;on
of
users
of
health
expenditure
by
expenditure
quin;le,
Peru
2010
(%
of
expenditure)
Health
Facility
Expenditure
quin;le
(1=
lowest)
1
2
3
4
5
Centers
and
health
posts
30.50%
27.70%
20.80%
14.40%
6.60%
Hospitals
7.30%
14.90%
22.50%
29.30%
26.00%
TOTAL
26.00%
25.20%
21.10%
17.30%
10.40%
Source:
MEF,
MINSA
 People
in
the
higher
quintiles
are
attended
mostly
in
hospitals,
where
the
subsidy
per
user
is
higher;
in
this
case,
public
subsidy
has
a
regressive
structure.
Health
sector
organiza;on
The Challenge of Universal Insurance
  The Universal Health Insurance Law seeks guaranteed
access to health, through a basic plan of benefits (PEAS).
Insurance
Rate
According
to
Insurer
(%)
Insurance
status
2007
2008
2009
SIS
18.4
30.3
36.4
EsSalud
18.3
18.9
19.6
Private
insurance
1.7
2.2
2.6
Others
3.3
2.7
2.6
Total
with
insurance
41.7
54.1
61.2
Total
without
insurance
58.3
45.9
38.8
Total
100
100
100
The Challenge of Universal Insurance
Normative aspects
•  In 2009, the Peruvian government passed the Universal Health
Insurance Law, which sets a mandatory membership in a health
insurance scheme.
•  The law establishes the agents linked to Universal Health
Insurance: stewardship (MINSA), financing (health insurance
funds institutional managers -IAFAS), service providers (health
services institutional providers -IPRES), supervision (National
Superintendence of Health Insurance –SUNASA).
•  The law determines the existence of three financial regimes for
health insurance: contributory, semi-contributory and subsidized.
The Challenge of Universal Insurance
Financing
  The total public health budget for 2010 was US$ 1,375.1 million,
of which US$ 184,1 million were allocated to SIS and US$ 57.7
million to INEN.
  The SIS budget was used to fund 30,994,797 of attention
demanded by 7,069,691 people, from a total of 12,385,998
insured –US$ 5.95 per attention or US$ 26.13 per insured
attended.
  An increased out-of-pocket spending to cover treatments is
appreciated, especially for the poor.
The Challenge of Universal Insurance
The Case of Cancer
  PEAS is a basic plan offered by all public and private insurers. It
covers the cancer diagnosis of cervix, breast, colon, stomach and
prostate. Only costs associated to cervix cancer are fully covered.
  High cost neoplasms treatments not covered by PEAS should be
funded through the Health Solidarity Intangible Fund. However,
FISSAL does not have sufficient resources to assume the
financing of treatments.
  SIS has published a list of insurable conditions additional to PEAS
for its affiliates in the subsidized regime. For tumors not included in
PEAS, SIS established a funding cap of 3,000 US$.
  For the 91 thousand insured people by SIS who were treated at
INEN, the average treatment payment was 50 US$.
The Challenge of Universal Insurance
  The system fragmentation contributes to waste current
resources. Universal Insurance Law, in order to integrate the
system, opens the possibility of developing mechanisms to
purchase and exchange services between providers.
  With respect to human resources, there is a shortage of
medical oncologists; health workers do not have the
necessary training.
  There is a problem of expensive cancer drugs. In the country,
30 cancer drugs are sold since ten years ago -24 have supply
monopoly and 5 have only two providers.
  Strategic Program of Cancer Prevention and Control has a US
$10M budget.
  Due to INEN degree of specialization, it is the driver of the
strategic program, without an effective mechanism of regulation
–to safeguard the proper use of public budget due to possible
conflicting interests generated by their multiple roles.
  The program creates an opportunity for cancer funding; but the
implementation process is fragmented: i) regions receive
resources to finance health activities; ii) SIS finances attention
service for poor; iii) INEN funds are allocated to cancer
prevention activities at national level, as well as care service
provider; and iv) FISSAL.
Conclusions
  The country faces different challenges regarding the
Universal Insurance.
  National information problems limit the implementation of
 
 
 
 
 
intervention strategies.
The institutions involved in health services need to develop and
exercise their roles according to their skills.
Ensure public funding for health care coverage for poor people.
FISSAL must be redefined to incorporate defined interventions
with clear funding schemes.
Fragmentation in financing the various interventions may
involve a misuse of resources.
The extension of service offer must not be made under
a tiering scheme. It is urgent to achieve an integration
of services in a network of public and private care to help
improve access.
Janice Seinfeld