1. Integrated Health Services Networks and Vertical Programs Regional Consultation Meeting Ministry of Health of Paraguay Vice Minister Dr. Edgar Giménez Cusco Peru, 11-12 November 2009 1

2. Ministerio de Salud Pública y Bienestar Social Health System of Paraguay Quo vadis…? Dr. Edgar Giménez Caballero Vice Minister of Health Paraguay - August 2008 - 2009

3. Introduction: The Context Health Situation 6,000,000 inhabitants Young country 35% of population living in poverty; 19% in extreme poverty High infant and maternal mortality rates Morbidity due to preventable causes and epidemics Vulnerable population: poor and indigenous Health System Fragmented and segmented 40% social exclusion High out-of-pocket expenditure on drugs Only 20% of population has insurance Health Policies 1989: Military dictatorship falls after 35 years 1990-95: Deconcentration of health services network 1996: National Health System and health councils created 2008: Change in government after more than 60 years significantly raises expectations The government declares decentralization as a strategy Focus on gender rights and equity is established in social policies Health policies incorporate principles of equity, solidarity, universality, and comprehensiveness 3 World financial crisis Climate change and environmental events Migration Regional and global epidemiological events

4. Conclusions of the National Technical Team Persistent slow and prolonged epidemiological transition High levels of social exclusion in health due basically to socioeconomic factors The system is fragmented and centralized, with little coordination, and is financed mainly by out-of-pocket expenditure, especially for drugs Structure and action taken have not had an impact in the medium term despite the substantial increase in resources It is necessary to make the system less fragmented, and to generate synergies and networks to improve performance, effectiveness, and efficiency Strengthening the current model by injecting more resources only leads to increased frustration We should address urgent problems with intelligent action but at the same time plan for the medium and long term 4

5. Change should be guided by general strategies such as: - Reforms based on primary health care - Building networks based on strengthened services - Policy on access to drugs - Policy on human resources development - Strengthening of epidemiological surveillance - Modernization of structure, administration, and management - Intersectoral coordination/partnerships - Social participation and focus on social territories - Decentralization These general strategies should gradually provide comprehensive and universal attention to priority public health problems and health care needs 5 Conclusions of the National Technical Team

6. Public Policies on: Quality of life and health with equity in Paraguay

7. 7 We CAN live longer and better in a country that promotes social justice with respect to the quality of life and health, that guarantees the rights of the people and protects life through the State’s responsibility to build a National Public Health System for all throughout the country with citizen participation. 7

8. 8 Political Philosophy Universality of the right to health and other human and social rights. Integrated responses to social needs. Equity as a principle of justice so that everyone can enjoy the highest attainable standard of health and quality of life, with social and economic security. Participation of communities and all citizens as a factor in the democratization and transparency of the State and the guarantee of rights. 8

9. Factors to Consider in a New Approach to Public Health in Paraguay Human rights approach in health Progressive, ongoing, and sustainable application Application of the current legal framework Articulation, coordination, and complementarity of actions and resources of the National Health System Programs to promote health and quality of life Organization of care networks Universalization of primary health care Decentralization, territories for social action and citizen participation 9

10. Factor to Consider for Policy Implementation Internal and external factors: Financing and budgetary feasibility Technical feasibility and productive capacity Political feasibility State policies Governance and other political aspects The health debate and its ideological aspects Regulatory and legal aspects Other 10

11. Stages for Action 11 200820092010201120122013 Q1Q1 Q2Q2 Q3Q3 Q4Q4 Q1Q1 Q2Q2 Q3Q3 Q4Q4 Q1Q1 Q2Q2 Q3Q3 Q4Q4 Q1Q1 Q2Q2 Q3Q3 Q4Q4 Q1Q1 Q2Q2 Q3Q3 Q4Q4 Q1Q1 Q2Q2 Q3Q3 Q4Q4 Contingency: Health Center Plan Improvements and innovations Beginning of structural reform

12. Gradually and steadily moving towards universal comprehensive care. Stage 1 A proposal

13. Objectives  Implement a series of immediate actions that address the most important aspects of priority public health problems  Begin preparations for the introduction of substantial improvements and innovations  Create a working group for results-based management  Build political sustainability for the development of the health plan at least through 2013 13

14. 1.High levels of social exclusion and out-of- pocket expenditure 2.Heavy health, social, and economic burden due to preventable diseases 3.Poor-quality services 4.Fragmentation, centralization, bureaucracy, and little transparency 14 Priority Problems

15. ACTIONS - 1 High levels of social exclusion and out-of-pocket expenditure Progressive elimination of tariffs and restructuring of financing Increased access to drugs with strengthening in four specialties of urgent care Increase in budgetary execution Greater efficiency and transparency Care for the indigenous population Prevention of cervical and breast cancer Street children Rural settlements Basic sanitation in selected districts Drinking water in selected districts Mental health and human rights Heavy social and health burden due to preventable diseases Substantial increase in the coverage of the Expanded Program on Immunization Prevention and mitigation of dengue and yellow fever through vector control and implementation of the Integrated Management Strategy Intersectoral coordination for priority programs Healthy schools Road safety 15

16. ACTIONS - 2 Poor-quality services Implementation of primary health care units New hospital projects Funding for organ transplants Greater availability of intensive care units Upgrading of teams/equipment in strategic hospitals Fragmentation, centralization, bureaucracy, and little transparency Simplification of processes Restructuring of the General Bureau of Administration and Finance (DGAF) Restructuring of the General Bureau of Human Resources in Health (DGRRHH) Creation of the General Bureau for Management of Strategic Inputs Audit Transparency and accountability Master plan: 310/350/530 Creation of the Decentralization Fund Amendments to agreements and conditioned transfer Local and Regional Plans with goals Creation of the National Technical Board Integration of new councils Activation of National Health Accounts 16

17. Gradually and steadily moving towards universal comprehensive care. Stage 2 A proposal

18. 18 Priority Problems High levels of social exclusion and high household expenditure for accessing health services, which especially affects poor and vulnerable populations. Significant deterioration in the health of the population due to preventable diseases, communicable diseases, chronic noncommunicable diseases, epidemics, and external injuries. Fragmentation, centralization, high levels of bureaucracy, and little transparency. Poor performance in intermediate results (efficiency, effectiveness, access, use, and quality)

19. Objectives  Increase availability and coverage of services throughout the life cycle  Increase access to services and use and quality of services  Reduce out-of-pocket expenditure  Bridge the exclusion gap  Increase efficiency and transparency of the Ministry of Public Health 19

20. Strategic Lines of Action 1.Renewal of the Primary Health Care Strategy in Paraguay with development and coordination of a network of accessible, quality services. 2.Strengthening the leadership of the Ministry of Public Health and the National Health System 3.Development and management of human resources in health 4.Intersectoral coordination, governance, and social participation 5.Development of the Health Information System 6. Social and environmental determinants of health 7. Drinking water and basic sanitation. 20

21. Gradually and steadily moving towards universal comprehensive care. Stage 3 A proposal

22. Objectives Coordinate a social, political, and economic pact for the reforms, guaranteeing the right to health based on explicit guarantees that consolidate a rights-based National Health System to ensure universal comprehensive care to an integrated package of services with social equity Set up legal and regulatory mechanisms that ensure and regulate implementation of the guaranteed benefits Set up a funding model that consolidates a National Health Fund Exercise stronger and more effective leadership, regulation, and control of the system, as well as public/public and public/private coordination and interinstitutional strategic partnerships Design and implement a model of care for regulated public services Consolidate primary health care as the core strategy of the sectoral reforms Set up mechanisms for ongoing quality improvement 22

23. F1F2Fn National Health Fund Lifestyles Epidemics Preventable diseases Primary health care Promotion and Prevention Prevalent diseases Specialized Catastrophic Primary health care Comprehensive care Explicit guarantees Social, Economic, and Political Pact for the Reforms: Legal and Financial Regulatory Regulation and Leadership UNIVERSAL COMPREHENSIVE CARE: GRADUALLY AND STEADILY With how much? What? How? 23 Public/Private coordination Strengthening and development of a public services network Community

24. 24 Priority problems High levels of social exclusion and out-of-pocket expenditure.. Significant deterioration in the health of the population due to preventable events, communicable diseases, chronic noncommunicable diseases, and external injuries, including high rates of maternal and child mortality. Fragmentation, centralization, poor quality of bureaucracy and transparency in the public subsystem. Strategic objectives Bridge the social exclusion gap in health, guaranteeing the right to health as a human right that includes health care, well-being, and citizen participation. Reduce the health, social, and economic burden of communicable and noncommunicable diseases, malnutrition, and external injuries, comprehensively addressing health needs throughout the life cycle. Coordinate and consolidate the National Health System in care networks. Strategic lines of action Renewal of the primary health care strategy with the development of a network of accessible and quality services. Strengthening the leadership of the Ministry of Public Health and the National Health System. Development and management of human resources in health. Intersectoral coordination, governance, and social participation Development of the Health Information System. Social and environmental determinants of health. Drinking water and basic sanitation. Funding General budget for expenditures approved by the National Congress. Contributions of subnational governments. International cooperation. Special fund projects. Formal instruments National Constitution, current laws, agreements, and international commitments. Decrees and resolutions. National Health Plan, National Policy for Human Resources Development in Health, National Policy on Access to Essential Drugs Agreements on decentralization in health; agreement with the Social Security Institute (IPS); agreement with the University of Asuncion Medical School (FCM); agreements with the private sector, cooperation agencies, and civil society organizations; strategic partnerships with the Ministry of Education and Culture, Ministry of Public Works and Communications, Public Functions Secretariat, Secretariat on Childhood, Secretariat for Women, Secretariat for Youth, Environmental Secretariat, and other government agencies. Consensus-building for the development of a parliamentary agenda for the health sector. Principles Universality of the right to health and other human and social rights. Comprehensive responses to social needs. Equity as a principle of justice so that all people can enjoy the highest attainable standards of health and quality of life, with social and economic security. Participation of communities and all citizens as a factor in democratization and the transparency of the State and a guarantee of rights. Stages of action Stage 1: 2008-2009: Contingency Health Plan Stage 2: 2009-2011: Plan for Substantial Improvements and Innovations Stage 3: 2011-2013: Plan for Structural Reforms

25. Tesai Ñembyaty - United for Health Progress and Challenges in Paraguay August 2008 – August 2009 4/14/201525

26. Meetings with Health Councils 1.Introduction: The Context and the Situation 2.New health policies in Paraguay: Decentralization, a strategy based on the principles of equity and universal comprehensive care 3.What are the main contributions of decentralization? 4.Immediate progress and challenges in decentralization 4/14/201526

27. Principal Approaches Human rights approach Gradual and sustainable application Articulation, coordination, and complementarity of actions and resources of the National Health System Organization of care networks Universalization of primary health care Decentralization, territories for social action and citizen participation Modernization of management Transparency Human resources development 274/14/2015

28. Principal Achievements in 15 Months Development of the information system with funding for a strategic five- year plan. Development of a modernization plan for management with funding for five years. Implementation of a system for accountability. Public and private coordination. Restoration of citizen trust. Development of a logistics system for strategic inputs. Creation of the Equity in Health Fund. Creation of 130 Health Councils to execute local and regional plans Creation of 150 Family Care Units. Improved epidemiological surveillance and adequate response to epidemics. 28

29. Principal Lessons Learned Lead the health debate Unify the language and concepts Develop a holistic view Consolidate a working team Weave a network of partners Good communications system Synchronize with financial processes Develop formal instruments Position the health agenda on the social policy agenda Ensure participation of the Ministry of Finance Governance Development of human resources in health 29

30. Immediate Actions to Address Challenges Facing Integrated Services Networks Define social territories for action Organize territories into a services and regulatory network Integrate vertical programs into health services Advance toward strengthening the health system Establish a policy to develop human resources in health Synchronize with social and economic policies Hold workshops on regional definitions for results-based management Diabetes, cardiovascular diseases, TB, HIV, dengue, yellow fever, etc. Leadership, coordination, National Health Fund, logistics and information system Management based on primary health care 30

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