1. Experiences and Lessons Learned from the Region of the Americas: Case Studies Regional Consultation Meeting: Integrated Health Services Networks and Vertical Programs Cusco, Peru 11 and 12 November 2009 Hernán Montenegro and Caroline Ramagem Area of Health Systems and Services PAHO/WHO

2. Content Background Summary of case studies Lessons learned Facilitating factors and barriers Future PAHO work

3. Why Integrate Service Networks and V ertical P rograms? Health Services Fragmentation Poor performance of health services Access problems Poor technical quality of services Inefficient use of resources Increased production costs Low levels of user satisfaction Other causes of poor system performance (For example, insufficient financing, weak governance of the health authority, lack of qualified human resources, etc.)

4. Integration Initiatives in LAC CountryInitiative ArgentinaLaw creating the Integrated Federal Health System BoliviaMunicipal Intercultural Family and Community Health Networks and Network of Services BrazilBetter Health: The Right of All 2008-2011 ChileHealth Care Networks Based on Primary Care El SalvadorLaw creating the National Health System GuatemalaCoordinated Health Care Model MexicoFunctional Integration of the Health System PeruGuidelines for forming networks Dominican RepublicRegional Health Services Network Model Trinidad and TobagoExperience of the Eastern Regional Health Authority UruguayIntegrated National Health System VenezuelaHealth Network of the Metropolitan District of Caracas

5. Progress of PAHO Technical Cooperation on Services Integration Degree of ProgressIntegrated Health Services Networks Integration of Vertical Programs * Review of literature and case studies ++++ Preparation of analytical framework, including definitions +++ Position paper++ Resolution of PAHO/WHO Governing Body +++ Implementation strategy +++ Regional technical cooperation platform + *Link with Global Health Initiatives.

6. Summary of Case Studies Lima Workshop, 9 November 2009 CountryType of Case Integrated health services networks (2 topical + 3 general = 5) Integration of vertical programs (6) Brazil Care for women and children: “Mãe Curitibana” (Curitiba, Paraná) Urgent/emergency care (Northern Macroregion, Minas Gerais) HIV/AIDS (National) Chile Ñuble Health Service Metropolitan Health Services Children: “Chile Grows With You” (National) Guatemala Ministry of Public Health and Social Welfare and Guatemalan Social Security Institute (Department of Escuintla) Colombia Tuberculosis (National) Peru HIV/AIDS (National) Dominican Republic HIV/AIDS (National) Trinidad and Tobago HIV/AIDS (National)

7. Some General Observations On cases: - Diversity of experiences reflect the regional reality - Of the 11 cases: 4-5 cases: exemplify fragmentation or have had little success in terms of integration, including sustainability 6 cases: varied success in terms of integration and improvements in access, quality, efficiency, social participation, and impact on health* On the dynamic of the discussion: - Issue that arouses passions - Positions were identified - Confusion in managing basic concepts of integration (what is understood as a vertical program)

8. Framework to Analyze the Implementation of Health Policies ContentsProcesses Context Actors As individuals As members of groups Walt and Gibson (1994)

9. Lessons Learned Context: Diversity of contexts Most successful experiences - framework of broad health services reforms consistent with integration Evaluate the consistency of the legal and administrative framework with integration efforts Most successful experiences in countries that already have strong health systems Content: People-centered solutions adapted to local conditions and consistent among themselves Clarity of objectives and roles 1st level of care: multidisciplinary with family/community orientation Assistance, managerial, and institutional coordination Results-based management Use of the intersectoral approach Processes: Gradual development of processes Vision of a long-term stable policy Ensure early demonstration successes High levels of commitment and strong leadership Transparency of processes Actors: Measures that promote mutual trust and knowledge (opportunities for dialogue) Cultivate commitment and a sense of belonging Close the gap between policymakers, managers, clinicians, and researchers Citizen participation: self-care; social control

10. Facilitating Factors and Barriers Facilitators: Political commitment and backing Availability of financial resources Leadership of health authorities and service managers Decentralization and flexibility of local management Alignment of financial and nonfinancial incentives Culture of collaboration and teamwork Active participation of stakeholders Structural barriers: Segmentation and weakness of health systems Reforms of the 1980s and 1990s: –Privatization of insurance –Differentiated service portfolios –Provider competition –Diversification and instability of labor regimes –Regressive cost-recovery schemes Powerful opposing Interest groups: –Specialists and super-specialists* –Private insurers and social security –Pharmaceutical industry, supply industry, etc. External financing modalities ( Global Health Initiatives ) Nonstructural barriers: Deficiencies in information, monitoring, and evaluation systems* Management weaknesses

12. Future Work for PAHO Integrated Health Services Networks: –Consolidate work on integrated health services networks Integration of Vertical Programs: –Produce a position paper that addresses: Definitions and analytical framework Indications for vertical programs, being the exception Strategy for integrating programs into health systems –Develop technical cooperation that provides: Instruments Direct technical assistance Educational programs Research