1. Building the Foundations for Better Health Health Services Organization

2. Policy Options for the Integration of Health Systems and Services VII REGIONAL FORUM Strengthening of Health Systems Based on Primary Health Care (PHC) Quito, Ecuador 29-31 October 2007

3. Health Systems Based on Primary Health Care Right to Health Equity Solidarity Capacity to respond to health needs Focus on quality Responsibility and accountability Social justice Sustainability Participation Intersectoral approach First contact Comprehensive, Integrated, and continuous care Family and community orientation Emphasis on promotion and prevention Appropriate care Mechanisms for active participation Acceptable legal, policy, and institutional framework Pro-equity policies and programs Optimal organization and management Adequate human resources Resources adapted to needs Intersectoral action Universal coverage

4. Health Services  The greatest challenge in terms of the organization and delivery of health services is fragmentation.

5. Policy Options for the Integration of Health Systems and Services  Starting Point …  Segmentation of health systems and fragmentation of health services  Pressures on health systems  Shortcomings of care and organizational models  Progress worldwide and in countries of the Region

6. Fragmentation Problems  Quality of Care and Results  Lack of continuity in care  Lack of coordination between the first level and specialized levels of care  Many practices and interventions are not evidence-based  Wide variety of clinical practices  No incentives for health promotion  Costs  Inefficient management of resources - Duplication (services, procedures, diagnostic tests, etc.)  Lack of incentives for quality. Disparity between levels of care

7. Policy Options for the Integration of Health Systems and Services  The Tower of Babel? :  Networks: “ Not all networks are integrated networks”  Coordination – Integration  Segmentation and Fragmentation  Primary health care (PHC) vs. primary care or first-level of care  Public health and public health services

9. What does the project aim to contribute? Policy Options for the Integration of Health Systems and Services

10.  Key questions: 1.What is the most appropriate response to the fragmentation of health services and the problems that it creates? 2.What defines an Integrated Health Services Network? 3.How can we measure the extent of health services integration? 4.How can we address the organization of integrated networks? Policy Options for the Integration of Health Systems and Services

11.  Integrated Delivery Systems (IDS): “An integrated system is a network of organizations that provides, or is organized to provide, ongoing and coordinated services to a particular population, and that takes responsibility for the clinical and financial results and the health outcomes of the population it serves. These systems, widely participatory and vertically integrated, offer a wide range of outpatient and in-patient services, care for acute and chronic illness, and home care.” (Shortell et al.) Definitions:

12. Additional elements:  Based on the Primary Health Care Strategy and coordinated from the first level of care  With geographic responsibility  Integrated vertically and coordinated horizontally  Also integrates public health services

13. Policy Options for the Integration of Health Systems and Services 1. An expanded definition: Integrated Systems of Health Services: “A network of organizations that provides, or is organized to provide, ongoing services based on primary health care and coordinated from the first level to a particular population in a particular territory, and that is accountable for the clinical and financial results and the health status of the population it serves. These systems, widely participatory, vertically integrated, and horizontally coordinated, offer a wide range of services to address the ongoing needs of their users, from promotion and prevention to outpatient and in-patient services, care for acute and chronic illnesses, home care, rehabilitation, palliative care, and public health services. ”

14. Policy Options for the Integration of Health Systems and Services 2.Attributes of integrated networks:  Reference population is in a defined area  Support systems are organized  Health needs and priorities  Scope of services  Distribution of roles  Integrated and coordinated care model  Measurement of the impact of services

15. Policy Options for the Integration of Health Systems and Services 3.Strategic and operational attributes for measuring integration:  Governance  Financial mechanisms  Management of the network  Computer support systems  Integration mechanisms  Identification of health needs  Care model  Intersectoral action  Monitoring and evaluation model  62 Operational Attributes

16. Evaluation of the Health Services Network Strategic Attributes Operational Attributes Degree of Compliance Governance Is there a single government structure? Does it have a Mission and Vision Statement geared to network integration and management? Does it have clearly established structures that differentiate between management of the network and the coordination of care? Is there user representation with at least an advisory role in the governance structure? Financial Mechanisms Sufficient and available financing Multiple contracts for the purchase of services, single or integrated financing of insurance Financing mechanisms: Capitation, annual budget Does it have a defined financial management system? Existence of financial incentives and an organizational structure that aligns government, management, medical entities, and other providers in order to achieve the objectives. Availability of information on costs, quality, results, and satisfaction for the different segments—users, employees, funders, and society Existence of incentives to keep people healthy that reward promotion and prevention activities?

17. Policy Options for the Integration of Health Systems and Services 4.Policy options for integration:  Options for governance:  Legal security for organization in an integrated network  Legal structure and framework for governance  Financing, payment mechanisms, incentives, financial protection for the population  Options for financing:  Capitation  New payment mechanisms for providers  Incentives

18. Policy Options for the Integration of Health Systems and Services  Insurance policies and protection of the population  Policies for the procurement of services  Public providers  Private providers Public-private participation (legal framework)  Policies for the organization of services  Care model  Vertical integration and horizontal coordination

19. Policy Options for the Integration of Health Systems and Services  Policies for the generation and use of resources:  Human resources policies Education Training Substitution Continuing education  Evaluation and introduction of technologies

20. Policy Options for the Integration of Health Systems and Services 5.Phases in the configuration of integrated health services systems 1.Situation analysis of health care and population-based health networks 2.Definition of the care model 3.Delimitation of health areas and levels of care 4.Design of services network 5.Configuration of the first level of care 6.Configuration of the second and third levels of care 7.Configuration of support services and logistical systems 8.Vertical integration of the services network 9.Configuration of the governance model 10.Design of monitoring and evaluation systems.

21. Success Factors 1.Align the delivery network with community needs 2.Strengthen primary health care and the first level of care 3.Strengthen and integrate the information system 4.Provide relevant information on costs, quality, and clinical results 5.Adopt a culture of shared risk 6.Align suppliers, managers, and government structures.

22. Health Systems Based on PHC Right to Health Equity Solidarity Capacity to respond to health needs Focus on quality Responsibility and accountability Social justice Sustainability Participation Intersectoral approach First contact Comprehensive, integrated, and continuous care Family and community orientation Emphasis on promotion and prevention Appropriate care Mechanisms for active participation Acceptable legal, policy, and institutional framework Pro-equity policies and Programs Optimal organization and management Adequate human resources Resources adapted to needs Intersectoral action Universal coverage

23. Health Systems Based on PHC : Comprehensive Health Services Systems HOSPITAL DAY HOSPITALS CENTERS THAT PROVIDE NURSING CARE HOME CARE SPECIALIZED CARE CENTERS Primary Care Teams Taken from Mendes V., Eugenio

24. Health Services Organization Integrated Hospitals and Health Services Systems Building the Foundation for Better Health Dr. Reynaldo Holder Regional Adviser holderre@paho.org