2. Integrated Health Service Delivery Networks (IHSDNs) Dr Malhi Cho Advisor HSS Venezuela, Aruba, Curazao, Sint Maarten and Netherland Caribbean Islands June 3 rd 2015

3. Overview Two visions of Health Systems The crisis of the current Health Care System IHSDNs (The response) o Integrated People Centered Care o Building an IHSDNs Systems Thinking for Health Systems Strengthening

4. Health System Bio-Medical ModelPHC – Based System VALUES Health as a privilege, a commodity or act of compassion Health as a Human Right Equity Solidarity FOCUS Patients/sick individualsPeople, Families, Communities GOVERNANCE Doctor - Patient Multiple involvement NHA/MoH leadership FINANCING Payment to providers (fee-for- service) Profit oriented Affordable Universal Access to health and Universal Health Coverage Social Protection in Health PROVISION OF SERVICES Acute, Episodic, Curative care Comprehensive integrated and continues Health care and Social Services DEVELOPMENT OF RESOURCES Physicians, Nurses and other professions akin to curative care Technology as a business tool Wide range of professions and competencies Rational use of technology SYSTEMS’ APPROACH LinearAdaptive System

5. Fragmentation of Healthcare Delivery Services Social Security Private Practice (High Technology) Other Providers Private Non-profit (NGOs) Local Govs Universities HIV-AIDS Malaria & Others Maternal-Child Health Ministry of Health Traditional Medicine

6. Fragmentation of Healthcare Delivery Services

7. The Current Health System Centered on acute, episodic care Supply driven and organized by levels that fragment care Hospital-based and dependent on costly technologies and specialist care Provision of curative services through fragmented process of care Lack of continuity, poor quality and safety Inefficient referral systems Generator of exclusion and dissatisfaction

8. The patient “vanishes” The patient “shows up” The patient is “treated” The patient is discharged The current health system and the radar phenomenon

9. Are we prepared for give responses to the need of people? “People with chronic conditions attempt to obtain continuous care in a systems where healthcare services and financial mechanisms are oriented to the delivery of episodic care”. Jesús María Fernández Dep. de Sanidad y Consumo Basque Country, Spain.

10. Gerard Anderson, Analysis of the Medical Expenditure Panel Survey, 2004.

11. Source:Medicare Standard Analytic File,2004

12. Integrated Health Service Delivery Networks (IHSDNs)

13. Integrated Health Services Delivery Networks Mandates, Context and Justification Resolution CD49.R22 (September, 2009) “Recognizing that integrated health services delivery networks are one of the principal operational expressions of the PHC approach in health service delivery, helping to make several of its essential elements a reality, namely universal coverage and access; the first contact; comprehensive care; appropriate health care; optimal organization and management; and intersectoral action… “ “…integrated health services delivery networks increase access to the system, reduce inappropriate care and the fragmentation of care, prevent the duplication of infrastructure and services, lower production costs, and better meet the needs and expectations of individuals, families, and communities…”

14. Systems Benefits of IHSDNs Improved accessibility; reduced fragmented care; improved overall efficiency; less duplication of services and infrastructure; more effective response to people’s needs and expectations; reduced production cost and increased cost-effectiveness; decrease in unnecessary hospital admissions; reductions in excessive utilization of diagnostic test; improvement in economy of scales; improved balance between specialist and generalist; better performance of total operating margins, cash flows and net income. Dowling, W.L. (1999). Hospitals and health systems. In: Introduction to health services. Williams, S.J.; Torrens, P.R., Editors. 5th ed. Delmar Publishers, An International Thomson Publishing Company. 43 Wan, T.T.H.; Lin, B.Y.; Ma, A. (2002). Integration mechanisms and hospital efficiency in integrated health care delivery systems. Journal of Medical Systems, 26: 127-143. 44 Lee, S.D.; Alexander, J.A.; Bazzoli, J. (2003). Whom do they serve? Community responsiveness among hospitals affiliated with systems and networks. Medical Care, 41: 165-174. 45 Aletras, V.; Jones, A.; Sheldon, T.A. (1997). Economies of scale and scope. In: Ferguson, B.; Sheldon, T.A; Posnett, J. Concentration and choice in health care. London: Financial Times Healthcare. 46 Soler, J.L.P (2003). Estrategia de gestion y organizacion de una red de laboratorios de diferentes hospitales publicos. Bogota, Primer Forum Internacional de Redes de Servicios y Ordenamiento Territorial en Salud. Secretaria de Salud de Bogota/Organizacion Panamericana de la Salud. 47 Dowling, W.L. (1999). Hospitals and health systems. In: Introduction to health services. Williams, S.J.; Torrens, P.R., Editors. 5th ed. Delmar Publishers, An International Thomson Publishing Company. 48 Shortell, S.M.; Gillies, R.R.; Anderson, D.A. (1994). The new world of managed care: creating organized delivery systems. Health Affairs, Vol. 13, Issue 5: 46- 64.

15. Clinical Benefits of IHSDNs Continuity of care is associated with improvements in clinical effectiveness, responsiveness, acceptability and efficiency; increased perception of effectiveness (healthcare managers and providers); improve timely access to First Level of Care and other levels when required; less unnecessary repetition of history-taking, diagnostic procedures, and bureaucracy; improved shared decision- making processes between provider and patient and facilitate the implementation of self-care strategies and chronic disease monitoring. Christakis, D.A.; Mell, L.; Koepsell, T.D.; Zummerman, F.J.; Connel, F.A. (2001). Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics 2001;107(3):524-29. 50 Hjordahl, P.; Laerum, E. (1992). Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;304(6837):1287-90. 51 Parchman, M.L.; Pugh, J.A.; Noel, P.H.; Larme, A.C. (1992). Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes. Med Care 2002;40(2):137-44. 52 Ham, Ch (2007). Clinically Integrated Systems: The next step in English health reform? Briefing Paper. The Nuffield Trust. 53 WHO European Office for Integrated Health Care Services (2001). Workshop on Integrated Care. Barcelona, WHO Integrated Care Meeting. Lloyd, J.; Wait, S. Integrated Care: A guide for policy makers. London: Alliance for Health and the Future. 55 Gillies, R.R.; Shortell, S.M.; Anderson, D.A.; Mitchell, J.B.; Morgan, K.L. (1993). Conceptualizing and measuring integration: findings from the health systems integration study. Hospital & Health Services Administration 1993; 38(4):467-89. 56 Hartz, Z.M.A.; Contandriopoulos, A.P. Integralidade da atenc ̧ a ̃ o e integrac ̧ a ̃ o de servic ̧ os de saude: desafios para avaliar a implantac ̧ a ̃ o de um “sistema sem muros”. Cadernos de Saude Publica 2004;20 Sup 2:S331-S336. 57 Gillies, R.R.; Shortell, S.M.; Anderson, D.A.; Mitchell, J.B.; Morgan, K.L. (1993). Conceptualizing and measuring integration: findings from the health systems integration study. Hospital & Health Services Administration 1993;38(4):467-89.

16. Integrated Health Service Delivery Networks (IHSDNs)

18. Progress in Country Implementation Countries with on-going reforms based on PAHO’s IHSDNs framework: o Brazil Ordinance 4.279 (2010) on organization of IHSDNs in the SUS Ordinance 7.508 (2011) on integration and coordination of care between states (Federal Regulation) National consultation on a new policy for Hospital Care (2012) The experience of Minas Gerais o Chile The experiences in Ñuble and the Western Metropolitan Regions o Colombia New legislation (Act 1438 of January 19, 2011) o El Salvador National Health Policy (“Building Hope”) o New Model of Care (People Centred integrated care) o Strengthening of the First Level of Care (ECOS) Intersectorial Health Commission o Others: Panamá, Perú, Paraguay, Uruguay, Trinidad and Tobago o Regional Level: PHC Collaborative Network Guidelines for implementation of IHSDNs Development of a Regional Agenda for Hospitals in IHSDNs Countries with on-going reforms based on PAHO’s IHSDNs framework: o Brazil Ordinance 4.279 (2010) on organization of IHSDNs in the SUS Ordinance 7.508 (2011) on integration and coordination of care between states (Federal Regulation) National consultation on a new policy for Hospital Care (2012) The experience of Minas Gerais o Chile The experiences in Ñuble and the Western Metropolitan Regions o Colombia New legislation (Act 1438 of January 19, 2011) o El Salvador National Health Policy (“Building Hope”) o New Model of Care (People Centred integrated care) o Strengthening of the First Level of Care (ECOS) Intersectorial Health Commission o Others: Panamá, Perú, Paraguay, Uruguay, Trinidad and Tobago o Regional Level: PHC Collaborative Network Guidelines for implementation of IHSDNs Development of a Regional Agenda for Hospitals in IHSDNs

20. Global Trends in Health Systems and Healthcare Delivery Título de la presentación

21. ORGANIZATION Strong resurgence of Primary Health Care (PHC) values and principles The demand for health services to provide integrated, coordinated and continuous care The First Level of Care (Primary Care) “in the drivers seat”FINANCING To provide more with the same or less resources Financial allocation linked to performance Increased accountability New ways of paying providers Push toward Universal Access of Health and Universal Coverage of Health and Social Protection

22. QUALITY People at the center of care Evidence based medicine Patient and Provider SafetyMANAGEMENT Professionalization More accountability Assignment /contracting based on competencies Results Based ManagementINNOVATIONS New modalities of delivery The technological revolution and the impact on healthcare cost New approaches to old problems…and new problems require creative approaches

23. Integrated People Centered Care “ the management and delivery of health services such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health systems, and according to their needs throughout the life course ” PAHO, 2010

24. Right to the highest attainable level of health Equity Solidarity Responsiveness to peoples’ health needs Quality-oriented Government accountability Social justice Sustainability Participation Intersectoriality First Contact Comprehensive, integrated and continuing care Family and community based Emphasis on promotion and prevention Appropriate care Active participation mechanisms Sound policy, legal & institutional framework Pro-equity policies & programs Optimal organization & management Appropriate human resources Adequate and Sustainable resources Intersectorial actions Universal coverage and access Systems Thinking in Building PHC-Based Systems

25. Thank you.