1. Integration of Systems and Services Operational Experience, MSPAS/IGSS Escuintla, Guatemala

2. Background 1989 pilot plan by Social Security Institute (IGSS) to expand coverage based on the Primary Health Care Strategy. MSPAS 1996 Expansion of Coverage and improved quality of basic health care services.

3. Expansion of Coverage Strategy to Expand Coverage: Proposed as one of the key elements of the Sectoral Reform. Contracts with NGOs for the delivery of basic health services, as well as administration of resources still allocated on the basis of national per capita.

4. Local Characteristics High proportion of the population are direct recipients or beneficiaries of Social Security Both institutions have extensive network of services Systematic coordination of the Departmental Bureaus since 1996 Commitment to the Puerto de San José Pact

5. Response Proposal to formalize the coordinated work developed in both institutions Proposal to develop the institutional strategy by both institutions Selection of a local administrative/ financing entity

6. Process Beginning of political negotiation process for both institutions (1 year) Harmonization of regulations with the technical authorities of both institutions (1 year) Develop the local validation process Raising awareness of the work teams

7. Process Selection and hiring of personnel. Development a uniform induction process. Development of a systematic horizontal training process. Joint care process begins with the signing of the agreement.

8. Key Elements of the Model Orientation of Financing Regulation Control

9. Progress Provision System: –Portfolio of Services 1.Reproductive Health Care 2.Pediatric Care 3.Management of Prevalent Diseases 4.Environmental Management

10. Progress Management System: –Annual Operating Plan –Resource management in the service network –Health surveillance and risk management –Development of joint promotion strategies –Monitoring, supervision, and evaluation

11. Progress Regulation System: - Vaccination - Acute respiratory diseases - Acute diarrheal diseases - Tuberculosis - Epidemiological surveillance - Vectors and the environment

12. Progress Information system: - Weekly, monthly, and bimonthly reporting.

13. Lessons learned The universal provision at first-level of care in the department improved equity Institutional conditions need to be favorable Continuing need for negotiation and lobbying, especially in times of political transition

14. Lessons learned The model needs a legal foundation. It should not be replicated except under optimal operative, technical, and political conditions. The involvement of operative personnel improves the likelihood of the model’s success.

15. Lessons learned A continuous feedback process must be developed Positive reinforcement processes Information generated locally must be analyzed at the local level There are no single solutions

16. Weaknesses Little understanding of the model at the technical and political levels. Continued human resource education with a curative, hospital-centered, biological approach. Centering the model’s promotion activities exclusively on provider institutions did not facilitate expansion to other sectors.

17. Weaknesses Scarce information on the model’s operation disseminated to the local, institutional, and national levels. The strategy for expanding coverage and the basic package of services does not recognize the value of promotion and educational activities. Model did not extend to the other levels of care.

18. Weaknesses Social Security Information System only partially developed and solely to evaluate production

19. Challenges Break with the notion that the first level of care is the same as PHC Use the local epidemiological profile to develop and define the service portfolios Influence decisionmakers to ensure the sustainability of the model

20. THANK YOU