Cobertura universal de salud Elementos conceptuales, origen y vistazo de la situación en la Región Cristian Morales Asesor Regional Financiamiento y Economía de la Salud, HSS/HS (moralesc@paho.org)

Introducción: ¿Qué es cobertura universal de salud? World Health Organization 17 April 2017 Introducción: ¿Qué es cobertura universal de salud? Es el objetivo que orienta la transformación de los sistemas de salud para que todas las personas y las comunidades tengan acceso equitativo a los servicios integrales, garantizados y exigibles que necesitan, a lo largo de su curso de vida, con calidad y sin dificultades financieras. La La cobertura universal de salud refuerza la necesidad de definir y ejecutar políticas e intervenciones para abordar intersectorialmente los determinantes sociales de la salud, y fomentar el compromiso de toda la sociedad para promover la salud y el bienestar; con énfasis en los grupos en situación de pobreza y vulnerabilidad. Valores Derecho a la salud Equidad Solidaridad Aborda los determinantes sociales de la salud, hace énfasis en los grupos en situación de pobreza y vulnerabilidad.

Cobertura poblacional Cobertura de servicios Marco analítico de la cobertura universal para catalizar la transformación de los sistemas de salud Compromiso políticos con el Derecho a la Salud y la cobertura universal Marco jurídico Políticas, planes y estrategias Prioridad fiscal SIS para monitorear la cobertura universal Factores habilitantes Enfoque intersectorial y acción sobre los DSS Dialogo social y participación social Capacidad regulatoria Eficiencia Cobertura poblacional Cobertura de servicios Cobertura de costos Modelos de atención centrados en las personas y basados en APS con RHS preparados y motivados

Reformas basadas en atención Atención Primaria de Salud Antecedentes: De la atención primaria de salud hacia la cobertura universal de salud Reformas basadas en atención primaria de salud ISM 2008 Atención Primaria de Salud Renovada 2005 Alma Ata 1978

El estado de avance de la cobertura universal de salud: Como medirla? Desafíos: Medidas simultanea pero separadas de c población con servicios de salud esenciales y c población con protección financiera. Medida de servicios integrales Medidas de protección financiera a todos los niveles del sistema de salud ya que pueden variar grandemente Medidas para todos los países (no como los ODM) Medidas desagregadas por estrato socio demográfico, sexo, etc. Sin embargo, cada país deberá definir su camino y ritmo, teniendo en cuenta su contexto social, económico, político, legal, histórico y cultural.

El punto de partida: La lucha contra la desigualdad y las inequidades! Disparidades en los resultados de salud Profundas desigualdades en la distribucion del ingreso

La nueva complejidad

World Health Organization 17 April 2017 11% 37% 3% Fuente: WB, 2012

4.5Millions TOTAL DE MUERTES X Enf Crónicas en 2009 Constituyen la 1a causa de mortalidad y siguen en aumento 149 millones de fumadores 30-40% de 25-64 son hipertensos 25% personas 15+ son obesas 37% de las muertes fueron en menores de 70 años Mas de 250 millones de personas que viven con enf crónicas Son multifactoriales e implican diversos sectores Buenas noticias: se puede retrasar su aparición / disminuir su prevalencia No tan buenas noticias: implementar intervenciones preventivas constituye un gran desafío TOTAL DE MUERTES X Enf Crónicas en 2009 4.5Millions Fuente: The NCD Alliance. The Global Burden of NCDs, 2011l; Institute for Health Metrics and Evaluation. Financing Global Health 2010, Development Assistance and Country Spending in Economic Uncertainty, Seatle, WA, IHME, 2010

Enf crónicas NT reproducen también las inequidades Mortalidad por tipo de cáncer e ingreso país * NCDs and poverty create a vicious circle. Poverty exposes people to risks factors for NCDs. In turn, the resulting NCDs may drive families into poverty. In this way, the NCD epidemic delay the development of countries. Some evidence shows that NCDs and their risk factors are distributed unevenly and are a potential economic burden for the poor. They affect the poor more heavily with a catastrophic impact on their finances and their families, as well as on governments. This is due to the costs of treatment and the loss of potential years of life and productivity caused by premature death and disability. These conditions counteract the countries’ efforts to combat poverty, further increasing health inequalities. The opportunity to survive from NCDs, and in particular cancer, should not be related to income but it is, as we can see on the graph. * Presented at the Global Health Council 38th Annual Conference 2011.

La situación de la Cobertura Poblacional Argentina: Plan nacer,… Brasil: SUS Uruguay: SIS/Fonasa México: Seguro Popular EEUU: Affordable care act (Obama care) Ecuador: Reforma de Sistema de salud Chile: GES (reforma Isapres?) Colombia: reforma de Salud (nuevo rol de las EPS) Costa Rica: consolidación de la sostenibilidad financiera de la CCSS El Salvador: reforma del Sistema público de salud Cuba: Sistema Universal de Salud Perú / Rep Dominicana / Honduras /… : ….

La situación de la Cobertura de Servicios These two graphics (ECLAC, 2008), show that even if all countries in the region have made progress over time with regards to some health variables like mortal maternity rate and infant mortality rate; there are persistent inequalities among countries. Indeed, while in 2006 countries like Haiti, Guyana, Bolivia, Guatemala, Peru and Equator showed extremely high rates of maternal mortality; others, like Bahamas, Chile, Cuba, Costa Rica, Trinidad and Tobago and Uruguay enjoyed rates of less than 50 deaths per 100,000 live births. The same pattern may be observed with regards to infant mortality; where the rate has decreased in LAC from over 40 death per 1,000 in 1990 to slightly over 20 per 1,000 in 2006 while some countries like Haiti, Bolivia or Guyana showed rates over 50 per 1,000 along with others like Cuba or Chile that present rates under 10 per 1,000. The two following graphs show the evolution by country and for LAC (line) of the proportion of deliveries attended by qualified personnel & the prevalence of use of family planning methods for 2001-2011. Both graphics present an important dispersion with countries having quite good results and others lacking behind, even if in general all of them show progress during the period. Recent Equilac studies (PAHO/WB) have shown the following results for some LAC countries: In Brazil, the poor reported worse health status than the better-off, while the wealthy reported more chronic diseases. Overall, income-related inequality in the use of medical and dental care is gradually declining, a trend associated with pro-equity policies and programs such as the Community Health Agents Program and the Family Health Program. In Chile, inequities in health service utilization have declined over time. Significant income inequality in the use of specialized and dental services persists and calls for attention from policymakers. Overall, the authors conclude that the pattern of health-care utilization is consistent with policies implemented and is trending in the intended direction. Colombia has made important progress in equity with regard to social health insurance affiliation, access to medicine and curative services, and perception of the quality of health-care services. Yet important gaps remain that affect poorer populations, especially their perception of their own health conditions and their access to preventive medical and dental services. In Jamaica, income-related inequalities in health status and health care have increased, and those who need health services most are using them least—despite measures taken to address health inequity. The findings suggest a need for more innovative programs geared toward improving health equity in the country. In Mexico, health-care utilization patterns improved from 2000 to 2006, but no significant changes in income-related health and health-care inequity were found. The evidence supports the idea that increasing the effectiveness of spending is necessary to ensure that more equitable funding translates into more equitable access to services and more equitable health outcomes. In Peru, inequity in the use of preventive services increased slightly between 2004 and 2008, but inequity in the use of curative services declined significantly. Overall, the country has low levels of inequality in health status. Contributing to the positive trends were increased household income, reduced economic inequality, the Juntos conditional cash transfer program and gradual expansion of Peru’s public health insurance, Seguro Integral de Salud. Proporción de municipalidades con menos de 80% de cobertura de DPT3 Diferencias en los indicadores de salud entre poblaciones indígenas y no indígenas

La situación de la Cobertura de Servicios

World Health Organization 17 April 2017 Población según Esquema y gasto per capita (USD ctes 2007), El Salvador 2007 - 2012 2007 2012

n = 20 N = 8