Informe ING

Report

Rio de Janeiro, January/February 2013

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This is the report from the South American Institute of Government in Health (ISAGS), the think tank on health of the Union of South American Nations (UNASUR) that aims to contribute to improving South America government quality in health by means of leadership training, knowledge management and technical support to health systems.

"South American health systems face a triple burden of disease: they are pressured by companies and governments to show improvements while are challenged by financing difficulties and inequalities. In that scenario, ISAGS must operate as a Health Council instrument to strengthen Unasur Networks and Technical Groups and to keep improving the bloc's mandate: the consolidation of the universal right to health" – José Gomes Temporão Check out summary of interview in ISAGS Report, page 4.

Unasur countries prepare reforms in their health systems In January, the Governments of five out of the twelve countries that compose the Union of South American Nations (Unasur) mobilized to reform their health systems throughout 2013.

In recent weeks, Colombia and Chile have been engaged in advancing their reform projects; Bolivia and Peru, in promoting a broad debate with civil society; while Guyana has begun the discussion on how its legislation will be updated.

As well as other Unasur countries, those are pressed by factors such as demographic transition, social transformations and the need to move towards the universalization of both the right to health and to health coverage.

ISAGS, which published last year the book "Health Systems in South America: challenges to the universality, integrality and equity", brings in this year’s first report a special edition on health reforms in the region and an interview with its Executive Director, José Gomes Temporão, explaining how Unasur deals with issues faced by health.

HEALTH REFORMS IN UNASUR ..

5 of the 12 members of the South American bloc discuss changes in their systems

Guyana Discusses a reform in the legislation of the health system through a new Health Promotion and Protection Bill to replace a regulation that dates back to 1934, during the colonial years

Colombia Prepares a “far-reaching reform” to “put the system in order” and mitigate the financial crisis of the sector, according to the Minister Alejandro Gaviria.

Proposal will be presented in March Peru Installed in January the National Health Council, responsible for proposing a reform of the system in order to advance towards the universalization of the right to health and social dialogue Bolívia Promotes in march the first National Health Conference, focusing in the public health system, participative management, financing, human resources and a healthy State Chile Is trying to approve a law to reformulate the private insurance system - Isapres -, creating an index to adjust the prices and a Guaranteed Plan for those with prior diseases

Informe Colombia is expected to propose a "deep reform" in March Colombia’s government prepares a "thorough reform" to "bring order" and tackle its financial crisis, affirmed the Minister of Health and Social Protection, Alejandro Gaviria, in an interview for the Colombian newspaper "El Tiempo" late January.

According to Gaviria, the government's bill is expected to be submitted by March and approved by the end of June. The initiative follows a wide-ranging debate held in the country last year and that resulted in the submission to Congress of five bills, whose suggestions are supposed to be partly absorbed in the official document.

Health care reform follows the tax reform approved by Congress in December, which reduced the payment of companies’ taxes to the Government, thus altering the collection provided for in Law 100 of 1993, which regulates the country's Social Security System.

Measures under consideration include the creation of a single fund to finance the contributory (funded by the State, companies and workers) and the subsidized (aimed at low-income population) systems.

They also include the role review of Health Promoters Entities that act as intermediaries between the State and service providers, among others.

The Minister of Health and Social Protection of Colombia, Alejandro Gaviria

Chile foments law that modifies the private insurance system The Chilean President, Sebastián Piñera, announced late January that one of his Government’s priorities in 2013 is the health care reform, whose first step was the submission, last month, of a bill that modifies the country’s private insurance system, called Isapres – Instituciones de Salud Previsional (Health Care Institutions).

"We’ll keep moving forward, strengthening public health by means of more infrastructure, but private health as well”, Pinera affirmed at the Council Cabinet’s first meeting of the year. “We’ll keep insisting on a new Isapres law, which allows for an IPC [price adjustment index] (...) but also for the strengthening of a Guaranteed Health Plan", he added.

The creation of IPC and of guaranteed plan for users with pre-existing diseases and without a grace period

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The Chilean Minister Jaime Mañalich (center) and senator of the Senate’s Health Committee

are the two main measures of the project and succeed to the Supreme Court decision, according to which "Isapres cannot increase plans prices unilaterally".

The Parliament passed Isapres Law, but vetoed the two measures upheld by the Government. The bill is now being processed in the Senate, whose Health Commission unanimously approved the text assessment, including the IPC and the Guaranteed Plan.

Bolivia confirms the 1st National Health Conference for March Bolivia’s Minister of Health and Sports, Juan Carlos Calvimontes, confirmed next March 5-8 the 1st Conference on the Revolution of Public, Universal and Free Health, to be held in the city of Tarija.

According to Calvimontes, the Bolivian Government is currently working in the assembly of groups, definition of social organizations percentage of participation and search for convergence of interests.

Demanded last year by President Evo Morales, the meeting aims to discuss the universal access to free and quality healthcare and is structured in five main lines: public health system, participatory management, financing, human resources and healthy State.

Informe Guyana plans to revise the public health legislation dated to the thirties

The Health Ministers of Peru, Midori de Hábich (left), and Ecuador, Carina Vance

Peru installs National Health Council to discuss reform Peru’s Health Minister, Midori de Hábich, presided, late January, the first 2013 session of the National Health Council, tasked to formulate and propose actions to the sector reform and to strengthen the National Health System, ensuring access to quality services and the gradual increase in health coverage.

During the meeting, the Minister introduced the document "The Right to Health: Elements for the Reform" and emphasized that the goal is to advance in the full universalization of right to health by

WHO Secretariat advocates Universal Health Coverage The World Health Organization’s Secretariat issued late January a statement that advocates the concept of Universal Health Coverage and reports steady progress of services related to the Millennium Development Goals, but points out the challenges for the definition of new Sustainable Development Goals after 2015.

Introduced during the 132nd Session of WHO Executive Board, held on January 21-29, the document provi-

means of a broad dialogue with the society and citizens.

Midori also highlighted the need for regulation and supervision, strengthening of primary care, exchange between public and private sectors, planning and public funding, in order to reduce out-of-pocket expenses.

The book “Health Systems in South America...”, published by ISAGS in 2012, can be downloaded for free at bit.ly/sistemasdesalud

Guyana plans to approve a reform of the country's health system law, said, last January, the Health Ministry’s Medical Director, Shamdeo Persaud. One of the main parts of health regulatory framework in Guyana, the Public Health Law, was passed in the 1930s, still during the colonial period. The draft of the Health Protecting and Promotion Law is already under discussion. The hope is that it be sent for the Parliament’s approval this year. In an interview for "Kaieteur News", the Health Ministry’s Parliamentary Secretary, Joseph Hamilton, informed that the document will be submitted for discussion with society and with regional, municipal and community health organisms. "[The old law] has to be revised, and we have already started this process," affirmed Hamilton.

Carissa Etienne is sworn as the new Director of PAHO/WHO

des that SDGs must take into account the new global health agenda, health as a human right, fairness, equal opportunities and health determinants, as well as the intersectoriality of sustainable development.

WHO Director-General, Margaret Chan, talked about the complexity of global health challenges and international cooperation, and urged countries to continue with their cooperation efforts. In order to prepare for the 66th World Health Assembly, in May, other topics were discussed, like WHO’s role in global health governance, WHO Reform, and the 2013-2020 Global Action Plan for Noncommunicable Diseases.

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Carissa Etienne assumed office as the new Director to PAHO/WHO On January 31st, Carissa Etienne was installed in office as the new Director of the Pan American Health Organization (PAHO/WHO) for the next five years, replacing the Argentinian Mirta Roses, who held the position for two terms, since 2003. Born in Island of Dominica, Etienne had been appointed at the 28th Pan American Sanitary Conference, held in September, and was made official at the 132nd Session of the WHO Executive Board.

In an interview for Efe, Etienne affirmed that her priorities in office will be universal health coverage and equity. "Many countries have reached or are close to attain universal coverage and improved their health systems, (...) but the benefits are not yet fairly delivered among countries and even within each country", she said.

Before taking office, Etienne worked as Assistant Director to PAHO/WHO and Deputy Director for Health Systems and Services at WHO in Geneva.

Informe "Tension between State and market characterizes current reform processes" Five Unasur countries are currently endeavoring reforms in their health systems: Bolivia, Chile, Colombia, Guyana, and Peru. Is it possible to draw parallels between these processes?

The movement pro-reform expresses, firstly, a society's pressure for better quality; secondly, the attempt of pressured governments to achieve better results; and, thirdly, the complexity of the transition processes that pervade every country of the world.

Some initiatives, such as Bolivia’s, are similar to the Brazilian model of unified system and universal approach; others, such as Colombia’s and Chile’s, are more complex, for enveloping mixed systems and carrying a strong presence of the private sector. The speech sometimes tricks. There is talk about universal coverage or insurance, but no mention about what is contained in the process.

So, what there is behind those processes is a great effort to understand what happens in the dynamics between societies and health. It is a process of ensuring health systems sustainability.

This might be a dilemma that affects every country.

How might changes in European health systems – with greater access, but in crisis – and South American ones – with great inequality – become more similar or different?

In Europe, the crisis is broadening inequality. There are cuts in the budgets of Health Ministries. This means that the weight of financing changes aside. The State participation is reduced and the families’ are increasing. There is a risk of restricting access and services.

In South America, the opposite happens.

In an interview for ISAGS Report, the Institute’s Executive Director, José Gomes Temporão, talked about the challenges faced by health systems in South America and the health integration efforts made by Unasur, its Health Minister Council and ISAGS. The complete interview is available at isags–unasur.org, in Portuguese, Spanish and English.

strategies generated in international or in the markets, such as the O Diretor-Executivo doorganisms ISAGS, José Gomes Temporão American "managed care", which The region is experiencing a period of remain posing as alternatives. Our vision growth and stability. But, as inequality is is to strengthen the path defined by CSS; too great, there is strong pressure for however, it is like a battlefield and expansion of social rights, such as health depends on a number of factors. care, which requires increasing spending.

ISAGS is 18 months now. Can it be It is in this field that tensions arise said that the Institute already fulfills between alternatives that see the its role? market as a solution and others that From my assessment, I would say yes. favor the State as provider and regulator.

We have a great challenge in 2013, and What are the strategies provided by a we are confident to achieve our goal, universal system and by a universal which is the conclusion of the institutiocoverage to deal with South nalization process. It misses the America’s problems? headquarters agreement ratification, The central question is how one sees which is still following the Brazilian health: whether it is a right of Congress channels. I'm pretty optimistic everyone or something purchasable. that 2013 is going to be the year of a The latter is the American model. complete socialization, with new tools, England and Canada have a distinct more agility, more autonomy, own logic, seeing health is a right. That budget, that is, the ability to work closer characterizes the way the system is to the Ministries. organized and financed and the ISAGS Annual Operating Plan dialoaccess is provided. Many experiences gues closely with Networks and the of universal insurance may hide great Technical Groups (GTs) that integrate inequalities. And there is the cultural the Advisory Board. How do you see dimension, i.e., the difficulty of this relationship? building a political consciousness in It has to be built, because it is a new society towards the understanding thing. On one hand, there are Networks that health is important and socially of Public Health Schools, Technical and politically constructed.

Schools, and Institutes, which are virtual Is it expectable for the coming years spaces of organisms that build a that a breakthrough occurs in the common agenda and work on it. On the region towards universal systems, other hand, there are the GTs – arrangebeing them one of the goals contaiments with Ministries’ representatives ned in the Quinquennial Plan of for themes. And there is ISAGS as a Unasur Health Council (CSS)? catalyst of those initiatives, but also in There is a CSS following a common charge of opening new paths. This strategy and ISAGS as a political instrumacro governance – GTs, Networks, ment to advance on that path. But they ISAGS, and CSS as the overall coordinaembody internal processes that include tor – is a process under construction. I changes in the law and in the funding see a lot of potential, although integramodel that have to follow the Congress tion tools still are in their beginnings. channels. There are also numbers of

INFORMATION AND KNOWLEDGE MANAGEMENT Coordinator: André Lobato Consultants: Amaro Grassi, Flávia Bueno and Manoel Giffoni comunicacao@isags-unasur.org