Estrategia regional para la cobertura universal de salud. Reunin de Gerentes. Centro Amrica. Marzo 2014. Por J. Fitzgerald. Director de HSS

Cobertura universal de saludElementos conceptuales, origen y vistazo de la situacin en la ReginCristian MoralesAsesor Regional Financiamiento y Economa de la Salud, HSS/HS(moralesc@paho.org)

# |1Es el objetivo que orienta la transformacin 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.Introduccin: Qu es cobertura universal de salud?

ValoresDerecho a la saludEquidadSolidaridad

Aborda los determinantes sociales de la salud, hace nfasis en los grupos en situacin de pobreza y vulnerabilidad.

# |La La cobertura universal de salud refuerza la necesidad de definir y ejecutar polticas 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 nfasis en los grupos en situacin de pobreza y vulnerabilidad.World Health Organization3 August 20142Marco analtico de la cobertura universal para catalizar la transformacin de los sistemas de saludCobertura poblacionalCobertura de serviciosCobertura de costosCompromiso polticos con el Derecho a la Salud y la cobertura universalMarco jurdicoPolticas, planes y estrategiasPrioridad fiscalSIS para monitorear la cobertura universalFactores habilitantesEnfoque intersectorial y accin sobre los DSSDialogo social y participacin socialCapacidad regulatoria EficienciaModelos de atencin centrados en las personas y basados en APS con RHS preparados y motivados

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Alma Ata1978Atencin Primaria de SaludRenovada2005

Reformas basadas en atencin primaria de saludISM 2008

Antecedentes: De la atencin primaria de salud hacia la cobertura universal de salud

# |5El estado de avance de la cobertura universal de salud: Como medirla?

Desafos: Medidas simultanea pero separadas de c poblacin con servicios de salud esenciales y c poblacin con proteccin financiera. Medida de servicios integralesMedidas de proteccin financiera a todos los niveles del sistema de salud ya que pueden variar grandementeMedidas para todos los pases (no como los ODM)Medidas desagregadas por estrato socio demogrfico, sexo, etc.

# |Sin embargo, cada pas deber definir su camino y ritmo, teniendo en cuenta su contexto social, econmico, poltico, legal, histrico y cultural.

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El punto de partida: La lucha contra la desigualdad y las inequidades!

Profundas desigualdades en la distribucion del ingresoDisparidades en los resultados de salud

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La nueva complejidad

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Fuente: WB, 201237%11%3%

# |World Health Organization3 August 20149 TOTAL DE MUERTES XEnf Crnicas en 20094.5MillionsConstituyen la 1a causa de mortalidad y siguen en aumento149 millones de fumadores30-40% de 25-64 son hipertensos25% personas 15+ son obesas37% de las muertes fueron en menores de 70 aosMas de 250 millones de personas que viven con enf crnicasSon multifactoriales e implican diversos sectoresBuenas noticias: se puede retrasar su aparicin / disminuir su prevalenciaNo tan buenas noticias: implementar intervenciones preventivas constituye un gran desafoFuente: 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

# |10Enf crnicas NT reproducen tambin las inequidades

* Presented at the Global Health Council 38th Annual Conference 2011.Mortalidad por tipo de cncer e ingreso pas *

# |11NCDs 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.

Argentina: Plan nacer,Brasil: SUSUruguay: SIS/FonasaMxico: Seguro PopularEEUU: Affordable care act (Obama care)Ecuador: Reforma de Sistema de saludChile: GES (reforma Isapres?)Colombia: reforma de Salud (nuevo rol de las EPS)Costa Rica: consolidacin de la sostenibilidad financiera de la CCSSEl Salvador: reforma del Sistema pblico de saludCuba: Sistema Universal de SaludPer / Rep Dominicana / Honduras / :.

La situacin de la Cobertura Poblacional

# |Proporcin de municipalidades con menos de 80% de cobertura de DPT3

Diferencias en los indicadores de salud entre poblaciones indgenas y no indgenasLa situacin 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 leastdespite 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 Perus public health insurance, Seguro Integral de Salud.13

La situacin de la Cobertura de Servicios

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Poblacin segn Esquema y gasto per capita (USD ctes 2007), El Salvador 2007 - 201220072012

# |World Health Organization3 August 201415

n = 20

N = 8

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