Moving towards a more equitable health system: prospects and challenges Janice Seinfeld
Agenda Introduction Low budget allocated to health sector is a problem Target spending is key System fragmentation generates inefficiencies The challenge of the Universal Health Insurance Normative aspects The case of cancer in the Universal Health Insurance: lessons Conclusions
Introduc;on Peruvian health sector has had major advances in last decades; however, it still presents high levels of deficiency: Low budget allocated to health sector (5.9% of the total budget; 1.6% of GDP). It is unsustainable when implementing Universal Health Insurance. Important inequalities is a problem that health sector faces. It is necessary to target spending to consolidate poorest people improvements. Inefficiencies in the sector should decrease. Fragmentation leads to poor use of scarce-resources.
Health care spending 2006 2007 2008 2009 2010 GDP 92 303.81 107 233.30 126 822.74 126 923.12 153 844.94 Health expenditure 1 209.18 1 426.20 1 521.87 2 145.00 2 399.98 Health expenditure (% of GDP) Executed Budget by Health Sector 1/ (Millions of current US$) 1.31 1.33 1.2 1.69 1.56 1/ Includes collec:ve and individual health, management, planning, science and technology Source: WDI, MEF, BCRP Health Sector Budget 2010 by Level of Government (Millions of US$ 2/) Health Sector Central government Regional government Local government Total Budget % Execu;on Budget % Execu;on Budget % Execu;on Budget % Execu;on Collec&ve health Individual health Other expenses 1/ 81 86,5 120 69 20 68,7 220 75,4 1036 89,9 1152 72 133 68,1 2321 79,7 114 92,1 158 95 2 56,5 282 91,1 Total 1 231 89,9 1 430 74,3 155 68,0 2 823 84,4 1/ Includes management, planning, science and technology 2/ 2010 Average US$ PEN exchange rate: 2,826 Source: MEF, BCRP
Health indicators Indicators ENDES 2000 ENDES 2009 URBAN RURAL URBAN RURAL Chronic malnutri&on (percent of children under 5 years) 13 40 10 33 Source: INEI Despite the marked improvement in the indicators of rural areas, the gap between rural and urban areas is still quite large.
Maternal Mortality Rate and Ins;tu;onal Delivery Ra;os, by poli;cal regions
Institutional Delivery Ratios, by areas Births by caregiver and area. Peru: 2009 Caregiver Urban Rural Doctor 63.1 24.4 Nurse 18.3 20.7 Obstetri&an 12.9 15.9 Health Especialist 0.1 1.7 Tradi&onal Birth AZendant 2.8 16.4 Other 2.7 20.3 None 0.1 0.6 Source: ENDES 2000, 2009. Births by health establishment and area. Peru: 2009 Establishment Urban Rural At home 5.9 41.5 Midwive's home 0.2 0.3 MINSA Hospital 48.3 23.2 ESSALUD Hospital 14.9 2.1 FF.AA./PNP. Hospital 0.6 0 MINSA Health Center 13.8 16.5 MINSA Health Post 2 13.5 ESSALUD Post/Center 1.7 0.1 Private Prac&ce 11.5 1.3 Other 1.2 1.6 Source: ENDES 2000, 2009.
Es;mated User Subsidy for 2010 (Includes dona;ons from public ins;tu;ons and SIS) Expenditure quin;le Served (number of people) Average subsidy per user (US$) 1/ Total Subsidy (%) First quin&le 2 389 495 7 12 Second quin&le 1 935 124 13 20 Third quin&le 1 524 138 20 23 Fourth quin&le 1 081 921 23 19 Fi\h quin&le 780 940 44 26 Total SIS 7 711 618 17 100 1/ 2010 Average US$ PEN exchange rate: 2,826 Source: BCRP, Enaho INEI Increased number of beneficiaries in the firsts quintiles. Amount of subsidy is, however, 6 times higher in the fifth quintile.
Distribu;on of users of health expenditure by expenditure quin;le, Peru 2010 (% of expenditure) Health Facility Centers and health posts Expenditure quin;le (1= lowest) 1 2 3 4 5 30.50% 27.70% 20.80% 14.40% 6.60% Hospitals 7.30% 14.90% 22.50% 29.30% 26.00% TOTAL 26.00% 25.20% 21.10% 17.30% 10.40% Source: MEF, MINSA People in the higher quintiles are attended mostly in hospitals, where the subsidy per user is higher; in this case, public subsidy has a regressive structure.
Health sector organiza;on
The Challenge of Universal Insurance The Universal Health Insurance Law seeks guaranteed access to health, through a basic plan of benefits (PEAS). Insurance Rate According to Insurer (%) Insurance status 2007 2008 2009 SIS 18.4 30.3 36.4 EsSalud 18.3 18.9 19.6 Private insurance 1.7 2.2 2.6 Others 3.3 2.7 2.6 Total with insurance 41.7 54.1 61.2 Total without insurance 58.3 45.9 38.8 Total 100 100 100
The Challenge of Universal Insurance Normative aspects In 2009, the Peruvian government passed the Universal Health Insurance Law, which sets a mandatory membership in a health insurance scheme. The law establishes the agents linked to Universal Health Insurance: stewardship (MINSA), financing (health insurance funds institutional managers -IAFAS), service providers (health services institutional providers -IPRES), supervision (National Superintendence of Health Insurance SUNASA). The law determines the existence of three financial regimes for health insurance: contributory, semi-contributory and subsidized.
The Challenge of Universal Insurance Financing The total public health budget for 2010 was US$ 1,375.1 million, of which US$ 184,1 million were allocated to SIS and US$ 57.7 million to INEN. The SIS budget was used to fund 30,994,797 of attention demanded by 7,069,691 people, from a total of 12,385,998 insured US$ 5.95 per attention or US$ 26.13 per insured attended. An increased out-of-pocket spending to cover treatments is appreciated, especially for the poor.
The Challenge of Universal Insurance The Case of Cancer PEAS is a basic plan offered by all public and private insurers. It covers the cancer diagnosis of cervix, breast, colon, stomach and prostate. Only costs associated to cervix cancer are fully covered. High cost neoplasms treatments not covered by PEAS should be funded through the Health Solidarity Intangible Fund. However, FISSAL does not have sufficient resources to assume the financing of treatments. SIS has published a list of insurable conditions additional to PEAS for its affiliates in the subsidized regime. For tumors not included in PEAS, SIS established a funding cap of 3,000 US$. For the 91 thousand insured people by SIS who were treated at INEN, the average treatment payment was 50 US$.
The Challenge of Universal Insurance The system fragmentation contributes to waste current resources. Universal Insurance Law, in order to integrate the system, opens the possibility of developing mechanisms to purchase and exchange services between providers. With respect to human resources, there is a shortage of medical oncologists; health workers do not have the necessary training. There is a problem of expensive cancer drugs. In the country, 30 cancer drugs are sold since ten years ago -24 have supply monopoly and 5 have only two providers.
Strategic Program of Cancer Prevention and Control has a US $10M budget. Due to INEN degree of specialization, it is the driver of the strategic program, without an effective mechanism of regulation to safeguard the proper use of public budget due to possible conflicting interests generated by their multiple roles. The program creates an opportunity for cancer funding; but the implementation process is fragmented: i) regions receive resources to finance health activities; ii) SIS finances attention service for poor; iii) INEN funds are allocated to cancer prevention activities at national level, as well as care service provider; and iv) FISSAL.
Conclusions The country faces different challenges regarding the Universal Insurance. National information problems limit the implementation of intervention strategies. The institutions involved in health services need to develop and exercise their roles according to their skills. Ensure public funding for health care coverage for poor people. FISSAL must be redefined to incorporate defined interventions with clear funding schemes. Fragmentation in financing the various interventions may involve a misuse of resources. The extension of service offer must not be made under a tiering scheme. It is urgent to achieve an integration of services in a network of public and private care to help improve access.
Janice Seinfeld