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SOCIAL PROTECTION IN HEALTH
CONTINUUM OF LIFE
DR. HORACIO TORO OCAMPO
TEGUCIGALPA
2006
VISION
• A continent that is united in order to reach the highest possible
level of health for all of its inhabitants
• Governments that exert leadership and the responsibility to
summon society as a whole to improve people’s health
• Individuals, families, communities and institutions that are
empowered to seek social justice through the promotion of
health and the protection of life
Dr. Mirta Roses
Director, PAHO
Family and Community Health Area - PAHO
• Joins all of the efforts of the different technical units
in order to ensure a more integrated, effective and
efficient technical cooperation response
• One of it central axes is to strengthen the
cooperation between countries, supporting the
documentation of experiences and the synthesis of
lessons learned
• Ensure that the achievements reached by countries
and by the Region are sustained
• Promote the scaling up of successful experiences
22,000 AVOIDABLE MATERNAL DEATHS
EACH YEAR






Child malnutrition / Poverty /
Illiteracy
Hemorrhages
24.8%
Early pregnancies
Unnecessary and harmful
practices
Indirect causes (HIV/AIDS,
Malaria, Violence)
Non evidence-based practices
Sepsis
14.9%
Indirect
Causes
19.8%
Access to maternal-neonatal
services and FP is still deficient
Other Direct
Causes
 Deficient quality of care
Complications
7.9%
Skilled care is not provided in high
of Abortion
proportions
12.9%
 Under-registration of maternal
deaths
DETERMINANT
IMPACT
Hypertensive
Disorders
12.9%
Obstructed Labor
6.9%
Prenatal care according to area of residence
Large differences between women in urban areas and rural areas persist
% of women that report 4+ prenatal visits
urban
Urbana
rural
Rural
100
92
90
83
80
74
73
66
70
62
66
56
60
51
46
50
40
40
30
25
25
23
20
10
0
Bolivia
(1998)
Dominican
Republic Guatemala
(1999)
(1996)
Source: AbouZahr and Wardlaw, 2002
Haiti
(1994)
Nicaragua
(1998)
Peru
(1996)
Latin America /
Caribbean
Pregnancy and delivery –
crucial moments in the health of women,
children and families
70% of maternal deaths
PP
57% foeto-neonatal deaths Before, during and after birth
Infant Mortality Rates in the Region of the Americas
per 1,000 live births. Estimates by FCH/CA. WHO/PAHO, 2005
90
80
80
> 30
70
60
< 10
54
50
39
40
35 35 34
33
15 15 15 14
10
PR
BEL
GUY
URU
PAN
COL
VEN
PAR
VEN
MEX
ECU
ELS
BRA
PER
HON
NIC
DOR
GUA
BOL
0
HAI
10
9
8
7
6
5
CAN
20 19 19 19
18
CUB
20
USA
22
CHI
25 25
COR
30
Main causes of mortality in children under-five in
the Region of the Americas
132,194 annual deaths
26.9% of all deaths
Malnutrition
14,444
2.9%
Others, 36,960
(19.8%)
Sepsis, 11,200 (6%)
Low Weight,
Peri-Neonatal
22,590 (12.1%)
Asphyxia,
39,200 (21.0%)
186,700
38.0%
Problems
during
Perinatales
Pregnancy and
38.0%
Delivery,
76,750 (41.1%)
Accidents
28,750
5.9%
Source: Estimates by the Child and Adolescent Health
Unit
(FCH/CA), using a database from the Health Analysis and
Information Systems Area (AIS). Pan American Health
Organization (PAHO). 2004.
Respiratory
59,600
12.1%
Infectious
58,150
11.8%
Others (congenital
anomalies, cardiovascular
diseases, etc.)
143,100
29.2%
Infant mortality at the national level and
among indigenous populations in selected
countries of the Americas
Infant mortality per 1,000 live births
100
NATIONAL POPULATION
Nacional
Población
indígena
INDIGENOUS
POPULATION
90
80
70
60
50
40
30
20
10
0
BOL
GUA
ECU
HON
PER
Source: PAHO/WHO 2000
VEN
MEX
I.
Favorable scenarios on
the International and
Regional agendas
Strategic alliances:
USAID-UNICEF-UNFPAPAHO/WHO-NGOs
OPPORTUNITIES IN LAC
• Revitalization of Primary Health Care
• Integrated health models
• The countries have national plans and policies to
attain the MDGs in Maternal-Infant Health
• The expansion process for the AIEPI strategy, both
the community and neonatal components
• Epidemiological Surveillance Systems in MNH under
development
• More universal health systems.
OPPORTUNITIES
• The “New Delhi” Declaration, World Health Day, April 7,
2005
• WHO Resolution on the continuum of maternal, newborn
and child care
• Global Alliance for maternal-newborn-child health
• Regional Agreement in support of the maternal, newborn
and child component
• Presentation of the Regional Strategy for reducing
neonatal morbi-mortality to the PAHO Directive Council 2006
• Presentation of the Regional Strategy and Plan of Action
on Nutrition and Development (SPP 2006)
III. Challenges
Challenge I:
Advances toward Action
EFFECTIVE
INTERVENTIONS
PRIORITY AREAS /
VULNERABLE POPULATIONS
IMPACT
Challenge 2: Political will translated
into national investment
– Creation of consensus
– Maintenance and support of working teams
– Adoption of State policies
– More rapid movement toward the reduction of
health inequities and access to basic services
– Extend social protection in health, providing
fundamental interventions for the most needy
populations
Challenge 3: Ensure a sustainable
focus: Continuum of care
– A continuum that considers the life cycle:
• Focus on sexual and reproductive health that includes
pregnancy, delivery and the postnatal period through childhood
– A continuum that extends:
• From the home;
• Through the primary level (ensuring appropriate care at each
level according to people’s needs);
• And, when necessary, at the referral level
– A continuum that cuts across the programs:
• Maternal Health, Child Health, Reproductive Health, STIs/HIV,
Malaria, Nutrition, Immunizations
A continuum of care and care practices
under construction
The Home:
Women and
Families
The
Community
Level of primary care:
Referral level:
EmOC
Skilled personnel
Referral system
Skilled personnel,
including other doctors,
nurses, others
Surgeons, nurses,
others
Interventions
Interventions
Interventions
Interventions
Interventions
• Self-care and
newborn care
• Community
awareness about
maternalnewborn health
needs and rights
• Care for normal pregnancies
that focuses on newborn care
• Management of
complications during
pregnancy, delivery and in the
post-partum period
• Blood transfusion
• Management of illnesses
that affect pregnancy and
delivery
• Intensive care - women
• Care-seeking
• Delivery and
emergency plan
• Social support
during delivery
• Involvement of
males and other
decision makers
• Awareness raising
among families and
individuals about
maternal-newborn
health needs and
rights
• Community
actions to
support
maternalnewborn health
• Links between
the community
and the health
services
• Delivery care (use of the
partogram and active
management of the third
stage)
• Exclusive early breastfeeding
• Early detection and timely
referral of women and children
with pregnancy complications
• Management of newborn
complications
• Family Planning, control of
malaria, STI/RTI
• Prevention of HIV in mothers,
including vertical transmission
Fuente: WHO,
OMS, 2003
Source:
• Cesarean section
• Surgery
• Intensive care - newborns
CHALLENGES
Challenge 4: Guarantee the human resources to
provide skilled care for women, their children and
families under the framework of the continuum
Challenge 5: Re-orient health care services
based on the renewed Primary Health Care
strategy that recognizes families and communities
as the subjects of change
Challenge 6: SOCIAL PROTECTION IN HEALTH
 Mechanisms to increase financing in a sustainable manner
 Maternal, Newborn and Child Health is at the center of the
right to health debate
 Evidence-based interventions form part of the insurance
packages at the level of home/family/community and
services
 Insurance packages that contribute to a decrease in gaps
(socio-economic level; urban/rural; ethnicity)
 Establishment of responsibility mechanisms (territorypopulation)
 Accelerate the growth toward universal coverage and
improvement in the quality of care
Continue Moving
Forward
Instruments
Social protection
Health promotion
Primary health
care
HFA & MDG
Information and knowledge management
Health as a human right
SOCIAL PROTECTION IN
MATERNAL-CHILD HEALTH
What is a social protection
in health scheme?
• Organized set of public interventions aimed at
guaranteeing that groups and individuals are able to
meet their health needs and demands through
access to health services under adequate conditions
of quality, dignity and timeliness, without ability to
pay serving as a restrictive factor
There are three strategies to operationalize
the idea of social protection
• Universal protection (for all citizens or residents)
• Protection for low-income people or groups in
specific situations
• Protection for people that contribute or have
contributed to a scheme (fund) or insurance (health,
unemployment, pension, other) (especially workers)
And they use diverse mechanisms or
instruments …
• Universal protection mechanisms: Benefits
determined by the citizenship credential or by simple
individual identification
• Protection mechanisms targeted at low-income
people or groups in specific conditions: Assistance
or benefits determined according to a means-test
(means-tested assistance)
• Contribution-based protection mechanisms: Benefits
determined by method of affiliation and actuarial
calculation
Premises of the analysis
• Equity is a central issue in the health of mothers,
newborns, boys and girls
• M-C health is strongly linked to the macro social
determinants of health
• Access to health goods and the quality of the
services provided are key factors in M-C health
outcomes
• The situation of the M-C population improves
when there is a social protection in health
scheme
Analytical framework: Questions to answer
• How will it be financed?
• Who will have the right (to benefits)?
• What are the benefits?
• How is this right guaranteed?
Analytical framework:
how will it be financed?
•
General taxes: tributary pressure – collection – allocation of health resources
– alternative sources of financing – consumption taxes
–
•
Contributions: method of contributions (obligatory/voluntary monthly
installments based on salary/willingness to pay/co-payments)
–
•
Tributary reform?
Who contributes? Employer/employee/State
Extension of guaranteed social insurance: for temporary/informal workers
–
How to collect their contribution?
•
Extension of employer responsibility: transnational companies
•
Anticorruption measures: the administrator of the contributions should not
have access to the fund of collected contributions
•
Co-responsibility of national States: Cross-border agreements
–
•
Portability of guarantee?
THE FINANCING OF PUBLIC HEALTH ACTIVITICES SHOULD BE CARRIED
OUT BY THE STATE AND DISTINCT CHANNELS
Analytical framework:
What are the benefits?
• Explicit set of guaranteed services (Insurance-based systems)
vs. Non-explicit services (National health services)
• Design of the guaranteed package: intensive in terms of
technology of generation, analysis and transfer of information
(identification of beneficiaries-accreditation of service
providers-identification and costing of services)
• Definition of the contents of the guaranteed package: by
disease / by diagnosis-intervention/ by cost-effectiveness
criteria/ by demographic-epidemiological criteria / by political
pressures
EXPERIENCES IN THE REGION
• Bolivia:
Universal Maternal and Child Insurance
• Brazil:
Family Health Program
• Chile:
Maternal-Child Health Protection
• Ecuador: Free Maternity and Child Care Law
• Honduras: Mother and Child Voucher
• Mexico:
Education, Health and Nutrition Program
• Peru:
Maternal-Child Insurance
OBJECTIVES OF THE SCHEME
• Reduce the maternal mortality and child
mortality rates by 50%
• Improve access and increase use of
services, reducing economic barriers
• The program focuses on free services for the
population
• The financing comes from the tributary coparticipation resources (municipal funds)
POSSIBLE IMPACTS
a) Increase equity in access to/use of services?
b) Control, eliminate or decrease the negative effects
of social determinants? (demand or state of affairs)
c) Increase access by eliminating a source of
exclusion from the health system?
d) Improve health outcomes?
Increase equity in access to/use of services
• Access to and use of health services covered by the
program should increase with the implementation of
the different schemes that they decide to implement
• Increase the quality of institutional care for pregnant
women during pregnancy, delivery and in the
postpartum period
• Decrease the gaps in inequity between rich-poor,
urban-rural and indigenous-non-indigenous
Increase access, by eliminating barriers of
exclusion from the health system
•
By removing the economic barrier, there
will be an increase in coverage
•
Households continue to be a source of
financing for the sector, 30% of total health
spending (purchase of prescription drugs)
•
Health insurance should be an element that
increases demand in rural areas
Millennium Development
Goals and Targets
1. Eradicate extreme
poverty and hunger
4. Reduce child
mortality
5. Improve maternal
health
6. Fight HIV/AIDS,
malaria and other
diseases
1.
Halve the proportion of people living on less than
a dollar a day (PPA), between 1990 and 2015
2.
Halve the proportion of people who suffer from
hunger, between 1990 and 2015
3.
Reduce by two thirds the mortality rate among children
under five
4.
Reduce by three quarters the maternal mortality ratio,
between 1990 and 2015
7.
Halt and begin to reverse the spread of HIV/AIDS by
2015
8.
Halt and begin to reverse the incidence of malaria
and other major diseases by 2015
9.
Reduce by half the proportion of people without
sustainable access to safe drinking water by 2015
STRATEGY TO ACCELERATE ACHIEVEMENT OF MDGs
FOCUSES ON THE 5 SRH PRIORITY ASPECTS
1- improve prenatal, delivery, postpartum and newborn care;
2- provide high quality family planning services, including infertility
services;
3- eliminate unsafe abortion;
4- combat sexually transmitted infections, including HIV, reproductive
tract infections, cervical cancer and other gynecological pathologies;
5- promote healthy sexual health and responsible reproduction.
WHA 57, 2004
Potential Reduction in Maternal Mortality for Latin America and the Caribbean.
Countries with Populations Over 2.5 Million People. 2003
Basic Indicators 2005 PAHO / SHA / 02.01
Possible Potential: ref. Chile Rate 13.4 %ooo
Countries (Mat. Mort. %ooo)
Desirable Potential: ref. Canada Rate 7.4 %ooo
C. Rica 30.0
Uruguay 38.0
Cuba 38.5
Argentina 42.5
Venezuela 57.8
Mexico 65.2
Panama 68.0
Brazil 73.1
Dom. Rep. 75.3
Ecuador 77.8
Nicaragua 82.8
Colombia 84.4
Jamaica 95.0
Honduras 108
Guatemala 153
El Salvador 173
Paraguay 174.1
Peru 185
Bolivia 230
Haiti 523
100
75
50
Potential Reduction %
25
25
50
75
Potential Reduction %
Update of: Maternal Mortality in Latin America and the Caribbean. Schwarcz & Fescina The Lancet 356.December 2000
100
REGIONAL AGREEMENTS
MATERNAL MORTALITY
•
Resolutions 13 and 14 of the 26th Panamerican Sanitary
Conference (PASC 2002)
•
Interagency Strategic Consensus for the Reduction of MM
CHILD HEALTH
•
AIEPI Resolutions from the 23rd and 26th PASC
•
Strategy and Plan of Action for Newborn Health on the MRN
continuum (2006)
HIV AIDS-STIs
•
Strategic Regional Plan for the Health Sector (2005)
ADOLESCENTS: Strategy under development, AISA
NUTRITION, HEALTH AND DEVELOPMENT: E. R. Plan (2006)
IMMUNIZATIONS: Regional Strategy (2006)
Elimination of Rubella and CRS
CHALLENGE - Political will translated
into national investment
– Creation of consensus
– Maintenance and support of working teams
– Adoption of State policies
– More rapid movement toward the reduction of
health inequities and access to basic services
– Extend social protection in health, providing
fundamental interventions for the most needy
populations
CHALLENGE - Ensure a sustainable focus:
Continuum of care
– A continuum that considers the life cycle:
• Focus on sexual and reproductive health that includes pregnancy, delivery and
the postnatal period through childhood
– A continuum that extends:
• From the home;
• Through the primary level (insuring the appropriate care at each level
according to people’s needs);
• And, when necessary, to the referral level
– A continuum that cuts across the programs :
• Maternal Health, Child Health, Reproductive Health, STIs/HIV, Malaria,
Nutrition, Immunizations
A continuum of evidence-based care and care practices
within the framework of the Primary Health Care strategy
Some
1) A continuum whose coverage begins with the start of life
Preconception
Pregnancy
Newborn
Childhood
complications
cannot be
predicted,
Therefore
2) A continuum that extends from
The Home
Female
Empowerment
The Community
1st Level of Care
Level of Referral
Families
Community
workers,
Self-taught
Health Centers
Skilled personnel,
Nurses, Obstetricians,
Midwives
Hospital, Skilled
pers., Obstetricians,
Neonatologists,
Nurses
all mothers
need to receive
Check-ups
Fuente: WHO,
OMS, 2003
Source:
CHALLENGE – Social Protection in Health
 Maternal, Newborn and Child Health is the center of the rights
to health
 Evidence-based interventions as part of the insurance
packages at the level of the home/family/community and
services
 Mechanisms to increase financing in a sustainable manner
 Insurance packages that contribute to a decrease in gaps
(socio-economic level; urban/rural; ethnicity)
 Establishment of responsibility mechanisms (territorypopulation)
 Accelerate the growth toward universal coverage and
improvement in the quality of care
CARE THROUGHOUT THE
CONTINUUM OF LIFE
“CARE FOR PEOPLE’S NEEDS, ASPIRATIONS AND
PROBLEMS, ENSURING THAT THEY ENJOY
COMPLETE PHYSICAL AND MENTAL WELL-BEING
AND SOCIAL DEVELOPMENT DURING THE
“CONTINUUM OF THEIR LIFE,” AS WELL AS
MONITOR THE BIOLOGICAL AND SOCIAL
DETERMINANTS THAT CAN AFFECT THEM AT ANY
STAGE OF LIFE”
ANTONIO HORACIO TORO OCAMPO
2006
Working Framework Family and Community Health
Social
Protection in
Health
Newborns
Primary
Health
Care
Infants
MDG 4
HIV/AIDS - STIs
MDG 5
Improve
maternal
health
Women’s,
Maternal,
Reproductive
Health
Reduce child
mortality
Children
Priority
Countries
Groups
Child /
Adolescent
Health
Immunization
Nutrition
MDG 3
Promote gender
equality and
empower women
MDG 8
Adults
Human
Resource
Development
Healthy life
styles
Youth
Establish
alliances
Healthy
Spaces