¿Como es un buen sistema de salud?

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Information about ¿Como es un buen sistema de salud?

Published on December 14, 2016

Author: Saludentodas

Source: slideshare.net

1. Prof. Rifat Atun MBBS MBA DIC FRCGP FFPHM FRCP Professor of Global Health Systems Harvard University How a good health system should be Salud en Todas IV Chilean Congress of Public Health and VI Chilean Congress of Epidemiology, La Serena, Chile, December 2-3, 2016

2. 1. Health in South America: achievements 2. Health systems: evolving landscape and challenges – Epidemiological transition and polarization – Productivity – Austerity, its consequences and the importance of UHC 3. Towards a new health system model © Prof. Rifat Atun, Harvard University, 2016 2

3. © Prof. Rifat Atun, Harvard University, 2016 3

4. Life expectancy at birth © Prof. Rifat Atun, Harvard University, 2015 4 50 60 70 80 Lifeexpectancyatbirth(years) Years Argentina Brazil Chile Colombia Costa Rica Cuba Mexico Peru Uruguay Venezuela

5. Health service coverage and health outcomes: selected countries of Latin America © Prof. Rifat Atun, Harvard University, 2015

6. Total gain in life expectancy 1950-55 to 2010-15 © Prof. Rifat Atun, Harvard University, 2016 6 0 5 10 15 20 25 30 Africa Asia Europe Latin America & Caribbean North America Oceania Totalgaininlifeexpactancy 1950-55 to 1990-95 1990-95 to 2010-15 Total

7. 1. Health in South America: achievements 2. Health systems: evolving landscape and challenges – Epidemiological transition and polarization – Productivity – Austerity, its consequences and the importance of UHC 3. Towards a new health system model © Prof. Rifat Atun, Harvard University, 2016 7

8. Epidemiological transition, polarisation and confluence 1. Epidemiological transition – Non communicable diseases and disability 2. Epidemiological polarisation – Widening inequalities among socio-economic groups 3. Epidemiological confluence – Co-morbidities and multimorbidity Atun R, Jaffar S, Nishtar S, et al. Lancet 2013 8 © Prof. Rifat Atun, Harvard University, 2016

9. Neglected tropical diseases: disability-adjusted life year rates by cause and region in 2010, excluding malaria Source: Murray C, et al. : The Lancet 2012 9

10. Cancer: disability-adjusted life years per 100 000 by cause and region in 2010 Source: Murray C, et al. : The Lancet 2012 10

11. Change in burden of disease © Prof. Rifat Atun, Harvard University, 2015 11 0 5000000 10000000 15000000 20000000 25000000 30000000 35000000 40000000 Argentina Brazil Chile Colombia Costa Rica Cuba Ecuador Mexico Peru Uruguay Venezuela DALYs 1990 2010 Epidemiological transition

12. The age of multimorbidity and disability © Prof. Rifat Atun, Harvard University, 2016 12 Transitioning health systems for multimorbidity Lives Grow Longer, and Health Care’s Challenges Change 95 Percent of People Have Some Illness or Injury Flambée mondiale des maladies chroniques Atun, Lancet 2015

13. Multimorbidity (2+ co-existing chronic diseases in populations aged 60+) 13 42 75 55 64 59 80 60 65 82 67 0 10 20 30 40 50 60 70 80 90 Australia (60+) Australia (75+) Canada(60+) Canada(80+) Germany (65+) India (70+) Ireland (70+) Scotland (65- 84) Scotland (85+) USA(65+) %ofolderpopulationwithmultimorbidity © Prof. Rifat Atun, Harvard University, 2016

14. What’s to come – Multimorbidity challenge: Estonia case study (1) © Prof. Rifat Atun, Harvard University, 2016 14 2.32 2.76 4.14 5.06 5.79 7.1 7.56 9.27 0 1 2 3 4 5 6 7 8 9 10 2005 2012 2005 2012 2005 2012 2005 2012 MM1 MM2 MM3 MM4 Averagenumberofyearly PHCvisits Atun et al JOGH 2016

15. What’s to come – Multimorbidity challenge: Estonia case study © Prof. Rifat Atun, Harvard University, 2016 15 0.04 0.03 0.17 0.12 0.36 0.3 0.7 0.56 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 2005 2012 2005 2012 2005 2012 2005 2012 MM1 MM2 MM3 MM4 AveragenumberofInpatientadmissions 1. Epidemiological Challenge Atun et al JOGH 2016

16. Coverage of maternal health services: selected countries of Latin America © Prof. Rifat Atun, Harvard University, 2015

17. Mortality rate per 1,000 in children aged 5 years or less and illiteracy rate in municipalities of Northeast Region of Brazil 17© Prof. Rifat Atun, Harvard University, 2016

18. Diabetes mortality rate per 100 000 population (2002-09) in persons aged 15 years or greater by educational attainment (years of schooling) 18 0 20 40 60 80 100 120 140 160 2001 2002 2003 2004 2005 2006 2007 2008 2009 Mortalityrateper100000population Years 0 - 3 years 4 - 7 years 8 years and more Total

19. All cause death rates (age standardised) by deprivation twentieth (England and Wales) (1999- 2003) 19 Source: WHO Commission on Social Determinants of Health

20. 1. Health in South America: achievements 2. Health systems: evolving landscape and challenges – Epidemiological transition and polarization – Productivity – Austerity, its consequences and the importance of UHC 3. Towards a new health system model © Prof. Rifat Atun, Harvard University, 2016 20

21. Health systems productivity challenge: US real sector growth 1990-2010 21 Kocher R, Sahni NR. Rethinking Health Care Labor. N Engl J Med 2011; 365:1370-1372 -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 US Economy Health & social care Manufacturing Retail Finance & insurance Professional, scientific & legal Real sector growth (%) Employment growth (%) Labour productivity growth (%)

22. Health expenditures as a % of GDP © Prof. Rifat Atun, Harvard University, 2015 22 0 2 4 6 8 10 12 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 TotalHealthExpenditureasa%ofGDP Years Argentina Brazil Chile Colombia Costa Rica Mexico Peru Uruguay Increasing financing for health

23. Average length of stay in hospital for acute myocardial infarction (OECD 2000 and 2011, or nearest year) 23 11.6 10.4 9.2 9.2 8.8 8.4 8.3 7.9 7.9 7.9 7.8 7.7 7.6 7.5 7.2 7.0 6.9 6.8 6.7 6.7 6.4 6.3 6.2 6.2 5.9 5.8 5.7 5.5 5.4 4.7 4.6 4.0 4.0 3.9 0 5 10 15 Korea Germany Estonia New Zealand Finland Hungary Austria Ireland Italy Portugal Chile United Kingdom Spain Slovenia Belgium Greece OECD33 Iceland Mexico Switzerland Czech Republic Luxembourg France Poland Canada Netherlands Israel Australia United States Sweden Slovak Republic Norway Turkey Denmark Days Efficiency © Prof. Rifat Atun, Harvard University, 2016

24. 1. Health in South America: achievements 2. Health systems: evolving landscape and challenges – Epidemiological transition and polarization – Productivity – Austerity, its consequences and the importance of UHC – Challenges 3. Towards a new health system model © Prof. Rifat Atun, Harvard University, 2016 24

25. South America: government and private health expenditures © Prof. Rifat Atun, Harvard University, 2015 25 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 1995 2000 2005 2010 Government(bottompart)andPrivate(toppart)HealtExpendituresasaPercentageofTotal Years Argentina Brazil Chile Colombia Costa Rica Cuba Mexico Peru Uruguay Venezuela Improving efficiency of health financing

26. Out of pocket expenditures as proportion of private expenditures © Prof. Rifat Atun, Harvard University, 2015 26 0 10 20 30 40 50 60 70 80 90 100 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 OutofPocketExpendituresasapercentageofprivate expenditures Argentina Brazil Chile Colombia Costa Rica Mexico Peru Improving efficiency of health financing

27. Persistent segregation and disparities © Prof. Rifat Atun, Harvard University, 2016 27

28. Economic crises and adverse effect on health outcomes © Prof. Rifat Atun, Harvard University, 2016 28 1. A1% rise in unemployment was associated with statistically significant deteriorations (p<0.05) in 5 population health outcomes, with largest deteriorations in 1–5 years of age and male adult mortality rates 2. A 1% rise in inflation rate was associated with significant deteriorations (p<0.05) in 4 population health outcomes, with the largest deterioration in male adult mortality rate 3. Lag analysis showed that 5 years after rises in unemployment and inflation, significant deteriorations (p<0.05) occurred in 3 and 5 mortality metrics, respectively

29. © Prof. Rifat Atun, Harvard University, 2016 29

30. © Prof. Rifat Atun, Harvard University, 2016 30

31. 1. Health in South America: achievements 2. Health systems: evolving landscape and challenges – Epidemiological transition and polarization – Productivity – Austerity, its consequences and the importance of UHC 3. Towards a new health system model © Prof. Rifat Atun, Harvard University, 2016 31

32. Towards a health system that focuses on individual health and social determinants to achieve sustainable development 32 Reduced morbidity and mortality Higher productivity, presenteeism and less loss of human capital Economic growth Sustainable development Good Health

33. Sustainable Development Goal 3 and Universal Health Coverage Goal 3: Ensure healthy lives and promote well-being for all at all ages • Target 3.8 achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all © Prof. Rifat Atun, Harvard University, 2016 33

34. Towards a new health system 34 Effective EfficientEquitable Empowering and Responsive Source: Atun et al. Lancet 2013© Prof. Rifat Atun, Harvard University, 2015

35. Health systems: time for a major transition 35 Structural focus Disease and functional focus Patient and population health focus Transition Transition 1.Primary care 2. Secondary care 1.Tertiary care 1. Episodic care 2. Individual disease management 1. Person centred care 2. Risk stratification 3. Bundled healthcare 4. Cross sectoral service integration 5. Population health © Prof. Rifat Atun, Harvard University, 2016

36. New health system: a transformed primary health care 1. Optimising scope and content for comprehensive primary care 2. Optimising delivery for person-centred and proactive integrated care © Prof. Rifat Atun, Harvard University, 2016 36

37. 1. Optimising content: ‘Traditional’ primary health care Doctor First-contact • Reactive, acute-demand led services Comprehensiveness • Fragmented health promotion and prevention • Few diagnostic services Co-ordination • Limited Continuity • Episodic chronic disease management © Prof. Rifat Atun, Harvard University, 2016 37 1. Optimising content

38. Optimising content: Transformed primary health care Person First-contact •Acute-demand led services • Plurality of providers • Mobile and e-health Comprehensiveness • Ongoing health promotion and prevention • Extended diagnostic services • Community based health care • Hospital at home Co-ordination • Local planning • Networks and Clusters • Intersectoral interventions Longitudinality • Integrated chronic disease management • Health management across the life cycle © Prof. Rifat Atun, Harvard University, 2016 38 1. Optimising content

39. 2. Optimizing care delivery 1. Operational integration – Integrated technology enabled care pathways for coordinated team centric care of multi-morbidity and risk 2. Structural integration – Networks 3. Optimised targeting of care – Person focused care to mitigate and manage risk © Prof. Rifat Atun, Harvard University, 2016 39

40. Resource use by population groups 40 % of population % of health system resources used 80% 20% 20% 80% Within the 20% group 5% 40% 1% 20% 3. Optimising targeting © Prof. Rifat Atun, Harvard University, 2016

41. Health maintenance Focus on individuals: risk based population segmentation Case management Integrated disease management Prevention Multi morbidity and risk Single high impact disease At risk General population 41 Lower risk Higher number of co-existing risk 3. Optimising targeting © Prof. Rifat Atun, Harvard University, 2016

42. Technology enabled person driven healthcare 42 Health coach / case manager Interactive Online Information Technology enabled monitoring and intervention Peer Group Support

43. Health systems that foster health as an intrinsic value of citizenship • “Beyond developing services and integrating populations within health insurance schemes, health systems have enabled democratisation of health and created an intrinsic value in building citizenship. By helping to develop citizenship, health systems emerged as a unifying value and an institute for society—an especially important achievement in Latin America, which is characterised by unequal societies.” © Prof. Rifat Atun, Harvard University, 2016

44. Thank you © Prof. Rifat Atun, Harvard University, 2015 44

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