National Health Authority

Republic of Colombia

National Health Authority

Republic of Colombia

INSPECTION, INSPECTION, SURVEILLANCE, SURVEILLANCE, AND CONTROL AND CONTROL

FUNCTIONSFUNCTIONS

National Health Authority

Republic of Colombia

Steering entity of the Health Inspection, Steering entity of the Health Inspection, Surveillance, and Control (ISC) System. Surveillance, and Control (ISC) System.

Sets inspection, surveillance, and control Sets inspection, surveillance, and control policiespolicies to be followed by the essential to be followed by the essential public health service. public health service.

Exercises ISC in the exempted and Exercises ISC in the exempted and special systems.special systems.

AREA

National Health Authority

Republic of Colombia

Coordinates user advocacy services. Coordinates user advocacy services.

Exercises legal authority over the services Exercises legal authority over the services monitored and provides mediation. monitored and provides mediation.

Enforces application of the beneficiary Enforces application of the beneficiary selection criteria (SISBEN)selection criteria (SISBEN)

AREA

National Health Authority

Republic of Colombia

Enforces compliance with the principles and Enforces compliance with the principles and fundamentals of the essential public service of fundamentals of the essential public service of the social security health system. the social security health system.

Protects the rights of usersProtects the rights of users

- Right to insurance- Right to insurance

- Right of individuals and groups to - Right of individuals and groups to health services. health services.

AREA

National Health Authority

Republic of Colombia

Health service delivery without pressure from or the Health service delivery without pressure from or the imposition of conditions by doctors. imposition of conditions by doctors.

Exercises authority over the services monitored in Exercises authority over the services monitored in terms of ISC.terms of ISC.

AREA

National Health Authority

Republic of Colombia

Ensures that EPS and IPS adopt the CODE OF Ensures that EPS and IPS adopt the CODE OF CONDUCT AND GOOD GOVERNANCE that CONDUCT AND GOOD GOVERNANCE that regulates the delivery of the services they regulates the delivery of the services they provideprovide

Authorizes the creation and accreditation of Authorizes the creation and accreditation of EPSEPS

AREA

National Health Authority

Republic of Colombia

INSPECTION, INSPECTION, SURVEILLANCE, SURVEILLANCE, AND CONTROL AND CONTROL

systemsystem

National Health Authority

Republic of Colombia

Thematic Areas of the ISC System

ISC SYSTEM

Financing Efficiency, effectiveness, and efficacy in the generation, flow, and administration of resources

Insurance Guarantee of members’ rights

Service Delivery

• Accessible individual and collective health services that adhere to quality standards

• Health promotion and disease prevention

• Diagnosis, treatment, and rehabilitationInformation Ensure that the actors involved guarantee the production of transparent, quality data

National Health Authority

Republic of Colombia

Thematic Areas of the ISC System

ISC SYSTEM

Care for users and social participation

Actions and special measures

Targeting of health subsidies

Guarantee respect for users’ rights and actors’ fulfillment of their responsibilities and promote citizen participation

Application of criteria for determining, identifying, and selecting beneficiaries

• Forcible administrative intervention to administer or close entities monitored

• Technical and administrative intervention in territorial health bureaus

• Oversight of voluntary closures• Closure after revocation of

operating license

National Health Authority

Republic of Colombia

DEFINITIONS FORDEFINITIONS FOR

THE EXERCISE THE EXERCISE OF AUTHORITY OF AUTHORITY

by THE NHSby THE NHS

National Health Authority

Republic of Colombia

Definitions

ISC SYSTEM

Inspection

Surveillance

Control

Ascertaining the situation with respect to the health services and their resources

Determining compliance with standards in entities responsible for financing, insurance, and service delivery

Order corrective measures for critical or irregular situations and sanction activities of entities monitored

Follow-up, monitoring,

evaluation

Warn, prevent, guide, assist, and

encourage

Correct and

sanction

National Health Authority

Republic of Colombia UNIVERSE OF ENTITIES MONITORED

ENTITIES ENTITIES MONITOREDMONITOREDContributory,Contributory,

Subsidized,Subsidized,

Exempted, andExempted, and

Special SystemsSpecial SystemsPublic andPublic and

Private IPSPrivate IPS

Departmental andDepartmental and

Municipal Municipal SecretariatsSecretariats

Fosyga,Etesa,Fosyga,Etesa, IdumilIdumil

State-owned State-owned Social Social

EnterprisesEnterprises

Public and private EPS

Entities thatEntities that generate generate resourcesresources

Special andSpecial and Exempted Exempted SystemsSystems

National Health Authority

Republic of Colombia

Entities subject to Inspection, Surveillance, and Control

Insurance Entities of the System(EPS, ARS, CCF, ARS, EAS, EMP, and SAP)

83

Public and Private Institutional Health Service Providers

3,920

Entities that generate resources(Lotteries, Apuestas Permanentes, Gaming, liquor, and beers)

500

Territorial Entities(Departments and Municipalities)

1,129

Other Monitored Entities

(CCF, Etesa, Fosyga, Fondo Cuenta, Indumil, special and exempted systems)

47

Subtotal 5,677

Employers 750,000

Total 755,681

National Health Authority

Republic of Colombia ORGANIZATION CHART

National Health Authority

Republic of Colombia

SUPERINTENDENCY SUPERINTENDENCY FOR THE FOR THE

GENERATION AND GENERATION AND MANAGEMENT OF MANAGEMENT OF

FINANCIAL HEALTH FINANCIAL HEALTH RESOURCES RESOURCES

National Health Authority

Republic of Colombia

Guarantee the efficient generation, collection, flow, administration, custody, and use of resources for health service delivery.

OBJECTIVE

National Health Authority

Republic of Colombia

SUPERINTENDENCY SUPERINTENDENCY FOR HEALTH CAREFOR HEALTH CARE

National Health Authority

Republic of Colombia

Perform inspection, surveillance, and Perform inspection, surveillance, and control of the entities under its control of the entities under its jurisdiction, ensuring compliance with jurisdiction, ensuring compliance with the standards set for the management the standards set for the management of health risk within the Social of health risk within the Social Security Health System.Security Health System.

OBJECTIVE

National Health Authority

Republic of Colombia

INSURANCE BUREAU

SUPERINTENDENCY FOR

HEALTH CARE

BUREAU FOR QUALITY AND

HEALTH SERVICE DELIVERY

PUBLIC HEALTH GROUP

HEALTH RISK INSURANCEGROUP

INSURER OPERATIONS

GROUP

QUALITYIMPROVEMENT GROUP

ADVISERS

HEALTH CARE GROUP

INTERNAL STRUCTURE

National Health Authority

Republic of Colombia

SUPERINTENdency SUPERINTENdency FOR user FOR user

PROTECTION AND PROTECTION AND CITIZEN CITIZEN

PaRTICIPAtionPaRTICIPAtion

National Health Authority

Republic of Colombia

POLICY OBJECTIVEPOLICY OBJECTIVE

Ensure respect for users’ rights in the SGSSS through inspection, surveillance, and control, and promote citizen participation and social control following the orientations provided in the participatory mechanisms established by law.

National Health Authority

Republic of Colombia

WORKING GROUPS:

USER CARE GROUP

CITIZEN PARTICIPATION GROUP

INSPECTION AND SURVEILLANCE GROUP

USER ADVOCACY GROUP

SUPERINTENDENCY FOR USER PROTECTION AND CITIZEN PARTICIPATION

National Health Authority

Republic of Colombia

SUPERINTENDENCY SUPERINTENDENCY FOR SPECIAL FOR SPECIAL MEASURESMEASURES

National Health Authority

Republic of Colombia

1. Perform inspection, surveillance, and control of entities subject to corrective measures.

2. By order of the National Health Authority, take over and implement the respective interventions in the entities monitored to administer or close them.

DECREE 1018 /07

National Health Authority

Republic of Colombia

Take over

Forcible intervention

Administer Close

Technical and administrative intervention

Territorialentities

DECREE 1018 /07

National Health Authority

Republic of Colombia

Superintendency for Superintendency for legal affairs and legal affairs and

mediationmediation

National Health Authority

Republic of Colombia

JUDICIAL AUTHORITYJUDICIAL AUTHORITY Hear and issue a definitive ruling, with the legal authority of a judge, on matters specified in the law; in addition, serve as a mediator in any disputes that arise among the entities monitored and/or between these and users that adversely affect the latter’s access to the health services.

National Health Authority

Republic of Colombia

NHS LEGAL FUNCTIONS Law 1122/07, Art. 41

COVERAGE:1. Activities, Procedures, Interventions - POS

REFUNDS:2. Beneficiaries x emergency care

Unjustified denial ornegligence of EPS

3. CONFLICTS Multiple coverage - Free Choice - Mobility--within the SGSSS

National Health Authority

Republic of Colombia

MEDIATION IN NHSLaw 1122/07, Art. 38

CONFLICTS THAT ARISE BETWEEN:

MONITORED ENTITIES AND USERS

MONITOREDENTITIES

(EPS, EPS-IPS, P.E.)

STEMMING FROM PROBLEMS THAT PREVENT THEM FROM MEETINGTHEIR OBLIGATIONS IN THE SGSSS, ADVERSELY AFFECTING USERS’ ACCESS TO THE HEALTH SERVICES.

National Health Authority

Republic of Colombia

National Health Authority

Republic of ColombiaPOLICY

OBJECTIVE

National Health Authority

Republic of Colombia USER CARE GROUP

National Health Authority

Republic of Colombia

THANK YOU!THANK YOU!

Ana Milena RizoAna Milena Rizo

arizo@supersalud.gov.coarizo@supersalud.gov.co