Building the Foundations for Better Health
Health Services Organization
Policy Options for the Integration of Health Systems and Services
VII REGIONAL FORUMStrengthening of Health Systems Based on
Primary Health Care (PHC)Quito, Ecuador
29-31 October 2007
Health Systems Based on Primary Health Care
Right to Health
Equity
Solidarity
Capacity torespond to
health needsFocus on
quality
Res
pons
ibili
ty
and
acco
unta
bilit
y
Social
justice
Sustainability
Participation
Inte
rsec
tora
l
appr
oach
FirstcontactComprehensive,
Integrated, and
continuous care
Fam
ily and
comm
unity
orientation
Em
phasis onprom
otion andprevention
Appro
pria
teca
re
Mechanisms
for active
participationAcceptable
legal, policy, andinstitutional framework
Pro-equity policies
and programs
Optim
al
organization
and managem
ent
Ad
eq
ua
te
hu
ma
nre
sou
rce
s
Res
ourc
esad
apte
d t
o ne
eds
Inte
rsec
tora
l
actio
n
Universal
coverage
Health Services
The greatest challenge in terms of the organization and delivery of health services is fragmentation.
Policy Options for the Integration of Health
Systems and Services
Starting Point … Segmentation of health systems and
fragmentation of health services Pressures on health systems Shortcomings of care and organizational
models Progress worldwide and in countries of
the Region
Fragmentation Problems
Quality of Care and Results
Lack of continuity in care
Lack of coordination between the first level and specialized
levels of care
Many practices and interventions are not evidence-based
Wide variety of clinical practices
No incentives for health promotion
Costs Inefficient management of resources - Duplication (services,
procedures, diagnostic tests, etc.)
Lack of incentives for quality. Disparity between levels of care
Policy Options for the Integration of Health
Systems and Services
The Tower of Babel? : Networks:
“Not all networks are integrated networks”
Coordination – Integration Segmentation and Fragmentation Primary health care (PHC) vs. primary
care or first-level of care Public health and public health services
What does the project aim to contribute?
Policy Options for the Integration of Health
Systems and Services
Key questions: 1. What is the most appropriate
response to the fragmentation of health services and the problems that it creates?
2. What defines an Integrated Health Services Network?
3. How can we measure the extent of health services integration?
4. How can we address the organization of integrated networks?
Policy Options for the Integration of Health
Systems and Services
Integrated Delivery Systems (IDS): “An integrated system is a network of
organizations that provides, or is organized to provide, ongoing and coordinated services to a particular population, and that takes responsibility for the clinical and financial results and the health outcomes of the population it serves. These systems, widely participatory and vertically integrated, offer a wide range of outpatient and in-patient services, care for acute and chronic illness, and home care.” (Shortell et al.)
Definitions:
Additional elements:
Based on the Primary Health Care Strategy and coordinated from the first level of care
With geographic responsibility Integrated vertically and coordinated
horizontally Also integrates public health services
Policy Options for the Integration of Health
Systems and Services 1. An expanded definition: Integrated Systems of Health Services:
“A network of organizations that provides, or is organized to provide,
ongoing services based on primary health care and coordinated
from the first level to a particular population in a particular
territory, and that is accountable for the clinical and financial results
and the health status of the population it serves. These systems,
widely participatory, vertically integrated, and horizontally
coordinated, offer a wide range of services to address the ongoing
needs of their users, from promotion and prevention to outpatient
and in-patient services, care for acute and chronic illnesses, home
care, rehabilitation, palliative care, and public health services.”
Policy Options for the Integration of Health
Systems and Services
2. Attributes of integrated networks: Reference population is in a defined area Support systems are organized Health needs and priorities Scope of services Distribution of roles Integrated and coordinated care model Measurement of the impact of services
Policy Options for the Integration of Health
Systems and Services
3. Strategic and operational attributes for measuring integration: Governance Financial mechanisms Management of the network Computer support systems Integration mechanisms Identification of health needs Care model Intersectoral action Monitoring and evaluation model
62 Operational Attributes
Evaluation of the Health Services Network
Strategic Attributes
Operational Attributes Degree of Compliance
Governance
Is there a single government structure?
Does it have a Mission and Vision Statement geared to network integration and management?
Does it have clearly established structures that differentiate between management of the network and the coordination of care?
Is there user representation with at least an advisory role in the governance structure?
Financial Mechanisms
Sufficient and available financing
Multiple contracts for the purchase of services, single or integrated financing of insurance
Financing mechanisms: Capitation, annual budget
Does it have a defined financial management system?
Existence of financial incentives and an organizational structure that aligns government, management, medical entities, and other providers in order to achieve the objectives.
Availability of information on costs, quality, results, and satisfaction for the different segments—users, employees, funders, and society
Existence of incentives to keep people healthy that reward promotion and prevention activities?
Policy Options for the Integration of Health
Systems and Services
4. Policy options for integration: Options for governance:
Legal security for organization in an integrated network
Legal structure and framework for governance
Financing, payment mechanisms, incentives, financial protection for the population
Options for financing:
Capitation
New payment mechanisms for providers
Incentives
Policy Options for the Integration of Health
Systems and Services
Insurance policies and protection of the population
Policies for the procurement of services Public providers Private providers
Public-private participation (legal framework)
Policies for the organization of services Care model Vertical integration and horizontal
coordination
Policy Options for the Integration of Health
Systems and Services
Policies for the generation and use of resources:
Human resources policies
Education Training
Substitution
Continuing education
Evaluation and introduction of technologies
Policy Options for the Integration of Health
Systems and Services
5. Phases in the configuration of integrated health services systems1. Situation analysis of health care and population-based health networks
2. Definition of the care model
3. Delimitation of health areas and levels of care
4. Design of services network
5. Configuration of the first level of care
6. Configuration of the second and third levels of care
7. Configuration of support services and logistical systems
8. Vertical integration of the services network
9. Configuration of the governance model
10. Design of monitoring and evaluation systems.
Success Factors
1. Align the delivery network with community needs
2. Strengthen primary health care and the first level of care
3. Strengthen and integrate the information system
4. Provide relevant information on costs, quality, and clinical results
5. Adopt a culture of shared risk 6. Align suppliers, managers, and government
structures.
Health Systems Based on PHC
Right to Health
Equity
Solidarity
Capacity torespond to
health needsFocus on
quality
Res
pons
ibili
tyan
d ac
coun
tabi
lity
Social
justice
Sustainability
Participation
Inte
rsec
tora
l
appr
oach
FirstcontactComprehensive,
integrated, and
continuous care
Fam
ily and
comm
unity
orientation
Em
phasis onprom
otion andprevention
Appro
pria
teca
re
Mechanisms
for active
participationAcceptable
legal, policy, and institutional
framework
Pro-equitypolicies andPrograms
Optim
al
organization
and managem
ent
Ad
eq
ua
te
hu
ma
nre
sou
rce
s
Res
ourc
esad
apte
d t
o ne
eds
Inte
rsec
tora
l
actio
n
Universal
coverage
Health Services OrganizationIntegrated Hospitals and Health Services Systems
Building the Foundation for Better Health
Dr. Reynaldo Holder Regional [email protected]
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