¿como es un buen sistema de salud?

Prof. Rifat Atun MBBS MBA DIC FRCGP FFPHM FRCP Professor of Global Health Systems Harvard University

How a good health system should beSalud en TodasIV Chilean Congress of Public Health and VI Chilean Congress of Epidemiology, La Serena, Chile, December 2-3, 2016

1. Health in South America: achievements2. 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

Life expectancy at birth


19901991

19921993

19941995

19961997

19981999

20002001

20022003

20042005

20062007

20082009

20102011

50

60

70

80

Argentina Brazil Chile Colombia Costa RicaCuba Mexico Peru Uruguay Venezuela

Years

Life

exp

ecta

ncy

at b

irth

(yea

rs)

Health service coverage and health outcomes: selected countries of Latin America

© Prof. Rifat Atun, Harvard University, 2015

Total gain in life expectancy 1950-55 to 2010-15


Africa

Asia

Europe

Latin Ameri

ca & Cari

bbean

North Ameri

ca

Oceania

0

5

10

15

20

25

30

1950-55 to 1990-95 1990-95 to 2010-15 Total

Tota

l gai

n in

life

exp

acta

ncy

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

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

http://www.thelancet.com/journals/lancet/article/S0140-6736(12)61689-4/abstract


Cancer: disability-adjusted life years per 100 000 by cause and region in 2010

Source: Murray C, et al. : The Lancet 2012 10



Change in burden of disease


Argentina Brazil Chile Colombia Costa Rica Cuba Ecuador Mexico Peru Uruguay Venezuela0

5000000

10000000

15000000

20000000

25000000

30000000

35000000

40000000

1990 2010

DALY

s

Epidemiological transition

The age of multimorbidity and disability


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

Multimorbidity (2+ co-existing chronic diseases in populations aged 60+)

13

Australia (60+) Australia (75+) Canada(60+) Canada(80+) Germany (65+)

India (70+) Ireland (70+) Scotland (65-84)

Scotland (85+) USA(65+)0

10

20

30

40

50

60

70

80

90

42

75

55

64

59

80

60

65

82

67

% o

f old

er p

opul

ation

with

mul

timor

bidi

ty


What’s to come – Multimorbidity challenge: Estonia case study (1)


2005 2012 2005 2012 2005 2012 2005 2012MM1 MM2 MM3 MM4

0

1

2

3

4

5

6

7

8

9

10

2.322.76

4.14

5.065.79

7.17.56

9.27

Aver

age

num

ber o

f yea

rly

PHC

visi

ts

Atun et al JOGH 2016

What’s to come – Multimorbidity challenge: Estonia case study


2005 2012 2005 2012 2005 2012 2005 2012MM1 MM2 MM3 MM4

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.04 0.03

0.170.12

0.36

0.3

0.7

0.56

Aver

age

num

ber o

f Inp

atien

t adm

issi

ons

1. Epidemiological Challenge

Atun et al JOGH 2016

Coverage of maternal health services: selected countries of Latin America


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

Diabetes mortality rate per 100 000 population (2002-09) in persons aged 15 years or greater by educational attainment

(years of schooling)

18

2001 2002 2003 2004 2005 2006 2007 2008 20090

20

40

60

80

100

120

140

160

0 - 3 years

4 - 7 years

8 years and more

Total

Years

Mor

talit

y ra

te p

er 1

00 0

00 p

opul

ation

All cause death rates (age standardised) by deprivation twentieth (England and Wales) (1999-

2003)

19Source: WHO Commission on Social Determinants of Health

21

Health systems productivity challenge: US real sector growth 1990-2010

Kocher R, Sahni NR. Rethinking Health Care Labor. N Engl J Med 2011; 365:1370-1372

US Economy

Health &

socia

l care

Manufacturin

gRetail

Finance

& in

surance

Professi

onal, scie

ntific & le

gal

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Real sector growth (%) Employment growth (%) Labour productivity growth (%)

Health expenditures as a % of GDP


1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2

4

6

8

10

12

Argentina

Brazil

Chile

Colombia

Costa Rica

Mexico

Peru

Uruguay

Years

Tota

l Hea

lth E

xpen

ditu

re a

s a %

of G

DP

Increasing financing for health

23

Average length of stay in hospital for acute myocardial infarction (OECD 2000 and 2011, or nearest year)

KoreaGermany

EstoniaNew Zealand

FinlandHungary

AustriaIreland

ItalyPortugal

ChileUnited Kingdom

SpainSloveniaBelgiumGreece

OECD33IcelandMexico

SwitzerlandCzech Republic

LuxembourgFrancePoland

CanadaNetherlands

IsraelAustralia

United StatesSweden

Slovak RepublicNorwayTurkey

Denmark

0 5 10 15

11.610.4

9.29.2

8.88.48.3

7.97.97.97.87.77.67.5

7.27.06.9

6.86.76.7

6.46.36.26.2

5.95.85.7

5.55.4

4.74.6

4.04.03.9

Days

Efficiency



– Epidemiological transition and polarization– Productivity– Austerity, its consequences and the importance of UHC– Challenges



South America: government and private health expenditures


19952000

20052010

19952000

20052010

19952000

20052010

19952000

20052010

19952000

20052010

19952000

20052010

19952000

20052010

19952000

20052010

19952000

20052010

19952000

20052010

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Years

Gov

ernm

ent (

bott

om p

art)

and

Pri

vate

(top

par

t) H

ealt

Exp

endi

ture

s as a

Per

cent

age

of T

otal

Argentina Brazil Chile Colombia Costa Rica Cuba Mexico Peru Uruguay Venezuela

Improving efficiency of health

financing

Out of pocket expenditures as proportion of private expenditures


1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

10

20

30

40

50

60

70

80

90

100

ArgentinaBrazilChileColombiaCosta RicaMexicoPeru

Out o

f Poc

ket E

xpen

ditu

res

as a

per

cent

age

of p

rivat

e ex

pen-

ditu

res

Improving efficiency of health

financing

Persistent segregation and disparities


Economic crises and adverse effect on health outcomes


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

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

GoodHealth

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


Towards a new health system

34

Effective

EfficientEquitable

Empowering and Responsive

Source: Atun et al. Lancet 2013© Prof. Rifat Atun, Harvard University, 2015

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

3.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


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


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


1. Optimising content

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


1. Optimising content

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


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


Health maintenance

Focus on individuals: risk based population segmentation

Casemanagement

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


42

Technology enabled person driven healthcare

Health coach / case manager

Interactive Online Information

Technology enabled monitoring and

intervention

Peer Group Support

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.”


Thank you


¿como es un buen sistema de salud?

Healthcare