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
[email protected]@supersalud.gov.co