perspectives on the health sector: challenges and opportunities josé gomes temporão, md, phd...
TRANSCRIPT
Perspectives on the Health Sector: challenges
and opportunities
José Gomes Temporão, MD, PhD
Former Minister of Health (2007-2010)
South American Institute of Government in Health (Isags)
THE PRESENTATION
1-BACKGROUND
2- THE TRANSITIONS
3- HEALTH AND DEVELOPMENT
4-THE NEW SOUTH AMERICAN HEALTH CONTEXT
Brazil - Economic and Institutional Scenario
• Macroeconomic stability (inflation, fiscal and monetary policies, etc.)
• Institutional strength (democracy, state organization)
• Stable growth trajectory
GDP 2010 growth: 7,5 %
Long Term Perspective: sustainable growth
Perspective: 5th position in world Economy
Brazil: Social, Demographic and Health System Changes
• Substantive improvement in social inclusion and income distribution
Social assistance programs
Expansion of middle class
GINI index decrease: 9% from 1999 to 2009 (Ipeadata, 2010)
• Universal health system consolidation (Datasus, 2009)
The primary “ Family health care program”: universal access
Infant mortality rate: the biggest decrease in the last 10 years worldwide - 5,2%/year
Life expectancy improvement (from 67 years in 1990 to 73 years in 2009)
Fonte: IBGEElaboração: Ministério da Fazenda
5
The New Middle Class and Mass Market Distribution by social class % of population
The Brazilian Health Reform The Brazilian Health Reform
and The SUS – Unified and The SUS – Unified
Health SystemHealth System
1980’s: After dictatorship’s end a new 1980’s: After dictatorship’s end a new Democratic Constitution is proclaimedDemocratic Constitution is proclaimed
Private services for those who could afford
Social Security for sectors formally employed
Public health for endemics and epidemic hazards
Health as Universal Right Health as State duty Decentralized to states and municipalitiesPublic/Private mixSocial participation at all levels
National (Unified) Health System
Fragmented system
1988198019701960… 1990 2000 2010
Democratic Constitution
SUS – Unified Health SystemSUS – Unified Health SystemSUS IndicatorsSUS Indicators
– 75%75% of the Brazilian population of the Brazilian population
depend on SUSdepend on SUS
– 6,000 hospitals6,000 hospitals
– 64,000 primary care units64,000 primary care units
– 30,000 family health care teams30,000 family health care teams
– 2,3 billion ambulatory 2,3 billion ambulatory
appointmentsappointments
– 12 million hospital admissions 12 million hospital admissions
– 9 million chemo- and 9 million chemo- and
radiotherapy proceduresradiotherapy procedures
‗ 19 thousand transplants sponsored by SUS
– 1 million CT scans and 160,000 1 million CT scans and 160,000
Magnetic RessonanceMagnetic Ressonance
– 8 million hemodialyses 8 million hemodialyses
proceduresprocedures
SUS CharacteristicsSUS Characteristics
1.1. Universality:Universality: SUS, as the SUS, as the Brazilian public system, provides Brazilian public system, provides healthcare for all, regardless of healthcare for all, regardless of distinctions and restrictions;distinctions and restrictions;
2.2. Unity:Unity: one system composed of one system composed of decentralized unities managed by decentralized unities managed by different governmental levels different governmental levels (Federal, State and (Federal, State and Local/Municipal)Local/Municipal)
More than 75% of the Brazilian population depends exclusively on SUS (150 million people) for its health needs
The other 25% has private coverture but uses also the SUS (transplants, high cost drugs, emergency care, vaccines, Aids etc)
NATIONAL HEALTH SYSTEM (SUS)
Private System: Insurance Health Plans Revenue (Brazil, 2000 to 2009)
Note: revenue growth is also the result of improved collection of information by ANS, expressing only partly real growth.
Targeting equityBRAZIL: an unequal country that chose to build
a universal health system
2- THE TRANSITIONS
Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases.
Demografic
Diet Transition
• Technological • (Cultural, organizational, economic)
The Transitions
Trends in deaths patterns according to causes, Brazil 1930-2007
Legenda(Óbitos/100000)
Schmidt MI, et al Lancet, 2011
Diabetes Mortality Rates 1996 - 2007
Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases.
Demografic – Increasing elderly population
Diet Transition
• Technological
The Transitions
1750 205019501850 200019001800
BRASILFecundidade
MortalidadeEUROPA
Mortalidade
Fecundidade
100 ANOS 80 ANOS
30 ANOS 60 ANOS
Ramos, Veras e Kalache, 1987 RSP
Demographic Transition: a Secular Trend
2
6.2
31.8
13.9
1950
1975
2000
2025
‘BOOM’ OF ELDERLY
IN
BRASIL
Ramos, Veras e Kalache, 1987 RSP
( millions of inhabitants 60 +)
Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases.
Demografic – Increasing elderly population
Diet Transition
overweight : de 12% (1975) para 43% (2008) obesity: de 3% (1975) para 13% (2008).
• Technological
The Transitions
0%
20%
40%
60%
80%
100%
Poorest 2nd 3rd 4th Richest
`Hei
gh
tD
efic
it(%
)
1974/5 1989 1996 2006/7
Poorest Richest
Countdown 2008 Equity Analysis Group, Lancet 2008
Height deficit in under 5 ys. according to family income, 1974/5-
2006/7
Poorest 3 42
47,252,1
14,411,4
0
10
20
30
40
50
60
70
80
OBESITY:
16 YEARS!
OBESITY +
OVERWEIGHT: 12 YEARS!%
27.1%
64.2%
NUPENS/USP
Obesity and overweight – How long will take to be at the same level as USA today?
VIGITEL (http://portal.saude.gov.br/) BRFSS para EUA
MEN
Epidemiological – reduction of infectious diseases and increase of cronic and cardiovascular diseases.
Demografic – Increasing elderly population
Diet Transition- overweight, obesity
Technological
The Transitions
3-Health and Development: General
Perspective From Brasil
Health and Development(The Duality of Health)
Health as a citizenship
condition and a
proeminent area of
development
The Duality of Health
Articulation of economic logic with health logic
• Development of production base combined with
health needs Health Sector In Brasil
• About 8% GDP
• 10% of qualified work of the country
• 12 million direct and indirect jobs
• Platform for new technological paradigms (fine
chemicals, biotechnology, eletronics,
nanotechnology, new materials, etc)
Perspective of demand explosion and a strong
pressure on the productive base: a challenge and an
opportunity
28
BRAZIL: Health Industrial Complex (HIC)
Chemical and Biotechnology industries
• Pharmaceuticals• APIs• Vaccines• Blood Products• Diagnostic Reagents
Mechanic, Electronic and Materials
Industries
Hospitals AmbulatoriesDiagnosis and Therapeutic
Services
Health Services
Industrial Sectors
• Mechanical equipments• Electronic equipments• Prothesis and orthosis• Materials
Source: Gadelha, 2003
STATE..
PROMOTION+REGULATION
Informações Selecionadas
Maior base industrial da América Latina
Mercado farmacêutico de US$ 20 billion (alta tx de crescimento)
Posição no ranking: entre os 9 maiores mercados mundiais
Estrutura internacionalizada, porém com um significativo fortalecimento do capital nacional com base nos genéricos
Elevado dinamismo nas vendas de medicamentos no período recente (todos segmentos)
Produção de vacinas com elevado dinamismo (PNI e produtores públicos): R$ 900 milhões
Estratégia nacional para Hemoderivados: Hemobrás
Produção de reagentes limitada e de baixo conteúdo tecnológico
Especialização em atividades de menor conteúdo tecnológico
Papel destacado do Estado nas compras de todos segmentos
Health within a Development Context: Panorama of the Pharmaceutical Productive Chain (1)
Indústria de Equipamentos e MateriaisInformações Selecionadas
Dinamismo do segmento no período recente
Mercado em torno de R$ 8 bilhões
Predomínio de empresas de pequeno e médio porte Estrutura empresarial fragmentada
Afastamento da fronteira tecnológica
Perda de competitividade nos segmentos mais dinâmicos
Papel destacado do Estado nas vendas do setor (50%)
Health within a Development Context: Panorama of the Pharmaceutical Productive Chain (3)
Market domain for the international leaders
Specialization of the local companies in activities of smaller technological content
Permanent commercial deficit even after the depreciation
Significant role of the government purchases (politics of blood and attendance in general)
Health within a Development Context: Panorama of the Pharmaceutical Productive
Chain (4)
Reagents for Diagnosis Industry – Selected Information
HIC 2009 – Evolution of Brazilian Health Trade Balance: General Overview
(values in US$ Billions, updated by USA Inflation)
HIC 2009 - Brazilian Health Trade Deficit by Sector
Health, Innovation and Development:
policy perspectives
Institutionalization of
an integrated policy
Productive Development Policy (PDP-2008)
Mobilization Programmes in Strategic Areas
Health Industrial Complex
Nuclear Energy
Information and CommunicationTechnologies
DefenseIndustrial Complex
Nanotechnology Biotechnology
Programmes to Strengthen Competitivity
AutomobileComplex
Capital Goods Textile Woods andFurniture
Hygiene,Perfumery
and CosmeticsCivil Construction Services Complex
BiodieselNaval Industry and
Cabotage
Leathers, Footwear and
ArtifactsAgro industry Plastics OTHEROTHER
Programmes to Consolidate and Expand Leadership
AeronauticsComplex
Mining SteelCellulose and
Paper
Petroleum, Natural Gas andPetro chemistry
MeatBio ethanol
PDP: The Context - Public PDP: The Context - Public PoliciesPolicies
Programme of Growth Acceleration (PAC): in expansion and oriented to overcoming structural bottlenecks
Plan of Science, Technology and Innovation: programmes oriented to the promotion of scientific and technological development and innovation in the country
Plan for the Development of Education: quality investments applied to overcoming the greatest restriction to long-term development – training of the Brazilian people
“Mais Saúde”*: directly responds to immediate needs and builds on future capacity in the field of public health in Brazil
Structural and convergent projects are currently under way in Brazil
*Plus Health
HIC: Actions and Measures (1)HIC: Actions and Measures (1)
Use of the state purchasing power
to stimulate domestic production
Revision of regulation for governmental purchases-Pre-qualification, competitive isonomy, taxes waving and orders ofstrategic products for health innovation
Financial supportfor increased
production capacity
New Profarma: Supporting Programmes for the Development of the Health Industrial Complex
- Objective: to increase the competitiveness of the HIC, by means of disseminating innovative activities and increasing the production of devices, materials, medicines and related products, contributing to the international insertion of national firms
- Resources: US$ 2 billion between 2008 and 2012
Governmental Purchases- US$ 7,5 billion/year between 2008 and 2011
Budgetary Resources of the Ministry of Health:- US$ 582 million between 2008 and 2011
ActionsActions MeasuresMeasures
HIC: Actions and Measures (2)HIC: Actions and Measures (2)
Expansion of available resources for R&D in strategic areas
Research and Technological Development in Health Priority and the Establishment of National Centres of Toxicology and Clinical and Pre-Clinical Research (at least two networks)- US$ 700 million between 2008 and 2013
New Profarma: Sub-Programme Innovation- Objective: to support projects of firms, the construction and consolidation of infrastructure for health innovation, as well as the internalization of competences and R&D&I activities in Brazil
ActionsActions MeasuresMeasures
FUNTEC – Technological Fund: Non-reimbursable resources
- Strategic Areas 2008: Health, Renewable energies and Environment
- Active Principles and Medicines for Neglected Diseases; drugs that use of the technique of recombining DNA; construction of infrastructure for health innovation that includes bioteries, pre-clinical and clinical research
HIC: Strategic Areas for R&D&IHIC: Strategic Areas for R&D&I
3 45 6
Production of devices and materials used in health
as a response to the National Health Policy
Reactives and Diagnostic Devices for Blood Control
based on Moderns Biotechnologies
Production of medicines and active principles for pharmochemicals
Productive and Scientific-Technological Challenges
1Domestic production of
hemoderivatives (factors 8 and 9, albumine
and globulines) 2 Development of Vaccines for the National Immunization
Programme
RegulatoryRegulatorylandmarklandmark
Production of Biotechnological
Products for Health
Health R&D – The MoH’s Role (2)
• Some relevant projects in course– National Network on Cell Therapy (RNTC).– National Network on Clinical Research (RNPC).– National Network on Health Technology
Assessment HTA (REBRATS).– National Cohort on Adult’s Health – CV diseases,
diabetes, mental conditions (ELSA).– National Cancer Research Network.– Research on Neglected Diseases (~ 460 projects on
Chagas Disease, Malaria, Leishmaniasis, Schistosomiasis, etc.) .
The Brazilian Policy for the Health Industrial Complex: recent trends
• Articulation between health, industrial and S&T policy
Intergovernmental Group involving 15 ministries and agenciesagencies
• Production Development Partnership
20 public-private partnership to produce strategic productsproducts
• Use of the public purchase power to stimulate innovation in health
• Regulatory System Evolution
Executive Group of the Health Industrial Complex - Executive Group of the Health Industrial Complex - GECIS GECIS
GECISGECIS
WG TributaryWG Tributary
exemptionexemption
WG TransversalWG Transversal
Actions Actions WG WG government government
purchasepurchase
WG WG Biopharmaceutical Biopharmaceutical
regulationregulation
Articulation Forum:
22 represents of the civil society, and from the entrepreneur sector.
Participants:
MS (coordinator), MCT, MDIC, MPOG, MF, MRE, Casa Civil, ANVISA, FIOCRUZ, FINEP, BNDES, INMETRO, INPI and ABDI.
The Brazilian Policy for the Health Industrial Complex: recent trends
• Articulation between health, industrial and S&T policy
Intergovernmental Group involving 15 ministries and agencies
Convergence of incentives (investment, market, innovation)
• Production Development Partnership
30 public-private partnership to produce strategic products
• Use of the public purchase power to stimulate innovation in health
• Regulatory System Evolution
Arrange a good balance between health access and innovation
Public and Private Development PartnershipPublic and Private Development Partnership (PPDPs)(PPDPs)
NINE PARTNERSHIP AGREEMENTS WERE
ALREADY ESTABLISHED INVOLVING :
• 9 public companies;
• 20 private companies ;
• Local development and production of 28 active principles (API`s).
• The public purchases with these API’s currently reach around R$ 1,5 billion per year.
• After full implementation, these partnerships will be able to save an estimated amount of R$ 390 million per year.
PPP’s em Andamento
The Brazilian Policy for the Health Industrial Complex: recent trends
• Articulation between health, industrial and S&T policy
Intergovernmental Group involving 15 ministries and agencies
Convergence of incentives (investment, market, innovation)
• Production Development Partnership
20 public-private partnership to produce strategic products
• Use of the public purchase power to stimulate innovation in health
• Regulatory System Evolution
Industrial Policy – MoH (2)
• Reforming the Health Regulatory Framework.– Building a special status for the health
government purchasings (“Buy Brazilian” Act for the health products).
– Improving the purchasing processes in the health public sector (quality guarantee).
– Improving the Sanitary Surveillance regulations, together with ANVISA
A New Agenda of Cooperation in The New National Context
• From simple trade and production relationship to:
Benefits in terms of universal access
Investment in higher technological products and process
Cooperative R&D in Brazil
Partnership with local private and public producers
Enhancement of trade balance results
Main innitiatives to expand rational access to medicines and vaccines in
Brazil.
1. Pharmaceutical Assistance Programs (strategic and high costs medicines)
2. Popular Pharmacies Program.
3. Generic Drugs Consumption Program.
4. The National Immunization Program.
Expenditure in Medicines – Ministry of Health Budget
(%)
Source: SCTIE/MS
Health and Development in BrazilPolitical Context
For the first time, Brasil has na
industrial policy in health, to
strengthen its pharmaceutical
industry, having production
capacity and reduce its
dependence on this area
Health as a Window of Opportunity
Dimension of the national market (SUS and Private Sector) and high demand
Existence in Brazil of a productive tradition (the most developed in Latin America)
Scientific structure and human resources A well structured sanitary regulatory system organized on
a national basis Macroeconomic stability (investment grade) Projected Industrial GDP growth (yearly): 5% (2008/11) Reduction of income inequalities (high market impact) Priority of Health Economic-Industrial Complex within
national policy
4- The Growing Importance of Health in the Globalization Context
• Health as a central issue in the international relations:
South-south cooperation• Latin America
• Portuguese-Speaking African Countries
• Haiti
• The Union of South American Nations (UNASUR)
Global Health: The South American Institute of Government in Health (Isags)
Governance for Health
•ISAGS is a public, intergovernmental
entity within the South American Health
Council of the Union of South American
Nations (UNASUR); with permanent
headquarters in Rio de Janeiro
Governance for Health
• Its activities will be closely articulated with the Ministries of
Health of UNASUR countries in:
• knowledge management and generating innovation in policy and
governance for health,
• offering the best available practices and evidence to guide health
management;
• developing leadership on systems, services, organizations and
programs on health-related areas,
• providing technical support to government institutions in the health
sector.
Networking
ISAGS will collaborate with other institutions of
national, regional and global scope.
South America Network of National Institutes of Health (RINS);
South America Network of National Public Health Schools
(REGS);
South America Network of Technical Health Schools (RETS);
South America Network of Workshops on International Relations
in Health (ORIS);
Latin-America Network of National Institutes of Cancer (RINC).
The Unasur Strategic Agenda
2010-2015 Health Quinquennial Plan
Health Surveillance and Response;
Universal Health Systems;
Universal Access to Drugs;
Health Promotion and Action on Social Determinants of
Health;
Human Resources for Health.
Cooperação Sul-Sul e CIS
• Saúde e Desenvolvimento• Cooperação não pode olhar apenas
para a oferta de insumos, tecnologias• Compreensão mais ampla do processo
de desenvolvimento das sociedades e como a saúde se insere nele
• Inclui a gestão de tecnologias, desenvolvimento e inovação, visando a redução da dependencia
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OBRIGADO!