PUBLIC INSURANCES IN PUBLIC INSURANCES IN BOLIVIABOLIVIA

BOLIVIA

Ministry of Health and SportsPublic Insurances Unit

Dr. Margarita Flores

Ministry of Health and Sports

Health protection, disaggregated by provider – 2003 (National Health Insurance Institute - INASES)

Public health: 30%

Short-term social security (SSCP): 25%

Private health services: 12%

“33% of the Bolivian population is unprotected”

INTRODUCTION

INTRODUCTIONHealth protection, disaggregated by provider – 2003 (INASES)

33% unprotected population

30% public health

25%SSCP

12% private

30% unprotected population

30% public sub-sector

28% SSCP sub-sector

12% private sub-sector

NATIONAL CONTEXT

Health protection coverage, 2004

Sources: National Health Information System - SNIS, National Institute of Statistics - INE and INASES, 2003-2004

National Health Spending, disaggregated by source of financing – 2002 (in thousands of current dollars)

Sources Total Percentage

Public Sector 113,416 20.94%SSCPPrivate InsuranceNGOHouseholds

Percentage of GDPTOTAL

222,410 41.07%3.83%1.49%

541,54732.67%

6.95%

176,908 8,086 20,727

Source: Estudio CNFGS. Cuentas Nacionales de Financiamiento y Gasto en Salud. Segunda Edición. Marina Cárdenas. Bolivia – 2004.

INTRODUCTION

INTRODUCTION

Public health: US$ 42 per capita(30%)SSCP: US$ 91.5 per capita (25%)Private: US$ 190 per capita (12%)

National Maternal and Child InsuranceD.S. 24403 in 199632 Services.

Basic Health InsuranceD.S. 25265 in 199892 Services.

Free Old-Age Health InsuranceLaw 1886 in 1998Comprehensive Health Care.

Universal Maternal and Child Insurance Law 2426 in 2002500 Services.

Expanded SUMI Law 3250 in 200527 Services in Sexual and Reproductive Health, Women of Reproductive Age.

Health Insurance for the Older Adult (SSPAM)Law 3323 in 2006Comprehensive Care, Payment is 100% Municipal.

PUBLIC HEALTH INSURANCES

Current situationCurrent situationSUMISUMI

Ministry of Health and Sports

WHAT IS THE SUMIWHAT IS THE SUMI

Component of of the Bolivian Poverty Reduction Strategy.

It is a state policy and health strategy for reducing maternal and child morbi-mortality.

It provides free services for the child under five years of age and the pregnant woman up to 6 months following delivery, in a compulsory, restrictive manner in public and social security establishments.

The services are provided using the existing technology and problem-solving capacity that corresponds to the levels of care and according to established protocols.

It is a State Policy created by the Law of the Republic 2426

Priority within the Health Policy of the Ministry of Health and Sports

Component of the Bolivian Poverty Reduction Strategy

Primary instrument for meeting the Millennium Development Goals

SUMISUMI

SUMISUMIReduce maternal and child morbidity and mortality

Protect the most vulnerable population groups in the country, where the highest mortality rates are concentrated

SUMISUMIBENEFICIARIESBENEFICIARIES

Girls and boys from birth to five years of agePregnant women, from the start of pregnancy until 6 months following the birthTARGET POPULATION:

– 1,279,269 children under 5 years of age

– 328,682 pregnant women

2002 327,216.99 1,235,5822003 327,700.37 1,252,1572004 328,190.95 1,267,3252005 328,681.52 1,279,2692006 329,172.10 1,287,4692007 397,520.00 1,293,1302008 398,193.00 1,297,0412009 398,893.00 1,300,0202010 399,280.00 1,302,868

CHILDREN UNDER 5 YEARS OLDYEARS EXPECTED PREGNANCIES

POPULATION PROJECTIONS

SOURCE: National Institute of Statistics - INE

SUMISUMI WHERE IS IT PROVIDED?WHERE IS IT PROVIDED?Throughout the country, in 2,259 health establishments, in urban and rural areasIn Public Health and Short-Term Social Security Establishments (National Health Insurance) and others that are included through agreementsAt all levels of care, according to problem-solving capacity and available technology

HOW IS IT PROVIDED?HOW IS IT PROVIDED?SUMISUMI

It is universal, comprehensive and free (For the user)

Provided in a compulsory, restrictive manner

For communities with difficult access or without health infrastructure, there are Mobile Brigades through the Extend (Extensa) Program

EXPANSION OF THE SUMIEXPANSION OF THE SUMI

In December 2005, Law Number 3250 for the expansion of the SUMI was passed

Services that have a close link with safe maternity:

1. Prevention of Cervical Cancer

2. Treatment of Pre-malignant Injuries

3. Voluntary Contraceptive Methods

4. Treatment of STIs

FINANCIAL ADMINISTRATIONFINANCIAL ADMINISTRATION

Ministry of Health and Sports

Financing of the SUMITributary

Co-Participation7% in 20038% in 2004

10% starting in 2005

Exceeds

Investment in Health Infrastructure, Basic

Sanitation and Special Health Insurance Programs

Lacks National Solidarity Fund

Up to 10% of the resources from the Dialogue Account 2000

Essential medicines, supplies and reagents

Human Resources

Public: National Treasury - TGN

Social Security: Own resources

Ministry of Health and

Sports

ACHIEVEMENTS OF ACHIEVEMENTS OF THE PUBLIC HEALTH THE PUBLIC HEALTH

INSURANCESINSURANCES

Ministry of Health and Sports

Ministerio de Salud y Deportes

 

One of the contributions of the Public Insurances implemented in the country is the reduction of the mortality rates. Although this represents an important process, we remain nevertheless the country with the second highest maternal mortality ratio and child and neonatal mortality rates.

Contribution to reductions in the Mortality Rates

ENDSA: Demographic and Health Survey

Source : Monitoring and Evaluation of the Poverty Reduction Strategy – PRS

7592

116

142

0

20

40

60

80

100

120

140

160

ENDSA 89 ENDSA 94 ENDSA 98 ENDSA 03

Dea

ths

x 1,

000

live

birth

sMORTALITY RATES IN CHILDREN < 5 YEARS OLD

-47%

54

6775

96

0

20

40

60

80

100

120

ENDSA 89 ENDSA 94 ENDSA 98 ENDSA 03

Dea

ths

x 1,

000

live

birth

sINFANT MORTALITY RATES < 1 YEAR OLD

-44%

INFANT MORTALITY RATES < 1 YEAR OLDP

er 1

,000

live

birt

hs

Infant MR

Urban

Rural

Years

MATERNAL MORTALITY RATEP

er 1

00,0

00 li

ve b

irths

Years

MDGs

PRS Project

5%

9%5%

18%

27%

1%

6%

4%

25%CHUQUISACA

LA PAZ

COCHABAMBA

ORURO

POTOSÍ

TARIJA

SANTA CRUZ

BENI

PANDO

PERCENTAGE OF TRIBUTARY CO-PARTICIPATION BY DEPARTMENT, SUMI 2004

81%

19%

135,558,560.00 100% Amount Paid Out109,590,618.00 81% Amount Utilized25,967,942.00 19% Unused Balance - Surplus

MUNICIPAL TRIBUTARY CO-PARTICIPATIONSUMI 2004

Expressed in Bs. and %

DepartmentsTotal

MunicipalitiesMunicipalities that

accessed funds%

La Paz 75 2 3%Cochabamba 44 4 9%Santa Cruz 50 10 20%Chuquisaca 28 4 14%Potosí 38 1 3%Tarija 11 2 18%Oruro 34 0 0%Beni 19 3 16%Pando 15 2 13%

314 28 9%

Percentage of Municipalities that accessed the National Solidarity Fund (FSN), by Department 2004

61%

39%

Porcentaje de ejecución

Porcentaje no ejecutado

28,172,160 100.00% Amount Allocated

17,313,275 61.46% Amount Utilized

10,858,885 38.54% Balance Not Utilized

NATIONAL SOLIDARITY FUNDSUMI - 2004 - Expressed in Bs.

Percentage used

Percentage unused

ANALYSIS OF THE S.U.M.I.ANALYSIS OF THE S.U.M.I.

Expansion of Coverage and Services,

Extension of Health to impoverished sectors,

Participation in Service Networks,

Standardization of care through Protocols,

Overall reduction of Maternal and Child Mortality,

Insufficient Information in the National SUMI Management Unit,

Lack of Technical Provisions in the Presentation and Application of the SUMI Expansion Law,

Mechanisms for controlling deficient Affiliation,

Unreal reference costs for services,

Care for the SUMI target population, with preference for the third level of care,

Irrationality in the selection of services and packages by level,

Complexity in administrative processes,

Bureaucracy and deficient management at the municipal level, which impedes timely payment to health establishments for services provided under the SUMI

Population that is highly concentrated in urban areas (64%), principally in the capital cities of La Paz (Including El Alto), Cochabamba and Santa Cruz

Work-related instability and high rotation of personnel, without information about the procedures, knowledge and norms for new human resources in the management sphere

Problems identified

ChallengeChallengeUNIVERSAL HEALTH UNIVERSAL HEALTH INSURANCE (SUSINSURANCE (SUS))

Ministry of Health and Sports

Gathering the experiences with public insurances, as a gradual building process, in

order to achieve UNIVERSAL HEALTH INSURANCE - SUS

FROM THE CURRENT GOVERNMENT AND THE MINISTRY

OF HEALTH AND SPORTS

UNIVERSAL HEALTH INSURANCEUNIVERSAL HEALTH INSURANCEOBJECTIVEOBJECTIVE

ACHIEVE ACCESS TO HEALTH SERVICES FOR THE ENTIRE BOLIVIAN POPULATION, THROUGHOUT THE WHOLE NATIONAL TERRITORY AND IN A COMPREHENSIVE MANNER

•Participation of the entire National Health System,•Improve the quality of medical care,•Implement the Model of Family, Community and Intercultural Health as an operational arm of the Insurance,•Ensure that Health Promotion and Prevention are pillars of the Health System,•Establish instruments to provide quality and efficiency in the provision of Health Services.

UNIVERSAL HEALTH INSURANCEUNIVERSAL HEALTH INSURANCESPECIFIC OBJECTIVESSPECIFIC OBJECTIVES

Source of Financing Percentage US$ / Annual

Municipal Tributary Co-participation 10% 30,500,000

HIPC-II* ResourcesNational Solidarity Fund 10% 2,900,000

HDI (Human Development Index) by Prefecture 14% 32,400,000

T O T A LT O T A L 65,800,00065,800,000

First PhaseYears 0-21

Implementation January2007

* HIPC: Heavily Indebted Poor CountriesSource: Ministry of Housing

SOURCE OF FINANCINGSOURCE OF FINANCING

Population Over Age 60

(SSPAM)6%

Short-Term Insured

Population (National Health

Insurance)25%

S.U.S. Target

Population69%

TARGET POPULATIONTARGET POPULATIONFrom 0 to 59 Years of AgeFrom 0 to 59 Years of Age

Legal Study

Socio-Economic

Study

Study ofthe

EpidemiologicalProfile

ActuarialMathematic

Study

SustainabilityStudy

Medical Technical

Study

Multi-disciplinaryTechnical

Team

CoveragePremium

SUS TargetPopulation

UNIVERSAL HEALTH INSURANCEUNIVERSAL HEALTH INSURANCE ANALYSIS FOR ITS IMPLEMENTATIONANALYSIS FOR ITS IMPLEMENTATION

FIRST PHASE

2006 ADMINISTRATIOND.S. 28748 – Financing of the harmonization of Health insurance measures- from years 5 to 21-

Development of the draft project for the SUS Law

REQUIRED STUDIESStudy of Population Projections, Actuarial Study disaggregated by levels of care, Analysis and Evaluation of the Cost-Effectiveness of Public Insurances,Study of the structure of costs based on Public Insurances,

UNIVERSAL HEALTH INSURANCE

FIRST PHASE

2006 ADMINISTRATIONREQUIRED STUDIESStudy of general costing of SUS services,Study of the Sustainability and Economic-Financial Viability of the SUS,Analysis of information on prevalent pathologies using statistics from the National Health Information System - SNIS, the National Health Insurance Institute - INASES, the National Health Insurance - Cajas de Salud, and others,Analysis of information on Incidence, Prevalence and FrequencyTechnical-medical-financial proposal for the Universal Health InsuranceAnalysis of indicators.

UNIVERSAL HEALTH INSURANCE

FIRST ACHIEVEMENT

D.S. 28748 – Financing of the harmonization of public health insurance measures

SECOND ACHIEVEMENTDraft project of the SUS Law

THIRD ACHIEVEMENTHealth Care Model: Family, intercultural and community

Quality management

UNIVERSAL HEALTH INSURANCE (SUS) 2006 Administration

“THOSE THAT ATTEMPT REFORM WILL HAVE AS ENEMIES EVERYONE THAT TAKES ADVANTAGE OF THE OLD SYSTEM, AND AS WARM ADMIRERS ONLY THOSE THAT HOPE TO OBTAIN SOME TYPE OF BENEFIT FROM THE NEW ORDER”

Anonymous

Ministry of Health and Sports