Atención Primaria y Reducciónde Desigualdades en Salud: La

importancia de la Política

Carles MuntanerUniversidad de Toronto

Congreso de Atención PrimariaGobierno de Chile/APSSantiago Abril 24 2017

EL CASO DEL MEDICO PROSELITISTA

Y LOSDETERMINANTESSOCIALESDE LA SALUD

Americans seeing DRs more often Gallup, Nov 30, 2004.

Éticamente discutible pero tenia su lógica…

CANADA: un país con una sanidad igualitaria

EN EL MEJOR DE LOS CASOS LA APS TIENE LIMITES EN SU CAPACIDAD PARA REDUCIR LAS DSS

Los Ministerios de Salud se resisten a ceder el liderazgo a otrosminiterios en la implementacion de Salud en Todas la Politicas.

Es necesario atenerse a los conflictos politicos para que losgobiernosn implementen exitosamente el enfoque de Salud enTodas las Politicas

(Freiler, 2012; Shankardaas, 2015; Molnar, 2016; Oneka, in press, Kokkinen, in press)

6

Organización Mundial de la Salud (OMS). Subsanar las

desigualdades en una generación. Informe de la Comisión sobre

Determinantes Sociales de la Salud. Buenos Aires: OMS; 2008.

Informe Final.

Solar y Iwrin OMS 2007

CONTEXTO SOCIOECONÓMI-CO Y POLÍTICO

Gobierno Circunstancias materiales

(condiciones de vida y trabajo)

Factores

conductuales y biológicos

Factores

psicosociales

Políticas públicas, salud, educación, protección social públicas

Cultura y valores sociales

Políticas macroeconómicas

Políticas sociales, mercado de trabajo, vivienda

Posición socio-

económica

Educación

Ocupación

Ingresos

Clase social Género Etnia

DETERMINANTES ESTRUCTURALES DE LAS DESIGUALDADES DE SALUD

DETERMIANTES INTERMEDIOS DE LA SALUD

IMPACTO EN LAS

DESIGUALDADES

EN SALUD Y EN

BIENESTAR

Sistemas de salud

Cohesión social

Marco Teórico de las DSS (Solar & Irwin 2007; OMS, 2008)

Política &Ideología

Mensajes clave La Atención Primaria (AP) constituye una gran

promesa para la reducción de las DSS, lo cual requiere acción política.

El conflicto político e ideológico establece los éxitos y fracasos de la equidad en la AP (para reducir las DSS)

La participación popular en la Atención Primaria ha de ceder poder mas allá de los diagnósticos y consultorías para reducir las DSS

1. Health Prevention & Promotion 2. Equidad

3. Appropriate Technology

4. Participación Comunitaria

5. Intersectoral Coordination

6. Decentralization

Recordemos: Principios de APS ALMA ATA (1978) y la reducción de lasDesigualdades Sociales en Salud (DSS)

Atención Primaria y Equidad (para la

reducción de las DSS):

El rol de la política

APSGLOBAL

PorqueTantasDiferencias

En Canadá el medico de família (AP) es la puerta de entrada al sistema de salud

Ello afecta la equidad del sistema

Sin embargo hay desigualdades en enfermedades ligadas a la AP

Falta de cobertura en odontología, oftalmología, servicios de rehabilitación, atención domiciliaria, fármacos.

Listas de espera para algunas cirugías electivas, MRIs Atención de enfermos crónicos Carencia de médicos de AP

Aumento de costes laborales Afán de lucro dentro del sistema

persisten las desigualdades en salud. Algunos retos relacionados directamente con la AP

DIAGNOSTIC RADIOLOGY 154 $198,895,432.57

OPHTHALMOLOGY 85 $132,896,672.16

CARDIOLOGY 57 $79,251,000.86

INTERNAL MEDICINE 42 $55,804,540.11

ADDICTIONS/METHADONE 25 $33,823,483.34

PAIN/NERVE BLOCKS 17 $22,289,807.43

OBSTETRICS AND GYNAECOLOGY 15 $21,611,960.53

GASTROENTEROLOGY 14 $16,039,029.96

ANAESTHESIA 10 $15,046,760.63

GENERAL SURGERY 13 $14,308,273.21

OTHER 8 $11,577,440.70

PAEDIATRICS 6 $7,519,161.90

ORTHOPAEDIC SURGERY 6 $7,357,597.07

DERMATOLOGY 5 $6,565,437.82

FAMILY PRACTICE AND GENERAL PRACTICE 6 $6,453,091.24

VASCULAR SURGERY 4 $5,700,953.93

UROLOGY 5 $5,578,424.76

OTOLARYNGOLOGY 4 $5,127,430.54

NEUROSURGERY 4 $4,934,137.74

NEPHROLOGY 4 $4,853,872.53

CARDIOTHORACIC SURGERY 4 $4,640,280.30

EMERGENCY MEDICINE 3 $4,208,882.70

NEUROLOGY 3 $4,059,286.28

PSYCHIATRY 3 $3,821,123.20

RESPIRATORY DISEASE 3 $3,328,406.49

PLASTIC SURGERY 2 $2,443,827.04

MEDICAL ONCOLOGY 1 $1,428,163.44

ENDOCRINOLOGY 1 $1,185,479.18

THORACIC SURGERY 1 $1,180,177.91

RHEUMATOLOGY 1 $1,138,161.87

Grand Total 506 $683,068,297.44

2016

Ministro de Salud en 2016:500 médicos cobran 700 MTodos > 1 millón

Rx, Oftalmologia, Odontologia,Cardiologia, OG, Interna, AP

Solución del Minsal! La “Patient First Legislation, Ontario 12/2016 Bill 41”

• Introducir modelos de AP sin Médicos.

• Dar a la administración local la capacidad de actuar en representación del MIN de Salud para monitorear y gestionar los contratos con los Médicos.

• Dar autoridad a la administración local para establecer reglas que obliguen a los médicos a notificar cambios en su consulta (e.g., vacaciones, jubilación, criterios de admisión, tiempos de espera).

Ontario doctors threaten job action if province does not meet demandsThe Globe and Mail

Published Tuesday, Nov. 29, 2016 7:47PM

EST

Last updated Tuesday, Nov. 29, 2016

8:13PM EST

A pesar de la mejoras previstas en ASP, la oposición de la OMA fue fulminante ….

Why your doctor may soon go on strike: HepburnPatients could face closed physicians' offices as pay fight with Queen's Park ramps up Toronto Star 9/3/17

“You are a c---. Crash and burn as you deserve to do!! This will be a NO vote and the end of the OMA. Sincerely, F--- YOU and the OMA!!!” Toronto Star 17/2/17

Algunas muestra de “mobbing” y “cyberbullying” de los miembros de OMA en contra del Dr Phil Berger (AP) quien apoya públicamente la reforma de la ASP, el Bill 41

“I hope none of your patients need to come here to have any kind of investigative radiology done,” a radiologist yelled at this doctor. Toronto Star 17/2/17

“Dr. Ramirez piled on: “C… hijo de p… anda a ch…. Berger.”” Toronto Star 17/2/17

“Dr. Ira Bernstein, also in Toronto family medicine, wrote Berger needed a stronger drug, an antipsychotic: “Ativan won’t be enough. Clopixol needed. This is clearly Psychosis.”

El conflicto político entre los médicos y el estado impide una mayor equidad de la APS en Canada

APS y Participación Comunitaria(para la reducción de las DSS): la importància de la política

Procesos de participación comunitaria en la planificación de serviciospara reducir las desigualdades sociales en salud (Katz, O´campo 2015)

Barreras políticas en la toma de decisiones (eg centro de AP)

Proceso se da al nivel equivocado (e.g. las decisiones se toman en otro lugar)

Proceso esta bajo el control total del convocante (gobiern0).

Discusiones y decisions ocurren al margen del proceso

El proceso es demasiado corto

Recursos insuficientes destinados a las partes interesadas de la comunidad para generar los resultados previstos

Representatividad y participació comunitària (clientelismo, grupos empoderados, sesgo de classe, horarios, ayuda a madres etc...)

Implementación y evaluación

sin participación comunitaria

Participacion Comunitaria: hablarde DSS y prioridades, OK però...

Comunicar las DSS entre barrios, entre mujeres y hombres, ocupaciones, migrantes, etnias...

Comunicación (lenguaje, dinámica, grupos representados (expertos) )

Delegación del control sobre la comunidad,

Explotación, burnout

Desmobilización, expectativas frustradas

Reducción del rol del estado

Sanciones

Los procesos políticos determinan el potencial de la participación comunitaria en la reducción de las DSS: los gobiernos locales no ceden poder

Hacen falta procesos transparentes, independientes i que cedan poder a la comunidad

Hace falta incluir a la comunidad no solamente durante el ¨diagnostico comunitario¨ y consulta sobre prioridades sino durante todo el proceso, es decir durante la planificación, la implementación i la avaluación de los programas

Muchas gracias por su atención!

References Shankardass K, Solar O, Murphy K, Greaves L, O’Campo P. A

scoping review of intersectoral action for health equity involving governments. Int J Public Health, 2012. 57(1):25-33

Freiler A, Muntaner C, Shankardass, K., Mah, C. L., Molnar, A., Renahy, E., & O'Campo, P. Glossary for the Implementation of Health in All Policies (HiAP). J Epidemiol Commun Health, 2013. 67:1068-1072

Shankardass K, Renahy E, Muntaner C, O’Campo P. Strengthening the implementation of Health in All Policies: a methodology for realist explanatory case studies. Health Policy Plan, 2015. doi: 10.1093/heapol/czu021

Molnar A, Renahy E, O’Campo P, Muntaner C, Freiler A, Shankardass K. Using Win-Win Strategies to Implement Health in All Policies: A Cross-Case Analysis. PloS one. 2016 Feb 4;11(2):e0147003.

References cont’ Muntaner C. Invited commentary: on the future of social

epidemiology—a case for scientific realism. American journal of epidemiology. 2013 Sep 5:kwt143.

Ng E, Muntaner C. A critical approach to macrosocial determinants of population health: engaging scientific realism and incorporating social conflict. Current Epidemiology Reports. 2014 Mar 1;1(1):27-37.

Mehdipanah R, Manzano A, Borrell C, Malmusi D, Rodriguez-Sanz M, Greenhalgh J, Muntaner C, Pawson R. Exploring complex causal pathways between urban renewal, health and health inequality using a theory-driven realist approach. Social science & medicine. 2015 Jan 31;124:266-74.

Muntaner C. Invited commentary: social mechanisms, race, and social epidemiology. Am J Epidemiology, 1999.

References cont’ Molnar A, O’Campo P, Ng E, Mitchell C, Muntaner C, Renahy

E, John AS, Shankardass K. Protocol: Realist synthesis of the impact of unemployment insurance policies on poverty and health. Evaluation and program planning. 2015 Feb 28;48:1-9.

Dunn JR, van der Meulen E, O’Campo P, Muntaner C. Improving health equity through theory-informed evaluations: A look at housing first strategies, cross-sectoral health programs, and prostitution policy. Evaluation and program planning. 2013 Feb 28;36(1):184-90.

O'Campo P, Molnar A, Ng E, Renahy E, Mitchell C, Shankardass K, John AS, Bambra C, Muntaner C. Social welfare matters: A realist review of when, how, and why unemployment insurance impacts poverty and health. Social Science & Medicine. 2015 May 31;132:88-94.

Outreach Inputs Outcomes

Immediate 0-6 months 6-12 months 12-24 months

Identify and engage individuals eligible for Pathways Housing services

Housing and collaborative care plan:ACT team + Job Development + PhysicianOR Case management & Physician

↑ Access to public benefits;IncomeMental health services

↑ participation in addictions treatment

↓ Problematic drug use

↓ Use of emergency response calls, ER for primary care↓Arrests/incarcerations↓ Return to homelessness↓ Hospitalizations (both medical and psychiatric)↑ Quality of life↑ Physical health

↑Working alliance with providers↑Hope for change

↓ Contact with non-supportive networks

↑ Participation in mental health treatment

↑ Subjective well being (symptom management, confidence in recovery)

↑ Access to community health services:AcuteChronic

↑ Participation in illness management and self-care

Assess client-centered interests:Job interestsJob development

↑ Participation in Desired activitiesEmployment

Assess client-centered interests:FamilySocialSpiritual

↑ Participation inSocial supportCommunity integration

Housing First Theory of Change Logic Model for Homeless Individuals with Severe Mental Illness (S. Tsemberis, 2010)

Sense oblidar els costos extres

http://masscare.org/health-care-costs/overhead-costs-of-health-care/

Alma Ata sigue siendo relevante

Com el Canada controla les despeses

• Low administrative costs - 16.7% of health spending vs. 31.0% in U.S.

• Stringent controls on capital spending for new buildings and equipment

• Single buyer purchasing reins in drug/device prices

Source: Himmelstein & Woolhandler, Arch Intern Med, December, 2012

Com el Canada controla les despeses

• Low litigation and malpractice costs

• Emphasis on primary care

• Exclusion of private insurers - private plans overcharged U.S. Medicare by $34 billion in 2012

Source: Himmelstein & Woolhandler, Arch Intern Med, December, 2012

com 300 Afro-americans, cada dia, tot l´any

Situació dels Metges

Mites

El petit secret Canadenc

ESPECIALISTES EN USD, 2004

DELSA/HEA/WD/HWP(2008)5

Figure 5. Remuneration of specialists in USD PPP, selected OECD countries, 2004 (or closest year available)

290236

219177

159153

144123

10593

763128

0 100 200 300

Netherlands (2004)*United States (2003)*Luxembourg (2003)*

Austria (2003)** Canada (2004)*

United Kingdom (2004)* France (2004)*

Switzerland (2003)** Iceland (2005)*

Denmark (2004)*Finland (2004)*

Czech Republic (2004)*Hungary (2004)*

USD PPP, thousands

Self-employedSalaried

Note: * indicates that the average remuneration refers only to physicians practising full-time and ** refers to the average remuneration for all physicians including those working part-time. In Austria, Switzerland and the United States, the data refer to all physicians (both salaried and self-employed), but since most specialists are not salaried in these two countries, the data are presented as referring to self-employed physicians. For the United Kingdom, data refer to England.

Source: OECD Health Data 2007 and for the US, Community Tracking Study Physician Survey, 2004-05.

47. In comparison with the average wage in the economy, the remuneration of self-employed specialists in the Netherlands is more than seven times higher, over five times greater in the United States and Austria, and almost five times greater in Luxembourg and Canada (Figure 6). The high remuneration level in the Netherlands might be due at least partly to the relatively low specialist density in the country (see section 5.4). On the other hand, the remuneration of salaried specialists is one-and-a-half times greater than the average wage in Hungary and about two times greater in the Czech Republic (for salaried specialists).

Figure 6. Remuneration of specialists as ratio to average wage, selected OECD countries, 2004 (or closest year available)

7.55.5

5.24.94.8

4.43.9

3.33.0

2.52.5

1.91.5

0.0 2.0 4.0 6.0 8.0

Netherlands (2004)*United States (2003)*

Austria (2003)** Luxembourg (2003)*

Canada (2004)*France (2004)*

United Kingdom (2004)* Iceland (2005)*

Switzerland (2003)** Denmark (2004)*

Finland (2004)*Czech Republic (2004)*

Hungary (2004)*

Ratio to average wage

Self-employedSalaried

Note: * indicates that the average remuneration refers only to physicians practising full-time and ** refers to the average remuneration for all physicians including those working part-time. Source: OECD Health Data 2007 and for the US, Community Tracking Study Physician Survey, 2004-05.

21

DELSA/HEA/WD/HWP(2008)5

Figure 5. Remuneration of specialists in USD PPP, selected OECD countries, 2004 (or closest year available)

290236

219177

159153

144123

10593

763128

0 100 200 300

Netherlands (2004)*United States (2003)*Luxembourg (2003)*

Austria (2003)** Canada (2004)*

United Kingdom (2004)* France (2004)*

Switzerland (2003)** Iceland (2005)*

Denmark (2004)*Finland (2004)*

Czech Republic (2004)*Hungary (2004)*

USD PPP, thousands

Self-employedSalaried

Note: * indicates that the average remuneration refers only to physicians practising full-time and ** refers to the average remuneration for all physicians including those working part-time. In Austria, Switzerland and the United States, the data refer to all physicians (both salaried and self-employed), but since most specialists are not salaried in these two countries, the data are presented as referring to self-employed physicians. For the United Kingdom, data refer to England.

Source: OECD Health Data 2007 and for the US, Community Tracking Study Physician Survey, 2004-05.

47. In comparison with the average wage in the economy, the remuneration of self-employed specialists in the Netherlands is more than seven times higher, over five times greater in the United States and Austria, and almost five times greater in Luxembourg and Canada (Figure 6). The high remuneration level in the Netherlands might be due at least partly to the relatively low specialist density in the country (see section 5.4). On the other hand, the remuneration of salaried specialists is one-and-a-half times greater than the average wage in Hungary and about two times greater in the Czech Republic (for salaried specialists).

Figure 6. Remuneration of specialists as ratio to average wage, selected OECD countries, 2004 (or closest year available)

7.55.5

5.24.94.8

4.43.9

3.33.0

2.52.5

1.91.5

0.0 2.0 4.0 6.0 8.0

Netherlands (2004)*United States (2003)*

Austria (2003)** Luxembourg (2003)*

Canada (2004)*France (2004)*

United Kingdom (2004)* Iceland (2005)*

Switzerland (2003)** Denmark (2004)*

Finland (2004)*Czech Republic (2004)*

Hungary (2004)*

Ratio to average wage

Self-employedSalaried

Note: * indicates that the average remuneration refers only to physicians practising full-time and ** refers to the average remuneration for all physicians including those working part-time. Source: OECD Health Data 2007 and for the US, Community Tracking Study Physician Survey, 2004-05.

21

La política también es la ideología del electorado

Que entenem per ‘privatitzar’?

La majoria de gent parla de Finançament: Hauríem de permetre el pagament per serveis mèdics

necessaris (assegurança, de butxaca) per introduir un sistema de ‘dues cues’?

Algunes persones parlen de Provisió: Hauríem de permetre que els nostres hospitals

tinguessin beneficis (eg. Shouldice clínic)?

Que fa el Canada?

Finançament

Públic(imposts)

Privat (assegurança,

al comptat)

Provisió

Pública Privada

Ànim de lucreSense Ànim

de lucre

70% public –Physician and

hospital services

30% private –drugs, dental, vision, rehab

Doctors offices, A few facilities

None are investor-owned

99% hospitals,And have their

own board.

1. Cobertura universal.2. Accessibilitat raonable de serveis3. Portabilitat dels beneficis entre províncies4. Cobertura per tots els serveis mèdics necessaris5. Administrat públicament, en un programa sense

ànim de lucre

Estàndards Mínims pels Programes Provincials Canadencs (5 principis basics

del Canada Health Act 1983)

Mes…

70% publica: Hospitals i serveis mèdics i 30% privada: dental, visió, OT/PT, fàrmacs

Finançament públic, oferta a nivell privat NFP i públic (NHI) sense privada amb afany de lucre

Cap co-pagament o ¨deductible¨.

Els pacients NO PODEN PAGAR per saltar la cua

Nogensmenys hi han problemes greus…

Els fàrmacs no estan coberts, ni els serveis dentals, oftalmologia, serveis rehabilitació, LTC, o l'atenció domiciliaria

Llistes d’espera – per algunes cirurgies electives i MRIs

Gestió de l'atenció a malats crònics

Manca de metges

Augment dels costos (com a tot arreu)

Interessos que volen treure profit del sistema sanitari

Solucions actuals? Sobre tot tècniques

Tractar els determinants socials “upstream” de la salut (HiAP). El pagador únic augmenta l'eficiència administrativa I l’equitat:

l'expansió del sistema públic en un Segon Nivell del Medicare. Presa de decisions ¨cost-efectives¨.

¨Bulk purchasing¨ eg. national pharmacare Quality Improvement: Checklists per disminuir els errors mèdics Models de Cures Compartides : eg. Hamilton

90 unitats amb 2 psiquiatres i 23 consellers- 70% de disminució de derivacions a psiquiatres, 90% de les necessitats de salut mental cobertes

EMR

Una qüestió de lluita de classes

Stergiopoulos V et al. Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. JAMA. 2015 Mar 3;313(9):905-15.

En resum

I i doncs pel procés constituent?

volem 100% publica (Mareas, la CUP...)

Però com ho fem per anar de A fins C ?

Oposició, ¨Path dependency¨...

Primero el contexto: Desigualdades Económicas y Cambio Político en el siglo XXI (el Elefante!)

Un ¨experimento natural¨ USA vs. Canada entre un país con énfasis en APS i otro sin

Comparada con la de los EEUU la calidad de la asistencia es ligeramente superior en Canada

Fuente: Guyatt G et al, Open Medicine, 2007 A Meta-Analysis of Patients Treated for Same Illnesses

(U.S. Studies Included Mostly Insured Patients)

“No nos cansaremos de decir que el peor enemigo de la salud es la desigualdad”

Toni Comín Ministro de Salud Generalidad de Catalunya2017

Stergiopoulos V et al. Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. JAMA. 2015 Mar 3;313(9):905-15.