¿como es un buen sistema de salud?
TRANSCRIPT
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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
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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
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© Prof. Rifat Atun, Harvard University, 2016 3
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Life expectancy at birth
© Prof. Rifat Atun, Harvard University, 2015 4
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)
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Health service coverage and health outcomes: selected countries of Latin America
© Prof. Rifat Atun, Harvard University, 2015
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Total gain in life expectancy 1950-55 to 2010-15
© Prof. Rifat Atun, Harvard University, 2016 6
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
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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 7
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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
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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
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Cancer: disability-adjusted life years per 100 000 by cause and region in 2010
Source: Murray C, et al. : The Lancet 2012 10
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Change in burden of disease
© Prof. Rifat Atun, Harvard University, 2015 11
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
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The age of multimorbidity and disability
© Prof. Rifat Atun, Harvard University, 2016 12
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
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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
© Prof. Rifat Atun, Harvard University, 2016
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What’s to come – Multimorbidity challenge: Estonia case study (1)
© Prof. Rifat Atun, Harvard University, 2016 14
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
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What’s to come – Multimorbidity challenge: Estonia case study
© Prof. Rifat Atun, Harvard University, 2016 15
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
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Coverage of maternal health services: selected countries of Latin America
© Prof. Rifat Atun, Harvard University, 2015
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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
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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
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All cause death rates (age standardised) by deprivation twentieth (England and Wales) (1999-
2003)
19Source: WHO Commission on Social Determinants of Health
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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 20
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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 (%)
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Health expenditures as a % of GDP
© Prof. Rifat Atun, Harvard University, 2015 22
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
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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
© Prof. Rifat Atun, Harvard University, 2016
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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– Challenges
3. Towards a new health system model
© Prof. Rifat Atun, Harvard University, 2016 24
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South America: government and private health expenditures
© Prof. Rifat Atun, Harvard University, 2015 25
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
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Out of pocket expenditures as proportion of private expenditures
© Prof. Rifat Atun, Harvard University, 2015 26
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
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Persistent segregation and disparities
© Prof. Rifat Atun, Harvard University, 2016 27
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Economic crises and adverse effect on health outcomes
© Prof. Rifat Atun, Harvard University, 2016 28
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
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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 31
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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
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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
© Prof. Rifat Atun, Harvard University, 2016 33
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Towards a new health system
34
Effective
EfficientEquitable
Empowering and Responsive
Source: Atun et al. Lancet 2013© Prof. Rifat Atun, Harvard University, 2015
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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
© Prof. Rifat Atun, Harvard University, 2016
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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
© Prof. Rifat Atun, Harvard University, 2016 36
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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
© Prof. Rifat Atun, Harvard University, 2016 37
1. Optimising content
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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
© Prof. Rifat Atun, Harvard University, 2016 38
1. Optimising content
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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
© Prof. Rifat Atun, Harvard University, 2016 39
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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
© Prof. Rifat Atun, Harvard University, 2016
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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
© Prof. Rifat Atun, Harvard University, 2016
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Technology enabled person driven healthcare
Health coach / case manager
Interactive Online Information
Technology enabled monitoring and
intervention
Peer Group Support
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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.”
© Prof. Rifat Atun, Harvard University, 2016
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Thank you
© Prof. Rifat Atun, Harvard University, 2015 44