Universal Access to Health and Universal Health Coverage

Universal Access to Health and Universal Health Coverage: Transforming Health Systems in the Caribbean Dr. James Fitzgerald Director, Health Systems and Services

The Alma Ata declaration 1978 • Health is a fundamental human right. • The attainment of the highest possible level of health is a social goal, and it is part of development in the spirit of social justice. • It requires inter-sectorial action. • Inequality is politically, socially and economically unacceptable. • The promotion and protection of health is essential to sustained economic and social development. • Social participation: people have the right and duty to participate • Governments have a responsibility for the health of their people. • Health for all in the year 2000: a main social target for the world. • Primary health care is key to attaining this. 2

Primary Health Care • Reflects and evolves from the sociocultural and political characteristics of the country and its communities. • Addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly. • Includes health promotion and prevention, treatment of common diseases and injuries, and essential drugs. • Involves all related sectors and demands coordinated efforts. • Requires maximum community and individual self-reliance and participation. • Sustained by integrated and mutually supportive referral systems. • Progressive improvement of comprehensive health care for all giving priority to those most in need. • Relies on health teams to respond to the expressed health needs of the communities (including traditional practitioners).

From Alma Ata to the World Health Report 2010: Alma Ata 1978 Renewal PHC 2005 Reforms based on PHC WHR 2008 Towards Universal Health Coverage, WHR 2010

Values and Principles : Underpinning Health Systems in the Americas • 19 countries in the Region have provisions in their constitutions that guarantee access to health for everyone within the national jurisdiction. The Right to the Highest Attainable Standard in Health (WHO Constitution 1948) • The Americas remains the most inequitable region globally – Equity has become central to health and development policy in the Americas; • Solidarity: the capacity of a social system to address both the individual and collective needs through social policy and equity in distribution of resources; 5

Concepts (1): Underpinning Health Systems in the Americas Universal health coverage Coverage Universal Coverage • Capacity of health system to meet the population’s needs; • Availability of infrastructure, HR, health technologies, and financing. Organizational mechanisms and financing sufficient to cover the entire population. Universal coverage alone is not sufficient to ensure health, wellbeing, and equity in health.

Concepts (2): Underpinning Health Systems in the Americas Universal access to health Access Universal access • Access is the capacity to use comprehensive, appropriate, timely, quality health services. • In accordance with needs. • Addresses SDHs with a multisectoral approach. • Active participation of individuals and communities. No geographical, economic, sociocultural, organizational, or gender barriers preventing anyone from using comprehensive health services.

Policy frameworks: from Alma Ata to Universal Health PAHO 2014 Alma Ata 1978 Renewal PHC 2005 Reforms based on PHC WHR 2008 Towards Universal Health Coverage, WHR 2010

Strategy for Universal Access to Health and Universal Health Coverage • All people and communities have access, without any kind of discrimination, to comprehensive, quality health services, without exposing users to financial difficulties. • Require implementing policies and actions with a multisectoral approach to address the social determinants of health and promote a society-wide commitment to fostering health and well-being. Values Right to Health ü Equity 9 ü Solidarity

Four Simultaneous and Interdependent Strategic Lines • Strategic line 1: Expanding equitable access to comprehensive, quality, people- and community-centered health services. • Strategic line 2: Strengthening stewardship and governance. • Strategic line 3: Increasing and improving financing, promoting equity and efficiency, and eliminating out-of-pocket expenditure. • Strategic line 4: Strengthening intersectoral action to address the social determinants of health.

Impact of Natural Disasters in GDP in the Caribbean Sources: EM-DAT, IMF estimates, 2016

• 0 2005 circa 2014 188, 2 179, 7 178, 7 175, 6 166, 3 Bermuda St. Kitts and Nevis Suriname Bahamas Jamaica Low risk Middle risk 79, 4 78, 7 67, 9 57, 9 47, 7 Montserrat French Guiana Anguilla Turks and Caicos Islands 121, 2 Guadeloupe Cayman Islands 130, 6 Belize 99, 0 140, 5 Martinique Dominican Republic 147, 1 The Americas 157, 4 193, 9 Puerto Rico Aruba 198, 2 Antigua and Barbuda 158, 6 200, 5 Barbados The Caribbean 231, 9 Grenada 164, 4 232, 4 Saint Lucia Dominique 254, 8 302, 4 50 Cuba Saint Vincent and the Grenadines Adjusted rate per 100, 000 population NCDs, violence and mental health Fig. 1: Potentially avoidable mortality by non-communicable diseases in the Caribbean 350 300 250 200 150 100 High risk In 2014, in the Caribbean at least 36, 831 premature deaths caused by NCDs (83. 8% of total) were considered avoidable because they could have potentially been prevented with effective first level interventions. 12

Access to Health Services: Maternal and Child Health Hospital births (%) Antenatal care coverage by skilled birth attendants of 4+ visits (%) Source: PAHO/ WHO, 2017

Health Services Coverage Unmet need for family planning (%) Source: PAHO/ WHO, 2017 Immunization coverage under 1 year (%) DPT 3 cv

Health Inequities Between Countries Maternal mortality reported (100. 000 live births) Under-five mortality reported (1000 live births) Source: PAHO, 2015

IS 4 H Strategic framework Information System for Health: A mechanism for managing interoperable systems with open data that comes from different sources and that is ethically used, through effective ICT tools, to generate strategic information for the benefit of public health. . Jamaica’s High Level Meeting . New conceptual framework. Standardized tools. Strategic goals. Caribbean Technical working group. National policy templates. Technical frameworks. Concept notes for donors Roadmaps Foundations Director’s Vision . CARICOM. Central America. OECS. Regional call for project proposals . Anguilla. Belize. BVI. Bermuda. Bolivia. Dominica. Ecuador. Guatemala. Guyana. Honduras. Panama. Jamaica. Turk & Caicos Technical cooperation

Health Financing Skewed Towards Hospital Care St Kitts and Nevis Dominica Barbados Prevention act Overseas care Prevention act Administrati on Overseas care Other Long-term care Administratio n Hospital Kitts Pharmacies Private outpatient clinics Administratio n Private outpatient clinics Princess Margaret Hospitals PHC Pharmacies Hospital Nevis PHC District Hospital PHC St Kitts PHC Nevis Source: National Health Accounts, 2012

Availability of Critical Resources for the Health System Public expenditure in health as % of GDP, 2015 6% Reference Line BEL DOM BAH JAM BAR SUR TRT ATB SVG DOR SLC GUY SKN GRN HTI 4 4 4 3 3 3 3 2 2 2 1

Availability of Critical Resources / # Physicians and Nurses per 10, 000 pop (2015) Critical Resources for the Health System CUB 157, 9 45/10, 000 population Reference Line CYI 127, 8 MTQ AMERICAS LAC 107, 9 GDL MNS DOM BAR TRT GRN STL 87, 6 SUR BEL GUY 77, 3 FGY SKN ANG BAH 70 68, 6 SVG 66, 2 65, 9 65, 1 DOR JAM HTI 61, 8 61 51, 5 44, 2 43, 2 32, 4 32, 2 28, 9 25 22, 6 21 17 5, 8

Health Systems Challenges in the Caribbean • Model of care, segmentation and fragmentation. • Organization of healthcare networks, tendency to shift care towards hospitals. • Health system strengthening initiatives and health reforms focus on financing and sustainability in the last decade, without due attention to improving efficiencies in service delivery, particularly strengthening first level of care, health promotion and prevention. • High cost of medicines and health technologies: purchasing, regulation, tertiary care. • Persistent gaps in availability, distribution and quality in Human Resources for Health, and limited ability for expansion, recruitment and retention. • Concerns on implications of the Single Market and Economy and the free movement of people on the demand for health care services. 20

Health Systems Transformation in the Caribbean ONGOING HEALTH SYSTEMS REFORM EFFORTS/PAHO TC Bahamas Implementation of the National Health Insurance (NHI) and single governance. Barbados Initial stages of preparing a strategic plan for health for 2016 -2021 Cayman Islands Dominican Republic Grenada Guyana Haiti Jamaica Monserratt Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenedines Sint Marteen (Dutch) Curacao (Dutch) Trinidad and Tobago Turks and Caicos Islands Virgin Islands (UK) Revision of the National Health Policy and Strategic Plan for 2012– 2017 Redesign of Health System’s architecture and reconstruction post Hurricane Maria; Plans to introduce a national health insurance; Health sector is undergoing reorganization within the “separation of roles” framework established by Law 123 -15 Expansion of the National Health Insurance (NHI) scheme. Creation of a National Health Fund, Implementation of Health Vision 2020 Comprehensive reform Revision of role of regional health authorities, Implementation of NHI Discussions to introduce National Health Insurance Scheme Launched Commission for the implementation of NHI. National Strategic Plan currently being revised. Discussions are under way to assess feasibility of a National Health Insurance Scheme Mo. H working on legislation to reform St Maarten's national health insurance system Mo. H working on proposal for health reform in the context of UH Ongoing assessments to identify various health service gaps, Initiating process for implementation of National Health Insurance Establishment of NHIP as the funding mechanism and model for universal access to health Establishment of the National Health Insurance System in 2016, developed road map for UH

Considerations in moving forward • • • Health systems transformations should focus on the core objectives of improving access, coverage and quality, addressing principles health needs. Health systems transformations are complex, require political commitment and real social engagement. Strong governance and regulatory capacity is is required. Any transformation of the health system should strengthen Primary Health Care as a means to move towards Universal Health. Improvements in the organization of health services with a stronger emphasis in prevention and health promotion interventions, combine with a highly resolutive first level of care, are required to increased efficiency in health outcomes. HRH, infrastructure, medicines and health information systems constitute critical inputs into the system, where resources are often locked-in. Health Systems transformations required a critical assessment of allocation and efficiency, to adapt these resources to the needs of the future health system. Health financing reform is critical - but in itself is insufficient- in any health systems transformation: Increases in public expenditure associated with more effective financial protection Investing in health results in better health outcomes and healthier populations An intersectoral approach to health and health systems transformation: 22

“The 21 st Century expression of Alma Ata” Dr. C. Etienne Director PAHO/WHO January 2018

James Fitzgerald, Director Health Systems and Services PAHO/WHO fitzgerj@paho. org