ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia

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1 Uruguayans healthcare coverage: analysis of observed changes in the direction of equity since the implementation of the National Integrated Health System Ec. Juan Pablo Pagano Health Economics Division Ministry of Public Health Uruguay

implementation of the National Integrated Health System Ec.

2 Uruguay: summary data Capital: Montevideo (40% pop.) Pop.: aprox. 94% urban Area: ,00 km 2 Climate: Mild (16º) HDI: 42nd (high) GDP: USD (per captita, ppp) the implementation of the National Integrated Health System 2

065,00 km 2 Climate: Mild (16º) HDI: 42nd (high) GDP: USD 14.

3 Introduction Law # of december 2007 creates the National Integrated Health System On the basis of the Human Right to Health One of the main objectives of the Health System reform: achieve equity in access to health care between different groups regardless of capacity to pay Also to guarantee a homogeneous set of health care services that define integral coverage the implementation of the National Integrated Health System 3

Health One of the main objectives of the Health System reform: achieve equity in access to health care

4 Flashback Until the year 2007 the uruguayan Health System was divided into two subsystems*: Public (basically for low income groups) Private (formal workers through social security and individual affiliates with capacity to pay) Each subsytem served approximately 50% of the population Public sector: 25% of total country health expenditure vs. 75% of private sector the implementation of the National Integrated Health System 4

affiliates with capacity to pay) Each subsytem served approximately 50% of the population Public sector:

5 Flashback (cont.) Consecuence: expenditure per capita in the private sector was 2,5 times higher than that of the public sector Moreover: public sector users had higher needs for care taking into account their socioeconomic situacion Therefore, there was a high correlation between quality of health care coverage and income levels / laboral status the implementation of the National Integrated Health System 5

public sector Moreover: public sector users had higher needs for care taking into account their

6 Creation of the SNIS Homogenize health care quality and access with distributive justice that equals the economic burden of health care spending for each citizen Financial reform: general taxes, employers and employees* all contribute to the FONASA (National Health Fund) Access to the private institutions of the SNIS formal workers and their sons/daughters in charge the retired (chronogram) sons/daughters of the unemployed individual affiliated the implementation of the National Integrated Health System 6

(National Health Fund) Access to the private institutions of the SNIS formal workers and their sons/daughters in charge the

7 6th international conference Cartagena de indias, Colombia Sources General taxes Employees contributions Employers contributions Households Funds Militar, police, University hospital FONASA FNR OOP Private insurance Supliers Police, Militar and University hospitals ASSE Public IAMC Private IMAE Private Clinics, etc Users Policemen, Militars, some civil servants Worst off (income) Formal workers, & family, and retired Households with Capacity to pay *Source: Aran D, Laca H the implementation of the National Integrated Health System 7

hospitals ASSE Public IAMC Private IMAE Private Clinics, etc Users Policemen, Militars, some civil servants Worst off (income) Formal

8 Coverage by type of institution 2006 Institution P eople P ercentage Public % Private % Other % Not covered % Total % 2010* Institution P eople P ercentage Public % Private % Other % Not covered % Total % Public Private Private Public the implementation of the National Integrated Health System 8

207 100% 2010* Institution P eople P ercentage Public 1.152.566 34% Private 1.797.073 53% Other 325.

9 Young people In 26: 22% of people under 18 years had access to the private sector This proportion more than doubles for the year 2010 (50%), representing the entrance of more than people of that age range to the private sector Consecuence: this group now represents 26% of total private sector* users, vs. 14% in the year Important changes in the risk profile of institutions the implementation of the National Integrated Health System 9

000 people of that age range to the private sector Consecuence: this group now represents 26% of total private

10 Institutions age structure 2006 Age range P ublic P rivate O thers <18 years years > T otal Age range P ublic P rivate O thers <18 years years > T otal the implementation of the National Integrated Health System 10

820 2010 Age range P ublic P rivate O thers <18 years 372.964 458.865 105.204 18 65 years 633.573 1.066.

11 Grafically Public 10% <18 (40%) (50%) 2006 Private 19% 15 % (67%) 13% 15% <18 (32%) <18 (26%) (55%) (59%) * Risk structure becomes more even between public and private sector institutions the implementation of the National Integrated Health System 11

12 ISEqH 6th conference Labor condition S ector E mployed Unemployed R etir/pens E s tudiantes P ublic 28% 60% 33% 46% P rivate 59% 20% 54% 36% Other 13% 20% 13% 18% T otal 100% 100% 100% 100% S ector E mployed Unemployed R etir/pens E s tudiantes P ublic 26% 57% 34% 33% P rivate 62% 24% 55% 53% Other 12% 19% 11% 14% T otal 100% 100% 100% 100% the implementation of the National Integrated Health System 12

E mployed Unemployed R etir/pens E s tudiantes P ublic 26% 57% 34% 33% P rivate 62% 24% 55% 53% Other

13 ISEqH 6th conference By income quintiles S ector/quintile 1s t 2nd 3rd 4th 5th P ublic 79% 60% 40% 20% 5% P rivate 6% 21% 42% 66% 83% Other 12% 16% 14% 11% 11% No C overage 2% 3% 4% 3% 1% T otal 100% 100% 100% 100% 100% S ector/quintile 1s t 2nd 3rd 4th 5th P ublic 74% 47% 30% 15% 4% P rivate 18% 41% 57% 72% 80% Other 4% 9% 10% 10% 14% No C overage 3% 3% 3% 3% 2% T otal 100% 100% 100% 100% 100% the implementation of the National Integrated Health System 13

ector/quintile 1s t 2nd 3rd 4th 5th P ublic 74% 47% 30% 15% 4% P rivate 18% 41% 57% 72% 80% Other 4% 9% 10% 10% 14%

14 By income quintiles Noticeable increase in the percentage of people of the first two quintiles that gain access to the private sector Small proportion of richier families tend to move to another type of coverage such as private insurance like Blue Cross The mayority of people tend to move from the public to the private sector if possible the implementation of the National Integrated Health System 14

of coverage such as private insurance like Blue Cross The mayority of people tend to move from the

15 Grafically Quintile Public Private Other No coverage the implementation of the National Integrated Health System 15

16 Consecuence Quintile P ublic P rivate Quintile P ublic P rivate 1 39% 3% 1 43% 7% 2 30% 10% 2 27% 15% 3 20% 19% 3 18% 21% 4 10% 30% 4 9% 27% 5 2% 38% 5 2% 30% T otal 100% 100% T otal 100% 100% From the institutions point of view, users profile changed considerably the implementation of the National Integrated Health System 16

17 Grafically Public Private 5th 1st 1st º 1º 2nd 1st the implementation of the National Integrated Health System 17

18 Per capita expenditure Important reduction of Public sector users + important budget increase (social security contributions, general taxes) Consecuence: important reduction of public private gap in per capita expenditure Private/public ratio 2010: 1,30* (vs 2,7 2006) the implementation of the National Integrated Health System 18

important reduction of public private gap in per capita expenditure Private/public

19 FONASA coverage Now some facts about people included in the National Health Fund (FONASA) Those FONASA covered can choose where to be affiliated (with some restrictions) the implementation of the National Integrated Health System 19

can choose where to be affiliated (with some

20 2010: FONASA coverage 33% 9% 29% 23% 7% 18 Age < Labor status 25% 59% 1% U 7% 7% <14y Employed S R 2% 9% 19% 23% 25% 24% Income 1st 2nd 3rd 4th 5th the implementation of the National Integrated Health System 20

21 2010 by institution FONASA Covered P eople % P ublic % P rivate % O ther % T otal % Not FONASA Covered P eople % P ublic % P rivate % Not C overed % O ther % T otal % the implementation of the National Integrated Health System 21

22 The not covered Stable percentage in the period, of about 2,7% 38% of them are in the age range No other relevant characteristic of this group that distinguishes them from the entire population Equitable distribution by income quintiles the implementation of the National Integrated Health System 22

23 The not covered (cont.) 53% are employed 12% declare contributing to a retirement insurance (inconsistent) At least a part of this is a measurement error the implementation of the National Integrated Health System 23

24 Summary Equity in terms of age: people under 18 years of age gained access to the private sector One third of total FONASA covered are <18 years Also inactive students gained access to the private sector Households of the first quintiles of the income distribution can choose the implementation of the National Integrated Health System 24

25 Summary (cont.) Increasing entrance of the retired to the FONASA (before 2007 they had to pay, to gain access to the private sector) Nevertheless Public sector users profile did not change dramatically The mayority FONASA covered choose a private institution (87%) Important reduction in expenditure private/public gap the implementation of the National Integrated Health System 25

26 Forthcoming Reform still taking place until 2016 when all the retired will be included in the FONASA Extended assistance (mental health, reproductive health, etc). Military and policmen User satisfaction surveys (waiting time, etc.) the implementation of the National Integrated Health System 26

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