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
Uruguay: summary data Capital: Montevideo (40% pop.) Pop.: 3.300.000 aprox. 94% urban Area: 176.065,00 km 2 Climate: Mild (16º) HDI: 42nd (high) GDP: USD 14.000 (per captita, ppp) the implementation of the National Integrated Health System 2
Introduction Law #18.211 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
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
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
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
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. 2011 the implementation of the National Integrated Health System 7
Coverage by type of institution 2006 Institution P eople P ercentage Public 1.253.256 41% Private 1.335.131 44% Other 393.931 13% Not covered 82.889 3% Total 3.065.207 100% 2010* Institution P eople P ercentage Public 1.152.566 34% Private 1.797.073 53% Other 325.894 10% Not covered 93.065 3% Total 3.368.598 100% Public Private Private Public the implementation of the National Integrated Health System 8
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 260.000 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 2006. Important changes in the risk profile of institutions the implementation of the National Integrated Health System 9
Institutions age structure 2006 Age range P ublic P rivate O thers <18 years 501.237 196.172 167.624 18 65 years 623.866 888.427 264.726 >65 128.153 250.532 44.470 T otal 1.253.256 1.335.131 476.820 2010 Age range P ublic P rivate O thers <18 years 372.964 458.865 105.204 18 65 years 633.573 1.066.532 270.575 >65 146.029 271.676 43.180 T otal 1.152.566 1.797.073 418.959 the implementation of the National Integrated Health System 10
Grafically Public 10% <18 (40%) 18 65 (50%) 2006 Private 19% 15 % 18 65 (67%) 13% 15% <18 (32%) <18 (26%) 18 65 (55%) 2010 18 65 (59%) * Risk structure becomes more even between public and private sector institutions the implementation of the National Integrated Health System 11
2006 2010 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
2006 2010 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
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
Grafically 2006 2010 Quintile Public Private Other No coverage the implementation of the National Integrated Health System 15
Consecuence 2006 2010 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
Grafically Public Private 5th 1st 1st 2006 2010 1º 1º 2nd 1st 2006 2010 the implementation of the National Integrated Health System 17
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
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
2010: FONASA coverage 33% 9% 29% 23% 7% 18 Age <18 26 45 46 65 65 + 25 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
2010 by institution FONASA Covered P eople % P ublic 137.419 8% P rivate 1.408.786 87% O ther 75.246 5% T otal 1.621.451 100% Not FONASA Covered P eople % P ublic 1.015.147 58% P rivate 388.287 22% Not C overed 93.065 5% O ther 250.648 14% T otal 1.747.147 100% the implementation of the National Integrated Health System 21
The not covered Stable percentage in the period, of about 2,7% 38% of them are in the 26 45 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
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
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
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
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