GOVERNMENT OF THE CITIZENS REVOLUTION President Rafael Correa

GOVERNMENT OF THE CITIZENS’ REVOLUTION President Rafael Correa Delgado Management by Dr. Caroline Chang Campos MINISTER OF PUBLIC HEALTH

ECU OR AD ECUADOR Land area: 256, 370 Km 2 2 km 2 2006 population (est. ): Population estimated 2006: 13, 408, 270 13/408, 270 inhabitants Population density: 52. 3 people 52. 30/Km 2 52. 30 /Km 2 per km 2 Starfield 10/04 04 -202

MAP OF POVERTY BY PROVINCE ACCORDING TO UNMET BASIC NEEDS (UBN) Source: INEC. CVD, fifth round 2005 -2006

MATERNAL MORTALITY RATES IN LATIN AMERICA AND THE CARIBBEAN 5. 6 T. and Tobago 18. 7 Chile Costa Rica Argentina Venezuela Belize Ecuado Dom. r Republic Nicaragua 38 43. 5 67. 2 (per 100, 000 live births) 73. 5 76. 9 82 97 Colombia 104. 9 Honduras 108 153 Guatemala 185 Peru 523 Haiti 0 100 200 300 400 500

A view of the south…

MPH IESS FFAA-PN J. BENEF O. PUBL NGOs PRIVATE Population with access to institutional health services 75% 30% 19% 2. 5% 3% 2% 1. 5% 17% Population with health insurance 25% 19% 2. 0% 3. 5%

OTHERS: FFAA/Police hospitals; JBG; Municipios; Centers Naturopaths; healers, etc. SOURCE: ENDEMAIN 2004

MINISTRY OF PUBLIC HEALTH OF ECUADOR Distribution of human resources by urban-rural sector : 2000 100% 90% 80% 70% 60% kjhkjh 50% Urban Rural 40% 30% 20% 10% 0% Doctors Dentists Nurses Health Professionals Source: INEC, Anuario de Recursos y Actividades de Salud, 2000. From: FESALUD Midwives Adm. -Stat. Personnel

COMPOSITION OF JOB SUPPLY: 1990 JOB SUPPLY, 1990 Private: 9446; 18% Public: 49939; 82%

COMPOSITION OF JOB SUPPLY: 2004 JOB SUPPLY IN 2004 PRIVATE: 23676; 32% PUBLIC: 49939; 68%

PERCENTAGE OF PARTICIPATION IN THE SECTOR 80% 60% 78% 40% -17% 20% 0% -20% PRIVATE PUBLIC REAL GROWTH 400% 350% 300% 250% 200% 150% 100% 50% 0% 364% 111% PRIVATE PUBLIC

MINISTRY OF PUBLIC HEALTH UNDERSECRETARIATE FOR THE EXTENSION OF SOCIAL PROTECTION IN HEALTH CREATION OF BUDGET LINES_4573: BY TYPE OF PROFESSIONAL 380 ADMINISTRATIVE P. 263 TYPE OF PROFESSIONAL TECHNICIANS 2, 321 BAS. NURSES 236 HOSP. NURSES 185 MED. RESIDENT 819 MED. SPECIALISTS 369 OTHER PROFESSIONALS 0 500 1, 000 1, 500 NUMBER OF PROFESSIONALS 2, 000 2, 500

At the middle of the world

MPH ESTABLISHMENTS 1. 842 1% IESS-SSC ESTABLISHMENTS 657 3 rd Level 1% 6% 2 nd Level 2% 97% 93% 1 st Level

MPH ESTABLISHMENTS C O U N T E R R R E F E R R A L IESS (SSC) ESTABLISHMENTS 3 rd HOSPITALS 2 nd HOSPITALS 1 st HEALTH AREAS R E F E R R A L C O U N T E R R E F E R R A L 3 rd HOSPITALS 2 nd HOSPITALS CLINICS 1 st MEDICAL CLINICS R E F E R R A L

IESS (SCC) ESTABLISHMENTS MPH ESTABLISHMENTS ? Vertical integration not achieved because: B A C K R R E F E R R A L 3 rd 2 nd 1 st ? The majority of 2 nd- and 3 rd-level establishments are not integrated with the network of 1 st-level establishments C because no resolution by levels has been O defined U ? Traditional budget is for the supply of N services, with nothing for network management. T R ? Population NOT assigned by E E geographical jurisdiction 3 rd F E R R A L R R E F E R R A L 2 nd 1 st R E F E R R A L

MPH ESTABLISHMENTS IESS (SSC) ESTABLISHMENTS ? Vertical integration achieved through: B A C K R R E F E R R A L 3 rd 2 nd 1 st ? Leadership of the network assumed by the insurer (General Bureau, individual and C family enrollment) rd O ? Budget based on billing carried out in each financial year U ? Specifically assigned population N (members) T ? Revenue coming into the network is from E first-level care. 3 R E F E R R R A L R R E F E R R A L 2 nd 1 st R E F E R R A L

MPH ESTABLISHMENTS IESS (SSC) ESTABLISHMENTS Interinstitutional integration (horizontal) is not achieved due to: 3 rd ? No budget for horizontal integration ? Lack of common pricing, common clinical guidelines (protocols) ? Lack of common instruments for billing and audits (clinic and financing) 3 rd 2 nd 1 st

Santo Domingo

METROPOLITAN DISTRICT OF QUITO Land area: 12, 000 km 2. 2006 population (est): 2, 036, 241 Population density: 169. /km 2.

PUBLIC (OTHER) PUBLIC SUBSECTOR ORGANIZATION INFRASTRUCTURE CONSUMERS STATE CONTRI BUTIONS DPSP FINANCING STATE EMPLOYERS EMPLOYEES DGS HOSPITALS HEALTH AREAS IESS SSC HEALTH UNITS DGS INS. UNITS STATE (traditional budget) Recovery (Dec. 502) 1 SPECIALTY HOSP. 6 SPECIALIZED HOSP; 2 GENERAL HOSP; 2 BASIC HOSP. ; 17 C. S; 75 SC. S U; 38 SC. S R; 4 PS UNINSURED POPULATION INDIVIDUALS (fee for service and/or premiums) DGS UNITS DIRECTORY 1 3 rd LEVEL HOSPITAL 13 DISPENSARIES 2 GEN. HOSP 3 HOSP. 14 CLINICS FORMAL LABOR SECTOR RETIREES MILITARY POLICE UNINSURED POP. PRIVATE INDIVIDUALS (fee for service and/or premiums) DIRECTORY HEALTH UNITS PREPAID MEDICINE 5 HOSP. 60 CLINICS 360 C. M. AND LAB. UNINSURED POPULATION

PUBLIC SUBSECTOR PUBLIC (OTHERS) PRIVATE

SOURCE: Baseline of the Proyecto Salud de Altura (“High. Altitude Health Project). Quito, 2007

MIDWIFE 1. 22 PRIVATE CFL 37. 12 MSP. SCS. 48. 25 PRIVATE SFL 1. 94 51% SOLCA 0. 1 MUNICIPIO QUITO FFAA 1. 56 0. 34 IESS 3. 11 MSP. HOSP 7. 04 SOURCE: Baseline of the Proyecto Salud de Altura (“High. Altitude Health Project). Quito, 2007

A view of downtown …

MPH STEERING PUBLIC FINANCING Q 1 -Q 2. SALE OF SERVICES (Comparison of accounts) ORGANIZATION LEADERSHIP HEALTH AREAS 3 rd 2 nd 1 st PRIORITY USERS EXCLUDED POPULATION Q 1 - Q 2 CLOSING THE COVERAGE GAP 1 st PRIORITY SUBSCRIBERS AND RELATIVES STATE FINANCING AND CONTRIBUTIONS. SALE OF SERVICES (Comparison of accounts) ORGANIZATION LEADERSHIP INSURER AND DISPENSARIES USERS

*Roemer, Milton. Medical care in integrated health programmes of Latin America

Consolidation of the National Health System of the Republic of Ecuador Scenarios

Consolidation of the National Health System of the Republic of Ecuador Stages of Scenario I and II