Ecuador's health system model

The Ecuadorian Health System is characterized by segmentation into sectors, private and public.

As in other Andean countries in the area, a social security system financed by contributions from workers in the formal sector coexists with private systems for the population with greater purchasing power and with public health interventions and assistance networks for the poorest.

model-of-health-system-of-ecuador

NATIONAL HEALTH SYSTEM ECUADOR

SITUATIONAL DIAGNOSTIC.-

Ecuador in the field of health develops a policy based on the development plan and good living, the same one that has generated an important impact on all social strata thanks to policies related to this area. However, doubts are still being generated about the results of the strong investment in Health.

The Ecuadorian Health System is characterized by segmentation into sectors, private and public. As in other Andean countries in the area, a social security system financed by contributions from workers in the formal sector coexists with private systems for the population with greater purchasing power and with public health interventions and assistance networks for the poorest.

The structure of the health sector in Ecuador, as indicated, is clearly segmented. There are multiple funders and providers: Ministry of Health, IESS Social Security, ICS, NGOs, etc., who act independently. Social security coverage is relatively low (IESS 10% and Seguro Campesino 10%) and the public assistance network is very limited, leaving approximately 30% of the population without coverage. Other providers that cover small insurance fees are: the Ecuadorian Society for the Fight Against Cancer (SOLCA), the Guayaquil Charity Board (JBG) and the services of the Armed Forces and the National Police.

The structure dependent on the MSP is seriously weakened by the lack of budget and its ability to lead the health sector is currently limited.

The network of health services dependent on the Ministry of Public Health (MSP) is structured regionally with two levels of decentralization: provincial (provincial health directorates) and cantonal (health areas).

The main problem that health networks have is the shortage of personnel and their limited resolution capacity in primary and specialized care at the cantonal and provincial level.

There are economic, cultural and geographic barriers that limit access to health services and that especially affect the poor population living in rural areas, mostly indigenous.

There are laws that support the reform of the sector, such as:

Organic Law of the National Health System; Law of Free Maternity and Child Care; Law of Generic Medicines for Human Use,  National Nutrition and Food Program, and  Law of Decentralization and Social Participation.

Several of these laws support the decentralization of the SNS in Cantonal Health Systems, citizen participation and increased coverage

Legal framework

The Ecuadorian legal framework reflects the conceptualization of the National Health System (SNS) and its functions in the Organic Law of the National Health System (Losns), and details in its article 2 that "its purpose is to improve the health and living standards of the Ecuadorian population and make effective the exercise of the right to health. It will be made up of public, private, autonomous and community entities of the health sector, which are functionally articulated on the basis of common principles, policies, objectives and standards. Thus, the SNS performs five fundamental functions shown:

Functions of the National Health System
Rectory	Coordination	Provision of services	Assurance	Financing
The State will guarantee the stewardship of the system through the National Health Authority, will be responsible for formulating the national health policy, and will regulate, regulate and control all activities related to health, as well as the functioning of the entities of the sector.	It is the function of the system that coordinates the relationship between the other functions and between the members of the System. Its exercise is the responsibility of the Ministry of Public Health, at all levels, as a national health authority, supported by the Health Councils.	The provision of health services is plural and with the coordinated participation of the provider institutions. The System will establish the mechanisms for institutions to guarantee their operation in networks and ensure the quality, continuity and complementarity of care.	It is the guarantee of universal and equitable access of the population to the Comprehensive Health Plan in compliance with the citizen's right to social protection in health. The expansion of health coverage of all entities providing services and Insurance will be promoted General Mandatory and Rural Social Security, belonging to the IESS, other public insurance, such as Issfa and Isspol.	Financing is the guarantee of availability and sustainability of the financial resources necessary for universal health coverage of the population. The National Health Council will establish mechanisms that allow the equitable and solidary allocation of financial resources among social groups, provinces and cantons of the country, as well as their efficient use.
Constitution of the Republic of Ecuador Art. 361	Organic Law of National Health System Art. 10	Organic Law of National Health System Art.11	Organic Law of National Health System Art.12	Organic Law of National Health System Art.13

Through the exercise of these functions, the SNS seeks to fulfill four main objectives:

Guarantee equitable and universal access to comprehensive health care services, through the operation of a network of deconcentrated and decentralized management services. Comprehensively protect people from risks and damage to health; the environment from deterioration or alteration Generate healthy living environments, styles and conditions Promote coordination, complementation and development of sector institutions Incorporate citizen participation in planning and oversight at all levels and areas of action of the National Health System

Statistical data of health of Ecuador:

The mortality rate in general was 4.3 deaths per thousand inhabitants, in the case of the maternal mortality rate it was 69.5 deaths per 100 thousand live births (2010), According to the national plan of good living 2013 -2017

SWOT

STRENGTHS.-

Constitutional protection, majority of medical units nationwide, national budget Political will Statistics with adequate coverage and segregation Report of infectious diseases with adequate functioning

OPPORTUNITIES.-

Intersectoral lack of coordination, negligence in decision-making, demotivation of human talent Moment of change and reform of the system Regulatory entities interested in improving their system Demand for new legislation to develop the system

WEAKNESSES.-

Stewardship, Health Promotion, Guarantee of equitable access to care  Decentralized provision of services Separation of Functions  Decentralization Social participation and control Financing and Expenditure Offer of Services Management Models Training and Training of Human Resources Quality and Technology Assessment Lack of Information available

THREATS.-

Low percentage in preventive and health programs Political changes and abandonment of initiatives Disintegration of various sources of information Resistance to change and exchange of information between institutions.

Proposal:

STRATEGIC DIRECTION

Principles.- Health is a constitutional right that, in accordance with article 42 (32) of the Political Constitution of the Republic, "The State will guarantee the right to health, its promotion and protection through the development of food security, the provision of drinking water and basic sanitation, the promotion of healthy environments in the family, workplace and community and the possibility of permanent and uninterrupted access to health services, in accordance with the principles of equity, universality, solidarity, quality and efficiency ". Health is not only the absence of disease, there must be a balance in the family, community and the environment in which it develops, in addition the individual must be protected by social security. Art. 34.- “The right to social security is an inalienable right of all people, and will be the primary duty and responsibility of the State. Social security will be governed by the principles of solidarity, mandatory, universality, equity, efficiency, subsidiarity, sufficiency, transparency and participation, for the attention of individual and collective needs. "

DIAGNOSIS

Lack of organic integration and poor management with difficult administration There is no adequate planning or budgets Excessive political centralization in the appointment of people and purchase of equipment and supplies Salaries out of logic for specialists with the return to Ecuador program, promising Lack of user satisfaction due to deficiency Of careRemodeling of medical units and maintenance of unused equipment The urban metropolitan area by the level of inhabitants monopolizes the coverage level of 60% of the country Inefficient administrations due to lack of knowledge of the people they manage due to their medical degree situation.

SYSTEM OBJECTIVES

Develop a National Compulsory System for the Quality Assurance of Health Care (a single head) with promotion, protection, recovery and rehabilitation Implement the preventive family medical system, community medicine Create a national public health fund (FONASA), with joint responsibility of applied research in areas of interest of the National Public Health Plan Legally decentralize each zonal, provincial and cantonal SIS Analyze situations of knowledge and technology transfer to the health area.

Values.-

It must be characterized by values such as responsibility, universality, solidarity, equity, efficiency, effectiveness, transparency in order to achieve excellence in the offer of services.

View.-

The Unified National Health System by constitutional decree will be an administrative, coordinating, regulatory and control institution; of health and sanitary services to strengthen the development and living conditions of the Ecuadorian population.

Mission.-

The Unified National Health System will be recognized as an administrative, coordinating, regulatory and control institution of health and sanitary services, through ethical values and intersectoral policy decisions, to implement strategic development that benefit society and the country.

Strategic objectives.-

Comply with the goals of the Plan of Good Living 2013-2017 in the area of preventive health Implement a Single National Health System that guarantees the quality of health care Have a decentralized functional organic model in administration with supervision and audits Continuous Strengthen rectory management as an intersectoral coordinating and regulatory entity.

COMPONENTS OF THE HEALTH SYSTEM

Proposal

STRATEGIES

Comply with the goals of the Plan for Good Living 2013-2017 and the Millennium Goals in the area of preventive health.

STRATEGY	ACTIVITIES	INDICATORS	RESPONSIBLE
Improve the quality of life of the Ecuadorian population.	Accessibility to health services and resources preventive and health	Public spending invested in Community health and development (percentage of GDP, contribution to IESS, GAD)	Unique System National Health

Implement a Single National Health System that guarantees the quality of health care.

STRATEGY	ACTIVITIES	INDICATORS	RESPONSIBLE
Promotion of rights and obligations within the Single National System of Health, with emphasis on Health Promotion in the family and community environment.	Create a decentralized body with accessibility to quality and effective services.	Rates related to the frequencies of the needs satisfied (waiting time, percentage of effectiveness, etc.) in a period of time.	Unique System National Health

Have a decentralized functional organic model in the administration with continuous supervision and quality audits of services.

STRATEGY

ACTIVITIES

INDICATORS

RESPONSIBLE

Advise for strategic decision making, implementation of the

reform and operation of a new health network.

Carry out a diagnosis of the network resources and its production of services (offer of services)

Determine the health care gap.

Identify the factors that affect the production of services

(resources: economic, physical, human).

Percentages of coverage of health services.

Unique System

National Health.

Strengthen rectory management as an intersectoral coordinating and regulatory entity.

STRATEGIES

ACTIVITIES

INDICATORS

RESPONSIBLE

Description of the stewardship management of the new single health system, with an intersectoral relationship.

Description of the stewardship model.

Evaluation of resources (physical, human, economic). Determination of the production and operation of the establishments.

Evaluate the Proposals and alternative solutions to health and sanitation policies in the country.

Indicators

health and sanitary

National System

Unique Health.

SUPERINTENDENCY OF HEALTH

OBJECTIVES

Regulate and supervise Health Services, in order to ensure compliance with area policies; for the promotion, preservation and recovery of the health of the population, strengthening the balance between users, providers and financers, in conditions of free competition, transparency, economic efficiency and social equity. Issue the rules to regulate and regulate the modalities of the development of the activities of regulation and control of Organizations. To control the functioning of the Social Work System of the Health Insurance Agents, of the intervening providers and of any other entity that provides or finances medical-assistance benefits that are included.Approve the requests for proposals for entry into the system of the entities and promote their intervention to ensure the continuity and normalization of health benefits Approve the Medical Benefits Program and the Budget of Expenditures and Resources for its execution Ensure and Control the freedom of choice of social works of the beneficiaries of the system, as well as guarantee their effective access Perform once a year, the Surrender of the actions of the Agency in Public Hearing Perform the control of compliance with the ethical obligations corresponding to the Agency and all its dependents and develop control mechanisms and processes against fraud and corruption.Verify the efficiency and effectiveness in the execution of the Strategic Plan of the Superintendency of Health Services and the annual operating plans, and develop the corrective measures to optimize the expected results. Negotiate the collective bargaining agreements.

INTERNAL AUDIT

Examine, investigate and evaluate the activities of the entire organization, identify irregularities or errors and develop recommendations for improvement and carry out their follow-up.

Actions:

Prepare the General Plan for the internal audit to be developed in the Superintendency of Health Services Raise the Annual Internal Audit Plan Verify compliance with the policies, plans and procedures established by the Superintendent Carry out audit plans that include all areas of the organization, coordinate its execution and verify its compliance. Produce audit reports and, where appropriate, formulate the corresponding recommendations and observations. Report on the matters that the Superintendent and the General Trustees of the Nation require. Carry out special investigations. based on requests from the Superintendent or the National General Prosecutor to identify those responsible for corruption or fraud, forming evidence that will serve to apply sanctions.Verify whether the jurisdiction's expenditures and income comply with the accounting principles and budgetary levels of current legal regulations. Follow up on the recommendations and observations made.

GENERAL MANAGEMENT

Actions:

Guide and articulate the management of the body in accordance with the political and strategic guidelines approved by the Superintendent, through direct interaction with the Managers and Deputy Managers. Promote and guide the strategic planning of the body, including the preparation, review and / or update of its plan, the formulation of multi-year budgets and all other aspects of strategic significance, for approval by the Superintendent Design the monitoring system for the management results of the Managements and carry out the monitoring Summon, periodically and regularly meet those responsible for the different areas and officials designated in each case by virtue of the topics to be discussed.Direct the coordination and control of the administrative settlements of the Insurance Agents that are in the process of liquidation. Provide the information requirements to be produced by the different areas for their subsequent integration and production of knowledge by the Strategic Management Department. in the negotiation of collective bargaining agreements to which the Agency is a party. Intervene in the summaries of the social works and the internal summaries of the Agency's personnel.Intervene in the summaries of the social works and the internal summaries of the Agency's personnel.Intervene in the summaries of the social works and the internal summaries of the Agency's personnel.

MANAGEMENT OF ARTICULATION OF THE MEMBERS OF THE HEALTH SYSTEM

Actions:

Implement the necessary instruments for the integration of the different health systems Coordinate activities with the competent bodies of health systems other than those covered by the Laws Propose to the superiority the adequate mechanisms to achieve the unification of all health systems Avoid duplication of the coverage guaranteed by other health systems.

PERFORMANCE CONTROL MANAGEMENT

Actions

Propose norms to standardize model contracts between insurance agents and providers, which include the Mandatory Medical Program, considering the definition of the aspects included in the National Program for the Quality Assurance of Medical Care and promote its observance. Record the contracts made between Insurance Agents and providers, verify compliance with the required requirements, propose corrective actions and eventually penalties for those who violate the rules that regulate their content Propose to the General Management the design and update of the rules on information to be claimed from the Actors of the system for their incorporation into the Health and Assistance Information System.Approve and control the correct management of the benefit programs of the Insurance Agents that they carry out through their own or contracted effectors Propose regulations on the verification and evaluation of the production and submission of the information related to the benefit profile, the co-insurance, the coverage additional to the Mandatory Medical Program, the use of the items of the Mandatory Medical Program and the lists of own and contracted effectors, to be provided by the Insurance Agents and / or providers. Control the inspection that the Insurance Agents carry out on the benefits in relation to assistance programs and quality assurance of care Provide technical assistance and training to Insurance Agents and providers regarding the signing of contracts, in terms of accessibility,coverage, comprehensiveness, solidarity and quality. Supervise compliance with the obligations of the social works regarding the payments for the benefits made to their beneficiaries by the Public Self-Management Hospitals, proceeding in the same way with respect to the social works associations and other agents that have their own effectors Integrate the coordination of the Receivership Committee in the aspects pertaining to its competence Propose norms related to the improvement of the performance control of the registries, sub-registries and of the Public Self-Management Hospital Guide the aspects of its competence that are executed through the Delegations within the Superintendency of Health Services.Supervise compliance with the obligations of social works with respect to payments for benefits made to their beneficiaries by Public Self-Management Hospitals, proceeding in the same way with respect to social works associations and other agents that have their own effectors. of the Sindicatura Committee in the aspects pertaining to its competence Propose norms related to the improvement of the performance control of the registries, sub-registries and of the Public Self-Management Hospital Guide the aspects of its competence that are executed through the Delegations within the Superintendency of Health Services.Supervise compliance with the obligations of social works with respect to payments for benefits made to their beneficiaries by Public Self-Management Hospitals, proceeding in the same way with respect to social works associations and other agents that have their own effectors. of the Sindicatura Committee in the aspects pertaining to its competence Propose norms related to the improvement of the performance control of the registries, sub-registries and of the Public Self-Management Hospital Guide the aspects of its competence that are executed through the Delegations within the Superintendency of Health Services.proceeding in the same way with regard to social work associations and other agents that have their own effectors Integrate the coordination of the Receivership Committee in the aspects pertaining to its competence Propose rules regarding the improvement of the performance control of the registries, sub-registries and the Hospital Public Self-Management. Guide the aspects of its competence that are executed through the Delegations within the Superintendency of Health Services.proceeding in the same way with regard to social work associations and other agents that have their own effectors Integrate the coordination of the Receivership Committee in the aspects pertaining to its competence Propose rules regarding the improvement of the performance control of the registries, sub-registries and the Hospital Public Self-Management. Guide the aspects of its competence that are executed through the Delegations within the Superintendency of Health Services.Guide the aspects of its competence that are executed through the Delegations within the Superintendency of Health Services.Guide the aspects of its competence that are executed through the Delegations within the Superintendency of Health Services.

LEGAL AFFAIRS MANAGEMENT

Actions:

Carry out the legality control and prior legal analysis of all administrative acts emanating from the Superintendency of Health Services Provide legal advice to the Superintendent and the agencies of the agency that require it Participate in the preparation of draft laws, decrees and regulations presented by the Superintendency of Health Services Organize, supervise and exercise legal representation and sponsorship in all lawsuits in which the Superintendency of Health Services is a party Manage records and sub-records of Health Insurance agents, of the operators and beneficiaries of the System.

SYSTEM FINANCING

Although in the last 4 years the budget for the Ministry of Public Health has increased (2007-614 to 2010-1243 million) it has not been enough to satisfy the health needs of Ecuadorian citizens, to this we will add the economic contribution carried out by workers, employers and the state, for the protection of health and social security, obligations that are contemplated in Art. 368.- "The social security system shall include public entities, norms, policies, resources, services and benefits social security system, and will operate based on criteria of sustainability, efficiency, speed and transparency. The State will regulate, regulate and control activities related to social security. And Art. 369.- The compulsory universal insurance will cover the contingencies of illness,maternity, paternity, work risks, unemployment, unemployment, old age, disability, disability, death and those defined by law. Health benefits for sickness and maternity contingencies will be provided through the comprehensive public health network.

Mandatory universal insurance will be extended to the entire urban and rural population, regardless of their employment status. The benefits for people who perform unpaid domestic work and care tasks will be financed with contributions and contributions from the State. The law will define the corresponding mechanism ”. All these constitutional articles have not yet been satisfactory for what is being sought. The creation of a new model, the same one that will be duly financed according to a Comprehensive Contribution System where a low out-of-pocket cost for the user results; In other words, the state is the largest accreditor, followed by the employer and, to a lesser extent, the beneficiary who has the right to choose the place of care. Considering the innovation of the type of service and quality.Contribution that would be administered and controlled by the Integrated System for the Control of Health Contributions.

PROVIDER

The health system plan must be linked as contemplated by the constitution of the republic and the recommendations given by the Pan American Health Organization.

In order to consider the changes that the Ministry of Public Health must make, we have considered legal fields such as:

In the DECLARATION OF ALMA ATA in 1978, with the participation of 140 countries, the commitment of "HEALTH FOR ALL" was concluded and in 1996 in a meeting in Argentina with the Latin countries it was agreed to "Reform the health services".

The National Single Health System will be the coordinator of health services, but the providers would be: the Public health network (IESS, ISPOL, etc.), the Ministry of Public Health, the complementary network (Solca, dialysis clinics,, private clinics, etc.) under unified protocols and regulation in order to bring instruments and institutional health regulations with permanent services 24 hours a day, preventive programs and permanent resources (infrastructure, human and economic) and good accessibility (geographical, quality services, quality of medicines) intellectual innovation and scientific research.

Considering the existence of health institutions: The Ministry of Public Health was created in 1967, the Rural Social Security in 1968 and the insurance fund in 1938.

Structure of the National Public Health System

According to the regulations of the Ministry of Popular Power for Health and Social Development, the National Public Health System is the set of entities, institutions and public organizations that provide health services, all regulated, including those of the private sector, by the ministry. It is made up of a set of health services and establishments, organized in networks that correspond to different levels of care and levels of complexity. Two types of health facility networks are recognized: The municipal health network made up of one or more first-level facilities and a more complex referral facility. For its conformation the association of municipalities can be used. And the regional health network,made up of municipal networks and third level complexity establishments, located in the capital cities of the state.

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