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

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

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

Uruguay: summary data

Capital: Montevideo (40% pop.) Pop.: 3.300.000 aprox.

94% urban

Area: 176.065,00 km2 Climate: Mild (16º)

HDI: 42nd (high)

GDP: USD 14.000 (per captita,

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since 

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  ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia • Also to guarantee a homogeneous set of health care  services that define “integral coverage”   

Flashback

• Until the year 2007 the uruguayan Health System  was divided into two subsystems

*

:   Public (basically for low­income 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   

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since 

Flashback (cont.)

• Consecuence: expenditure per­capita 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  ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia

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  • 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      • Financial reform: general taxes, employers and  employees* all contribute to the FONASA (National  Health Fund)   

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since

6th international conference September 26, 27, 28

Cartagena de indias, Colombia

Sources Funds Supliers

Users

General 

 taxes contributions Employees’   contributions Employers   Households  Militar, police, 

University hospital  FONASA  FNR  OOP  insurance  Private   Police, Militar and 

 University hospitals  “PublicASSE ”  “PrivateIAMC ”  IMAE  _{Clinics, etc} Private  

Policemen, Militars,  some civil servants  Worst­off   (income)  Formal   workers,   & family,  and retired  Households with  Capacity to pay  *Source: Aran D, Laca H. 2011

2006

2010*

Coverage by type of institution

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%

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 

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since 

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

2006

2010

Institutions’ age structure

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 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

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since  Public Private 18­65 (55%)  <18 (32%)  <18 (26%)  18­65 (59%)  18­65 (50%) <18 (40%)  18­65 (67%)  15 %  10%  13%  _15%  19% 

Grafically

2006

2010

* Risk structure becomes more even between public and  private sector institutions    ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia

2006

2010

Labor condition

S ector E mployed Unemployed R etir/pens E s tudiantes

P ublic 26% 57% 34% 33%

P rivate 62% 24% 55% 53%

O ther 12% 19% 11% 14%

T otal 100% 100% 100% 100%

S ector E mployed Unemployed R etir/pens E s tudiantes

P ublic 28% 60% 33% 46%

P rivate 59% 20% 54% 36%

O ther 13% 20% 13% 18%

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since  2006 2010

By income quintiles

S ector/quintile 1s t 2nd 3rd 4th 5th P ublic 74% 47% 30% 15% 4% P rivate 18% 41% 57% 72% 80% O ther 4% 9% 10% 10% 14% No C overage 3% 3% 3% 3% 2% T otal 100% 100% 100% 100% 100% S ector/quintile 1s t 2nd 3rd 4th 5th P ublic 79% 60% 40% 20% 5% P rivate 6% 21% 42% 66% 83% O ther 12% 16% 14% 11% 11% No C overage 2% 3% 4% 3% 1% T otal 100% 100% 100% 100% 100% ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia

 

 

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 

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since 

Grafically

2006 2010

Quintile 

Public Private Other No coverage

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

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since  From the institutions point of view, users profile  changed considerably  2006

2010

 

 

Consecuence

Quintile P ublic P rivate

1 39% 3% 2 30% 10% 3 20% 19% 4 10% 30% 5 2% 38% Total 100% 100%

Quintile P ublic P rivate

1 43% 7% 2 27% 15% 3 18% 21% 4 9% 27% 5 2% 30% Total 100% 100%

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since  2006  2010  1º  1º  1st  2nd  Private  5th  Public  1st  1st  2006  ₂₀₁₀ 

Grafically

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

Per capita expenditure

• Important reduction of Public sector users +  important budget increase (social security  contributions, general taxes)  Consecuence: important reduction of public­private  gap in per capita expenditure    • Private/public ratio 2010: 1,30* (vs 2,7 2006)   

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since 

 

 

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

Age

<18  18  26­45  46­65  65 +  25  33% _{9% 29% 23% 7%}

Labor

status

<14y  S  R  25% 59% 7% 7% 2%

Income

1st  2nd  3rd  4th  5th  9% 19% 23% 25% 24%

2010: FONASA coverage

Employed  1%  U

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since   FONASA Covered 

2010 by institution

 Not 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% 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% ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia

The “not covered”

• Stable percentage in the period, of about 2,7%  • 38% of them are in the 26­45 age range  • No other relevant characteristic of this group that  distinguishes them from the entire population  • Equitable distribution by income quintiles  

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since 

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

Summary

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

Uruguayans’ healthcare coverage: analysis of observed changes in the direction of equity since 

Summary (cont.)

• Nevertheless Public sector users’ profile did not  change dramatically  • Increasing entrance of the retired to the FONASA  (before 2007 they had to pay, to gain access to  the private sector)  • The mayority FONASA covered choose a private  institution (87%)  • Important reduction in expenditure  private/public gap  ISEqH 6th conference September 26, 27, 28 Cartagena, Colombia

Forthcoming

• Reform still taking place until 2016 when all the  retired will be included in the FONASA  • Extended assistance (mental health, reproductive  health, etc).  • User satisfaction surveys (waiting time, etc.)   • Military and policmen