REVIEW ARTICLE | https://doi.org/10.5005/jp-journals-10009-1627 |
Health System and Markers of Health in Uruguay
Perinatal Department, Pereira Rossell Hospital, Montevideo, Uruguay
Corresponding Author: Ana Bianchi, Perinatal Department, Pereira Rossell Hospital, Montevideo, Uruguay, Phone: +598 2 94416150, e-mail: anabbianchi@gmail.com
How to cite this article Bianchi A. Health System and Markers of Health in Uruguay. Donald School J Ultrasound Obstet Gynecol 2020;14(1):70–75.
Source of support: Public Health Ministry, Montevideo, Uruguay
Conflict of interest: None
ABSTRACT
We describe the implementation of a new National Health System in 2007 in Uruguay, South America, to improve the health for all the Uruguayan population and improve the markers of health. A health system for the private and public hospitals was set up under the strict control of the Ministry of Public Health. We identified 15 critical health problems unresolved, which were also considered important factors to improve and we control their improvement during the next years. The Integrated National Health System incorporated high-cost technology such as cardiac surgery, medication of high-cost chemotherapy, treatments for the burned, and programs of organ transplants completely subsidized by the health system.
Keywords: Health markers, Health system, Infant mortality, Maternal mortality, National sanitary goals.
The Integrated Health System was created in Uruguay in 2007. This health reform has wholly integrated all the population—National Integrated System of Health (SNIS)—allowing a 85% coverage by the National Health System.
Previous to the implementation of this abovementioned single Integrated Health System, some problems that had existed before 2007 in all institutions (private and public) were identified:
- Inequity of benefits in the different medical centers, which depended on the user’s capacity of payment
- Public sector with huge weaknesses of assistance
- Recurrent shutting of private medical centers resulting in dismissals of medical and nonmedical staff
- Delays of payments to providers
- Uncertainty of management in health sector along the country
There was identified a lack of health plan oriented or determined toward sanitary objectives or to modify the health system in favor of the population. Special weaknesses were also identified regarding the control of medical centers (public or private) by the Ministry of Public Health. Nor was there an area of health economics that made comprehensive decisions for all health services in the country according to the health properties of society.
OBJECTIVES TO IMPROVE THE INTEGRATED HEALTH SYSTEM
- Rationalize structures all over the country—sanitary map
- Increase work on the first level of assistance—networks rationalizing appointments with specialists (NETS)
- Continuity of assistance to the user within the health system
- A digital computer system of the medical records of population
- Improve the rectory and control of sanitary policies of the Public Health Ministry
- Participation and communication of health policies to the population by means of education programs in preventive medicine
- Quality control in national health and creation of operating strategies of public and private medicine within the country
NATIONAL SANITARY GOALS
- Achieve to improve the health situation of the population
- Decrease inequities in health rights
- Improve the quality of the health assistance processes
- Generate the necessary conditions for people to have a positive experience in terms of assistance
STRATEGIC OBJECTIVES
- Favor healthy lifestyles as well as decrease risk factors by means of education campaigns of the society
- Decrease the burden of morbimortality of the population
- Improve health access and assistance facilitating controls, decreasing time of appointments and surgeries, increasing the implementation of community centers of primary medicine, improving the transferring of patients, the creation of a bus with primary medical assistance and pregnancy controls able to circulate daily through marginal areas where people have difficulties in accessing centers of assistance
- Constitute an institutional culture upon quality and safety of health assistance
- Implement a centralized system based on the sanitary necessities of people
Implementing this new Health Integrated System for public and private centers under the strict control of the Public Health Ministry allowed to identify 15 critical health problems1–3 yet unresolved, which were also considered important factors to improve health in the population:
- Pregnancy in the adolescent not wanted
- Premature and low-weight pregnancy
- High index of C-section
- Syphilis and HIV vertical transmission
- Development alterations in first infancy
- Critical nutritional problems in first infancy
- Morbimortality due to nontransmitted diseases such as cardiovascular, chronic respiratory diseases, and diabetes
- Morbimortality due to cancer
- Morbimortality due to HIV-AIDS
- Suicidal incidence and mental health problems
- Lesions and death due to accidents at work or on roads
- Gender and generational violence
- Difficulty of access for the disable and assistance of the vulnerable elderly
- Problematic consumption of alcohol and psychoactive substances
- Leak persistence in the quality of sanitary assistance
The implementation of these public policies allowed us to improve our health indicators (Figs 1 to 5).
Expenses figures
The national health insurance multiplied by 5 the public funds destined to health coverage and by 3 the expenses for public hospitals.
Fig. 1: Infant mortality rate and its evolution. Contribution of health policies
Fig. 2: Maternal mortality. The conditions of each health center were set up under a systematical evaluation of all health providers along the country. First evaluation of all integral system of the country in 2017
Fig. 3: Evaluation of the advances of the system integration
WHO goal: public expense greater than 6% GDP, pocket expense less than 20% GDP
COMPUTER REGISTERS OF ELECTRONIC CLINICAL RECORDS
The clinical record (CR) is part of the assistance process. They are of user’s property and under the custody of the health provider.
The quality of patient assistance is assessed by CR audits of Public Health Ministry (qualitative and quantitative).
The importance of access of micromanagement indicators of assistance processes is substantive toward quality accreditation.
The knowledge of quality indicators by users encourages a healthy competence among public and private services.4
In 2019, 26 million of registers were achieved in health system platforms.
Good practice policies work successfully on the first line of assistance
Maternities of excellence are the objective of all health centers.
Computing Agency of Public Health Ministry
Assess the assistance costs of all health providers (public and private) in order to evaluate quality of benefits over which all citizens have rights and pay taxes.
There is a control of rectory of health system reform that regulates the way that private centers work and the amount of users in each center. It also regulates the sanitary lines, national objectives, and goals within each center every year.5,6
Also controlling:
Georeferencing. Coverage of emergency and urgency services
Professional enablement and registration of qualifications
The perinatal computer system (SIP-PLUS) is the network system that we use in all the country to have the data of all the maternities and allows us to monitoring the maternal, perinatal morbidity and mortality.
- Death certificate
- Integral vaccination certificate
- TB national register
- New system of service enablement
Fig. 4: Evaluation in 2018 of advances of each line of action in each strategic objective (in percentage)
Fig. 5: Evaluation in 2019 facing the 15 critical problems. Evaluation of government expenses in the Integrated Health System-SNIS
HEALTH WORKERS
They have represented (2018) the 6.8% of the total working force with a decrease in precariousness and underemployment, a drop of 32% in multi-employment in 2008 and a drop of 27% in 2018.
HIGH-COST TECHNOLOGY INCORPORATION COMPLETELY SUBSIDIZED BY THE HEALTH SYSTEM
Through a National Fund—Institutes of Highly Specialized Medicine (IMAE)—the ministry subsidizes high-technology procedures as well as high-cost procedures such as neonatal cardiac surgery, adult surgery, treatments for the burned, programs of organ transplants, specialized and high-cost medication, and treatments such as chemotherapy.
From 2015 up to date, new technologies and medication have been incorporated to the health fund—IMAE:
- Surgical treatment of refractory epilepsies
- Implementation of a pilot plan for cardiac defibrillators implants on primary prevention
- Incorporation of surgical treatments of aorta aneurisms
- Financing congenital retinoblastoma
- Incorporation of new chemotherapy treatments and new diseases coverage
- Policies for coverage of infertility treatment by the government
- Free incorporation for all providers of screening since the first trimester of pregnancy for all the population7–9
This health system has wholly implemented social strategies in the community aligned to decrease nontransmitted diseases based on prevention, avoidance of tobacco consumption, nutrition, social vaccination programs were set up, prevention of pregnancy diseases and pathologies through increasing prenatal controls, and screening since the first trimester of pregnancy.10–13
This system has allowed a better sanitary control of the society with a qualified and equitable assistance of the population, therefore improving the health indicators of our country: better access to health, better coverage and quality of assistance, as well as more quality of the expense.14–16
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