Can accountability contribute to the enforcement of normative priorities?

An experience from Latin America

Leonardo Cubillos, MD, MPH

Brocher Foundation WorkshopNovember, 2015

Improving equitable access to health care through increasing patient and public involvement in prioritisation decisions.

OBJECTIVES

• To share some key elements of the Latin American health care systems

• To present the experience of judicial accountability in some Latin American countries,

• To [hopefully] generate a discussion about the relevance of accountability as a mechanism to deepen public and patient involvement in prioritisation

INDEX

• Overview of Latin American health systems –successes and challenges

• Historical background and current rationale for judicial accountability

• Critical analysis of judicial accountability –separating judicial accountability from accountability

• Lessons learnt and challenges ahead

OVERVIEW OF THE HEALTH SYSTEMS: RELATIVE LOW INVESTMENT IN HEALTH (%GDP) AND HEAVILY DEPENDENCE

ON PRIVATE SPENDING (45% THE)

Source: Daniel Titelman, Oscar Cetrangolo, Olga Lucia Acosta , "Universal healthcoverage and litigation in Latin America: How to improve solidarity-based schemes. Lancet 2015; 385:1359-63

Significant heterogeneity in

total health expenditure as well as in public

spending as %THE. This

variation is not explained by the

health system model

Source: Rifat Atun, Luiz Monteiro et al, “Health-system reform and universal health coverage in Latin America. Lancet 2015; 385:1230-47

Source: Daniel Cotlear, Octavio Gomez-Dantes et al, “Overcoming social segregation in health care in Latin America. Lancet 2015; 385:1248-59

SIGNIFICANT IMPROVEMENT IN KEY HEALTH INDICATORS AND PROGRESS ALTHOUGH PERSISTENT HEALTH DISPARITIES IN ACCESS AND OUTCOMES SUBSIDE

Improvement in aggregate infant mortality

Source: Adam Wagstaff et al. Health Aff 2015;34:1704-1712

Gap In Maternal And Child Health Coverage

Between The Poorest And Richest Population

Quintiles Of Selected Latin American Countries.

Source: Rifat Atun, Luiz Monteiro et al, “Health-system reform and universal health coverage in Latin America. Lancet 2015; 385:1230-47

LAC HAS DEVELOPED DIFFERENT MODELS FOR PUBLIC PARTICIPATION. EACH COUNTRY HAS

MORE THAN ONE MODEL

• BRAZIL: Multi level involvement in wider health policy issues (Conferences & councils)

• COLOMBIA: Systematic involvement in HTA and design of clinical guidelines (The experience of IETS)

• PERU: Culturally-sensitive involvement in health service delivery for indigenous communities (Quechua and Aymara women’s health right projects)

StateHealth System

(Agent)

Citizens(Principal)

ACCOUNTABILITY IS USED TO IMPROVE THE PRINCIPAL-AGENT RELATIONSHIP

TAXONOMY OF THE CASES BROUGHT TO THE MECHANISMS OF JUDICIAL ACCOUNTABILITY

Are citizens adequately accessing all the health care services they want or need?

Co

vere

d S

ervi

ces

and

P

op

ula

tio

n

No

No

Si

Yes

Litigation to access services that are prioritized but are not delivered at all or are delivered with suboptimal standards

Adequate access, adequate effective coverage, adequate service delivery hence there is no need to litigate

Litigation to access services that are not covered in the health basket, or to receive quality standards that exceed what was initially agreed in the social contract

Judicial accountability increases effective coverage

Judicial accountability may threaten financial sustainability

No litigation but inappropriate use of services

Source: Leonardo Cubillos, Maria-Luisa Escobar, Sebastian Pavlovic, Roberto Iunes, (2012),"Universal healthcoverage and litigation in Latin America", Journal of Health Organization and Management, Vol. 26 Iss: 3 pp. 390 - 406

JUDICIAL ACCOUNTABILITY IN A LAC COUNTRYRED QUADRANT

Plaintiff: Flor Fonseca is a 66 yo woman with chronic and severe knee pain who has been on the waiting list for arthoplasty four years. She has not yet received a surgery date. Due to pain the woman cannot longer walk and she has increased deformities.Defendant: The hospital cannot increase the number of surgeries per day as: the hospital lost beds after the fire that broke in 2010, it lacks enough anesthesiologists, the arthroscopy device has been broken for two years, and the number of emergency surgery has increased.Ruling: This situation is unreasonable. 1. To set a reasonable date for Mrs. Fonseca’s surgery; 2. To compensate the plaintiff; 3. To design and implement a health policy in order to bring waiting lists to reasonable levels. 12 months to design it & 12 months to implement it.

Source: World Bank Institute – SaluDerecho Case 14 Third Latin American Symposium on the Right to Health and Health Systems, June 2013

• Normative priorities have been established

• Patients and civil society organizations are fairly involved in the decision making process.

– Although we are still improving

• Since we face implementation challenges of this social contract, how can we enforce these priorities?

• How can we monitor its enforcement?

ACCOUNTABILITY IN A LAC COUNTRYIssues Highlighted

• Health System Goal: Citizens having equal access to the benefits (services & procedural) of the health-care system irrespective of the contribution they make to its financing.

• Health systems opportunities and challenges are visibly imbedded within broader societal dynamics.

• Constitutional anchor of the specific protection of human rights and the expedite procedural mechanism to hold agents [health systems] accountable.

• The transition out of authoritarian regimes or the societal hopefulness about renewed democracies were cornerstone to the invigoration of public accountability and engagement.

ACCOUNTABILITY IN A LAC COUNTRYRegion specific ethical or social values

StateHealth System

(Agent)

Citizens(Principal)

ACCOUNTABILITY IS USED TO IMPROVE THE PRINCIPAL-AGENT RELATIONSHIP … BUT THERE IS RISK OF

CREATING A NEW OR CONFLICTING AGENT

StateHealth System

(Agent)

• Major societal transformations paved the way to increased accountability of the health system.

• Increased [judicial] accountability has played an important role in health care policies and it has also increased access to health care services

• Negative unintended consequences are observable. (regressivity, commercial interests, double agency)

• There is insufficient data to fully understand the effects of [judicial] accountability in LAC.

• Normative anchor is a necessary but not sufficient condition to achieve adequate accountability in the LAC Health Systems

ACCOUNTABILITY IN LAC COUNTRIESLessons Learnt

FUTURE PLANS TO ENHANCE ACCOUNTABILITY IN THE REGION

• To increase public accountability using endogenous administrative mechanisms.

• Increased inter sectorial action to promote social engagement and accountability in social sectors

• Discussions about utilization of real access data to enhance the monitoring of the performance of health systems.

• Utilization of real access, utilization and cost data to inform HTA.

• Strategic utilization of ICT to strengthen social accountability in the health system.

• Countries continue to work towards integration of their Health Systems

MANY THANKS!