Documento Bid Colombia Apoyo Reforma Al SGSSS

Embed Size (px)

Citation preview

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    1/22

    PUBLIC

    DOCUMENT OF THE INTER-AMERICAN DEVELOPMENT BANK

    COLOMBIA

    SUPPORT FOR REFORM OF THE GENERAL SOCIAL SECURITY

    HEALTH CARE SYSTEM

    (CO-L1127)

    LOAN PROPOSAL

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    2/22

    CONTENTS

    PROJECT SUMMARY

    I. DESCRIPTION AND RESULTS MONITORING..................................................................... 1A. Background, problems, and rationale ................................................................... 1B. Objectives and components ................................................................................10C. Key indicators in the results matrix ....................................................................12

    II. FINANCING STRUCTURE AND RISKS..............................................................................12A. Financing instruments .........................................................................................12B. Environmental and social safeguard risks ..........................................................13C. Risks and political economics of reform ............................................................13

    III. IMPLEMENTATION AND ACTION PLAN ..........................................................................14A. Summary of implementation measures ..............................................................14B. Summary of measures for the evaluation and monitoring of outcomes .............14C. Policy letter .........................................................................................................14

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    3/22

    - ii -

    ANNEXESAnnex I Summary Development Effectiveness Matrix (DEM)

    Annex II Policy matrix

    ELECTRONIC LINKS

    REQUIRED

    1. Policy Letterhttp://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=378267472. Means of Verification

    http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736720

    3. Results Matrixhttp://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736629

    OPTIONAL

    1. Ex Ante Economic Analysishttp://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37740142

    2. Monitoring and Evaluation Arrangementshttp://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37738264

    3. Safeguard Policy Filter Reporthttp://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736693

    4. Implementing and Designing High-Quality Primary Health Care: Outcomes in Colombia I and IIhttp://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735476

    http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735487

    http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37826747http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736720http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736629http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37740142http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37738264http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736693http://pcdocs//IDBDOCS/37735476/1http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735476http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735487http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735487http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735476http://pcdocs//IDBDOCS/37735476/1http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736693http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37738264http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37740142http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736629http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37736720http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37826747
  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    4/22

    - iii -

    ABBREVIATIONS

    CREE Impuesto sobre la renta para la equidad [income tax for equity]DNP Departamento Nacional de Planeacin [National Planning Department]ICBF Instituto Colombiano de Bienestar Familiar [Colombian Institute for

    Family Welfare]IETS Instituto de Evaluacin de Tecnologas Sanitarias [Institute for the

    Evaluation of Health-related Technologies]

    IMAN Impuesto Mnimo Alternativo Nacional [National Minimum AlternativeTax]

    ISC Inspection, surveillance, and controlLIBOR London Interbank Offered RateMINSALUD Ministry of Health and Social ProtectionOECD Organization for Economic Co-operation and DevelopmentPOS Plan Obligatorio de Salud [Mandatory Health Plan]SENA Servicio Nacional de Aprendizaje [National Apprenticeship Service]SGSSS Sistema General de Seguridad Social en Salud [General Social Security

    Health Care System]SNS Superintendencia Nacional de Salud [National Superintendency of Health]WAL Weighted average life

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    5/22

    PROJECT SUMMARY

    COLOMBIASUPPORT FOR REFORM OF THE GENERAL SOCIAL SECURITY HEALTH CARE SYSTEM

    (CO-L1127)

    Financial Terms and Conditions

    Flexible Financing Facility *

    Borrower:Republic of ColombiaAmortization period: Bullet on 15 December 2025

    Original WAL: Maximum 12.38 years **

    Executing agency:Ministry of Finance and Public Credit (MHCP), intechnical coordination with the National Planning Department (DNP)

    Disbursement period: 1 year

    Grace period: Bullet on 15 December 2025

    Source Amount Interest rate: LIBOR

    IDB (Ordinary Capital) US$250 million Inspection and supervision fee: ***

    Local - Credit fee: ***

    Total US$250 million Currency: U.S. dollars from the BanksOrdinary Capital

    Project at a Glance

    Program objective:

    This is the first in a series of two operations to support reform of Colombias General Social Security Health Care System (SGSSS), using aprogrammatic policy-based loan. The objective of this programmatic series is to assist in designing and implementing reforms to thesystem, as a means of generating ongoing improvement in health care outcomes, enhancing financial protection for users of the system, andensuring the systems long-term financial sustainability. The new reforms are expected to strengthen the health care system, by establishinga service delivery model that will improve health care outcomes, promote management of the risk of disease through preventive care,establish equitable access to high-quality services, enhance efficiency in managing resources, promote the rational and equitable use o

    health-related technologies, and provide for a higher degree of inspection, surveillance, and control in the health sector.Special contractual clauses:

    The disbursement of resources is subject to fulfillment of the policy reform measures described under the specific program components,along with fulfillment of the other conditions established in the loan contract (paragraphs1.34 to1.39 andAnnex II).

    http://pcdocs//IDBDOCS/37740073/Rhttp://pcdocs//IDBDOCS/37740073/Rhttp://pcdocs//IDBDOCS/37740073/Rhttp://pcdocs//IDBDOCS/37740073/R
  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    6/22

    I. DESCRIPTION AND RESULTS MONITORINGA. Background, problems, and rationale1.1 Over the last two decades, Colombias General Social Security Health Care System

    (SGSSS) has made significant progress in coverage with regard to health careinsurance, access to services, equity, and financial protection for households.Nevertheless, challenges remain in terms of the flow and transparency of publicresources for the health sector, and with regard to the legitimacy of the system. In

    light of this situation, the Government of Colombia, through the Ministry of Healthand Social Protection (MINSALUD), has been working on plans to reform theSGSSS, with the goal of introducing a service delivery framework that providesincentives for prevention, so as to ensure greater efficiency in resource managementand improve access to health care services. The Bank is supporting the nationalauthorities in reorganizing the sector and in discussions on relevant issues for thereform process.

    1.2 This is the first in a series of two operations to support reform of ColombiasSGSSS, under the programmatic policy-based loan (PBP) modality. The objectiveof this programmatic series is to assist in designing and implementing reforms tothe system, as a means of generating ongoing improvement in health careoutcomes, enhancing financial protection for system users, and ensuring the flowand transparency of public resources for health care. The reforms described in thisdocument are expected to strengthen the health care system, by establishing aservice delivery model that will improve health care outcomes, promotemanagement of the risk of disease through prevention, establish equitable access tohigh-quality services, enhance efficiency in managing resources, promote therational and equitable use of health-related technologies, and provide for improvedinspection, surveillance, and control (ISC) in the health sector.

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    7/22

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    8/22

    - 3 -

    resources, the reform created the income tax for equity, known as the CREE, whichis calculated based on the profits earned during a given taxable period, rather thanon employer payroll. This tax is expected to generate Col$10.4 billion in 2014, andmore than Col$12 billion as of 2016, to be divided among health care, the ICBF,and SENA. The government has acknowledged the importance of not changingdelivery of the services provided by these entities or the proper functioning of thehealth care system. To this end, the tax reform established that, should the resourcesobtained through CREE collections be insufficient, these needs will be financed out

    of the National General Budget. These changes not only assure resources for thehealth care system, but will also increase the share of tax revenues used for healthcare, which will constitute more than 60% of SGSSS financing beginning in 2014. 3

    1.10 External sector. The countrys balance of payments from January to September2012 constitutes an increase in the current account deficit from 2.7% to 3.1% ofGDP over the same period in 2011. There was also an increase in the financialaccount surplus from 4.0% to 4.5%, and an accumulation of gross international

    reserves of US$3.532 billion. It is expected that, by the end of 2013, the balance ofpayment current account deficit will have stabilized at around 3% of GDP.

    2. Current status of the SGSSS in Colombia1.11 Law 100 of 1993.With the passage of this law, Colombia transformed its National

    Public Health System into a health insurance system, known as the SGSSS, inwhich private and public insurers participate, making up a service delivery networkof both public and private providers. The insurers, known as Health Promotion

    Enterprises, compete to be part of, and to manage, insurance for the population, andare responsible for collecting the users financial contribution. The serviceproviders, known as Service Provider Institutions, compete to sell health careservices. The SGSSS is divided into two categories: the Contribution-based Regime

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    9/22

    - 4 -

    needed, was 40% higher among the insured than among the uninsured.4

    Moreover,the percentage of poor women who received four prenatal check-ups increasedfrom 41.5% in 1990 to 86.2% in 2011; while between 1993 and 2010, access tomedical care during delivery rose by 116% for women in the poorest segments ofthe population.

    1.13 Financial protection for households. As of 2013, 95% of the urban populationreports out-of-pocket spending of less than US$200;5 in 2010, private spendingrepresented 27.3% of total health care expendituresa figure comparable to theaverage for Organization for Economic Co-operation and Development (OECD)countries (28.2%), and less than the average for Latin America and the Caribbean(42.5%).6

    1.14 Weaknesses of the system. Despite the major achievements of the SGSSS, thereare deficiencies in health care outcomes and quality of care. Payments that thesystem must make that are not covered by the POS (non-POS services) haveincreased dramatically, above all for medications. Adding to this are the high

    operating costs of administering the system, for which the resource flow has beenbecoming increasingly problematic. Lastly, implementation of the ISC system,which is essential to a system as deconcentrated and decentralized as is Colombias,has experienced difficulties.

    1.15 The current model for care is focused on high-cost services, as opposed to healthpromotion and preventive carean issue of vital importance in an environment ofepidemiological transition and a burden of preventable chronic illnesses. Access to

    high-quality primary care is difficult, with 40% of the urban population having towait more than six days for a general medical consultation (excludingemergencies), while, for a group of 11 OECD countries, only 15.6% of thepopulation has such a long wait.7Due to the problems of accessing primary care,

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    10/22

    - 5 -

    created regional inequities. For example, 16% of the rural population was unable toaccess health care services when needed, because the medical center was too farfrom the patient, while in the case of urban patients, 2.3% were unable to accesshealth care services. There are also differences between regions: fewer usersperceive their health to be unsatisfactory in urban areas (22.5%) than in ruralzones (34.1%).10 These disparities are due in part to geography and the lack ofcomprehensive, coordinated health care services in remote areas, leading to greaterinequity in care.

    1.16 Heath-related technologies. Evidence indicates that the main determinant ofincreases in per capita spending on health care in recent decades has been theemergence and use of ever more expensive medical technologies.11The increasedcost of technology in Colombia can be seen primarily in increased requests for newtechnologies that were not included in the POS. These non-POS services are paidfor using exceptional mechanisms, and are reimbursed from public coffers underthe category of reimbursement payments.12 Such payments have increased at an

    accelerated pace, from Col$0.1 billion in 2004 to nearly Col$2.4 billion in 2010an amount equivalent to almost 20% of the Contribution-based Regimes receiptsfor that same year.13According to a Bank study, the largest portion of the publicresources used to finance these non-POS services are for medications, includinghigh-cost, latest-generation biotechnological medications.14It is noteworthy that, inaddition to the fact that reimbursement payments have increased, there is an addedelement of inequity involved: 44% of the reimbursement payments have benefitedthe highest income quintile of the population.

    1.17 The Banks study also found that the issue cited above is due, in part, to thefollowing factors: (i) the current structure of the POS incentivizes requests forreimbursement payments; and (ii) weaknesses and lack of clarity in pharmaceutical

    li I t f th f th t fi ti f th POS

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    11/22

    - 6 -

    emerged on the importance of having a legitimate, transparent, participatory, andtechnically sound framework for evaluating new technologies.

    1.18 Structure for collection and management of resources. In spite of the fact that,since 2012, Colombia has had a single health benefits plan for the entire populationand the majority of the funding comes from general taxes, the resource-management and collection structure continues to be highly complex andfragmented. The Contribution-based Regime is financed primarily through payrolltaxes of salaried workers. The financing of the Subsidized Regime is more complexand derives from various sourcesprimarily from specific levies (taxes on liquor,cigarettes, lottery tickets, and gaming), revenues from petroleum exploitation, andthe general share-out system, which is based on the percentage of the generalbudget that, by law, is transferred to the municipios and departments for investmentin the social sectors. In addition, approximately one percentage point ofContribution-based Regime payments is used to help finance the SubsidizedRegime. According to data from MINSALUD, the SGSSS collected Col$26 billion

    in 2012 from 16 different sources.1.19 The complexity of the structure for resource management and collection has created

    a number of problems. First, an evaluation of the Subsidized Regime concludes thatthe transaction costs could reach nearly 2% of the regimes per capita cost, with this

    figure being higher in small municipios with scant economies of scale. These costsare the result of the complex system for allocation and execution of the 1.2% ofGDP used by the Subsidized Regime, which must process more than 27,000contracts for 1,100 municipios each year.15 Second, the fragmentation of public

    financing into multiple, separate, inflexible and financially uncoordinatedbudgetary categories produces inequities in resource allocation. An equitablesystem would provide the same level of resources to all citizens, regardless of the

    i i hi h th ti i t d L tl t t H lth P ti E t i

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    12/22

    - 7 -

    hindered the implementation of an effective ISC system. These include: (i) thediversity and number of actors overseen by the SNS; (ii) the centralized nature ofthe institution; (iii) the proliferation of rules and regulations; (iv) the weak inter-institutional and extra-institutional coordination; and (v) the lack of sufficienthuman resources.

    3. Reform of the SGSSS in Colombia1.21 In addressing the situation in the sector, the Government of Colombia, through

    MINSALUD, is working on a plan to reform the SGSSS, in an effort to establish aservice delivery framework that ensures the health care services capacity toachieve health outcomes, and makes the system more transparent, efficient, andequitable in administering and allocating resources.

    1.22 Service delivery model. In attempts to improve capacity to achieve healthoutcomes and comprehensive and ongoing quality, with the goal of eliminatingbarriers to access, the reform proposals lay the groundwork for major change in theservice delivery model and structure, with an emphasis on health promotion andpreventive care.17The new model defines geographic areas for operating health careservices and establishes Health Management Zones, in which the inhabitants mustbe assured delivery of all of the services covered under the benefits plan known asMy Plan, except for highly complex services not available in the area. TheseHealth Management Zones will be run by the health care managers responsible fororganizing and managing the network of service providers, and by the serviceproviders responsible for providing care or individual services. The proposal

    includes the formation of Special Health Care Zonesareas of the country wherethe population is highly dispersed that are managed differently than other areas ofthe country.18

    1 23 Health care managers will need to organize and manage the service delivery

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    13/22

    - 8 -

    care in general medicine, as well as care in certain specialized areas. Thesupplementary providers, in turn, will be responsible for providing individual healthcare services that require human, technological, or infrastructure-based resources ofa more specialized or technological nature; preferably, these providers will treatpatients referred to them by the primary providers.

    1.25 Management of the system.The model aims to align incentives with successfulmanagement and health outcomes. The managers will be overseen by amanagement unit (called Salud-Ma, or My Health) that is part of MINSALUD.The manager will receive an annual sum to cover administration costs, to beprovided on the basis of a per-capita value and divided into two categories: (i) thefirst will cover the costs of the new Health Benefits Plan (Mi Plan); and (ii)thesecond will be contingent on achieving health outcomes. The managers will nolonger receive funds from payments for the services included in Mi Plan; these

    will instead be paid to the health care providers, after review and authorization bythe managers.19

    1.26 Benefits plan and pharmaceutical policy. In order to rationalize the use ofresources and make it more efficient, equitable and effective in terms of healthoutcomes, the government is proposing a new structure for Mi Plan. It calls formoving from an explicit, restrictive list of active principles with pharmaceuticalforms and concentrations (current POS) to a less detailed list of active principlesgrouped by use (Anatomical Therapeutic Chemicalor ATCclassification)20anda list of explicit exclusions. Similarly, the government has adopted a nationalpharmaceutical policy,21whose principal objective is to develop public policies that

    give the Colombian population equitable access to effective medicines, throughhigh-quality pharmaceutical services, based on the principle of co-responsibility ofthe sectors and agents involved in their fulfillment. Implementation of this national

    li i tl i d th t i di i l t

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    14/22

    - 9 -

    assisting in its initial evaluations of technologies that will be available in 2013, toupdate the POS.

    1.27 Strengthening of ISC. The reforms proposed by the government in the currentlegislative bill for sector reform focus on closing existing legal gaps and definingthe responsibilities and functions of the SNS, as well as establishing the role ofsubnational entities as central actors in the control system. At present, theColombian SNS is in a process of restructuring and institutional strengthening,based on the new powers given to it under Law 1122 of 2007, and on the additionalresponsibilities assigned to it under Law 1438, such as the delegation of some of itscontrol functions to the subnational entities. The most important change proposed isfor the SNS to concentrate on the issues of service delivery and protection of thesystems users, with many of the functions of financial oversight being taken overby the Financial Superintendency. Through the institutional redesign and proposedreforms, the SNS will be able to impose corrective, preventive, and punitivemeasures to ensure delivery of health care services.

    4. Bank support for the health sector1.28 To address the institutional, structural, financial, and technical challenges of

    Colombias health sector, the Bank, pursuant to requests from the government, hasworked on and provided support for overcoming these challenges. In order toimplement Law 100, which provided for the creation of the SGSSS between 1992and 1995, implementation of an investment loan and a Health Care ImprovementProgram programmatic loan (loan 716/OC-CO) and Program to Support Health

    Sector Reform (loan 910/OC-CO) were designed and supported jointly.1.29 Owing to the fiscal crisis in the late 1990s, there were cuts in financing for the

    vaccination program, resulting in a reduction in the programs coverage. The SocialEmergency Program (loan 1455/OC CO) an emergency loan for the social sector

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    15/22

    - 10 -

    restructuring and modernizing the Public Hospital Network and developing a Policyon Health Care Services Quality.

    1.31 Since 2010, given the financial crisis in the sector, the Bank has been supportingand working with the government to ensure the sustainability of the health caresystem. This has led to two nonreimbursable technical cooperation operations, oneregional and the other just for Colombia (operations ATN/SF-11853-RG24 andATN/FI-12861-CO25). These operations are supporting the design of Mi Plan (themain cause of the financial bleeding). In addition, the Bank helped in structuringthe new IETS and is financing technical support for preparing the procedures andmethodologies to be used in evaluating technologies and the design of thepharmaceutical policy.

    1.32 The Banks country and sector strategy. The present operation falls under theBanks Institutional Strategy in the Report on the Ninth General Increase in theResources of the Bank (document AB-2764), which supports attaining the regionaldevelopment targets through ongoing participation by the Bank in expanding access

    to basic health services, as well as support for new efforts to expand the preventivehealth protocols and measures, in light of the epidemiological transition. Similarly,the strategy is aligned with the Banks current country strategy with Colombia(document GN-2648-1), on the objective of improving the quality and sustainabilityof the health care system. It is also aligned with the strategies of the NationalDevelopment Plan 2010-2014, which calls for promoting well-being and a healthylife, based on health promotion and preventive care, and on offering timely, high-quality care to users of the SGSSS, which is charged by the government with

    addressing the factors and determinants that contribute to disease prevention andcontrol and timely care.

    B. Objectives and components

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    16/22

    - 11 -

    1.35 Component 2. Redefinition of the SGSSS. This component seeks to strengthenthe SGSSS by reorganizing service delivery and establishing incentives for riskmanagement in the area of health, with emphasis on prevention. The aim of thisfirst operation is to prepare and present to the Congress a bill redesigning theSGSSS that lays out the structure for health services delivery, the role of the variousagents involved, and the incentives for achieving health outcomes, with anemphasis on prevention; it also seeks to ensure that MINSALUD identifies generalguidelines for service delivery in regions with dispersed populations, through a

    technical document that spells out a health services model with a differentialapproach. Triggers for the second operation would consist of MINSALUDestablishing the incentives model for promoting positive health outcomes, alongwith providing a viable operational health care model, including a differentialapproach for regions with dispersed populations.

    1.36 Component 3. Greater efficiency and equity in managing health careresources.The objective of this component is to promote efficiency and equity in

    the collection and administration of health care resources, while rationalizing theuse of health-related technologies. This component seeks to reduce financialintermediation and to ensure greater transparency in resource management. Thus, inthe first operation of the programmatic series, MINSALUD is expected to prepareand present to the Congress a bill redefining the SGSSS that lays out the creation ofa management unit with administrative, financial, and budgetary autonomy toprovide unified management of the resources used to finance the system. Thismanagement unit, to be known as Salud-Ma [My Health], is being formed to

    eliminate financial intermediation and improve payments, remittances, and/ortransfers to the service providers.

    1.37 In addition, as part of the mechanisms to improve efficiency in the use of resourcesd t h l i th t i t d t d t t ti l

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    17/22

    - 12 -

    Thus, this first operation will aim to prepare and present to Congress a billredefining the SGSSS that calls for building the ISC capacity of the SNS and itsdelegates, and to prepare a proposed executive decree for reorganization of thesystem. These activities will help improve the monitoring of the system andpromote transparency among service providers. The second operation will seek tohave the regulations for reorganizing the SNS approved, with an emphasis onprotecting users and overseeing service providers.

    C. Key indicators in the results matrix1.40 The expected outcomes of the programmatic operations are conceived as short- and

    medium-term changes, resulting from the implementation of reform measuresdesigned to increase the health care systems efficiency, effectiveness,transparency, and equity. Major impacts are expected with regard to healthoutcomes, through the following interventions supported by the programmaticseries: (i) reorganization of health care services, with increased emphasis onprevention, establishing a differentiated health care model for regions with highly

    dispersed populations and for traditional peoples; (ii) reductions in mortality ratesin one of the remote regions identified;26 (iii) streamlining of the collection andmanagement of the health sectors financial resources; (iv) prioritizing health carespending on cost-effective technologies; (v) increasing ISC in the health sector; and(vi) providing increased health care insurance coverage.

    1.41 Economic analysis. An extensive economic analysis of the impacts associated withthe policy reforms being promoted through this programmatic series was

    conducted. It calculated the overall financial benefits with regard to the mainelements of the health care reform and found that the reform measures, based oneconomic estimates, would produce overall social savings of more thanUS$750 million per year. Moreover, the study identifies a clear opportunity,

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    18/22

    - 13 -

    and Implementation. The choice of a programmatic series was based on its abilityto strengthen policy dialogue with the government regarding regulatory reforms andmanaging the SGSSS, and on the ability to provide the system greater flexibility inadapting to changes in strategy for implementing the reforms over the mediumterm.

    2.2 The present operation is for US$250 million, financed out of the Banks OrdinaryCapital, under the Flexible Financing Facility and will be disbursed in a singletranche. The amount of financing for the subsequent operation will be specified in atimely manner in the course of the annual programming dialogue, taking intoaccount the countrys external financing needs, priorities in the Banks strategy

    with Colombia, and the progress made, based on the Policy Matrix.

    B. Environmental and social safeguard risks2.3 This operation does not finance physical investments, nor does it envisage activities

    with adverse effects on natural resources and, therefore, does not require an ex anteimpact classification (B.13) under the Environment and Safeguards CompliancePolicy (OP-703). Using the Environmental Safeguard Filter, this was classified as acategory Coperation. The social impact of the program is expected to be positive,with improved access to higher-quality health care services in the country,particularly in areas with dispersed populations, including areas with indigenouspopulations.

    C. Risks and political economics of reform2.4 Given the reforms implications and scope, it faces major risks. Agents, such asinsurers, pharmacists, hospitals, medical associations, local authorities, and users

    could impede the progress of reform in the event they see potential losses in thenew model In this context, MINSALUD is making an effort to promote dialogue

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    19/22

    - 14 -

    negative perception of the systemonly 17% says the health system functionsquite well.

    III. IMPLEMENTATION AND ACTION PLANA. Summary of implementation measures3.1 Borrower and executing agency. The borrower is the Republic of Colombia.

    Through the Ministry of Finance and Public Credit (MHCP), which will serve as

    the executing agency, it will execute the program and use the proceeds of the Bankloan. The executing agency, in turn, will conduct the program in coordination withthe DNP, which will be responsible for coordinating with MINSALUD themonitoring of fulfillment of the policy measures necessary for the reform of theSGSSS proposed under the program.

    B. Summary of measures for the evaluation and monitoring of outcomes3.2 Program monitoring involves verifying compliance with the policy measures

    agreed to as conditions of the loan. There is, in addition, ongoing monitoring,within the programs, of the outcomes of those policy reforms, using indicators forthe operational procedures of the programs involved. Evaluation of the reforms willoccur in two ways: (i) through a before-and-after evaluation of indicators associatedwith the performance of the health care system, using an existing baseline for 2013,as well as through a national survey of the users of the health care system, to befinanced with technical cooperation resources from the Bank, the results of which

    can be found in the attached document (Implementing and Designing High-QualityPrimary Health Care: Outcomes in Colombia IandII); and (ii) through the designand implementation of a special health care model for widely dispersedpopulations, which will be evaluated by a quasi-experimental evaluation study that

    http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735476http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735476http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735487http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735487http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735487http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735487http://idbdocs.iadb.org/wsdocs/getDocument.aspx?DOCNUM=37735476
  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    20/22

    Annex I - CO-L1127

    Page 1 of 1

    1. IDB Strategic Development Objectives

    Lending Program

    Regional Development Goals

    Bank Output Contribution (as defined in Results Framework of IDB-9)

    2. Country Strategy Development Objectives

    Country Strategy Results Matrix GN-2648-1

    Country Program Results Matrix GN-2696

    Relevance of this project to country development challenges (If not aligned to country

    strategy or country program)

    II. Development Outcomes - Evaluability Highly Evaluable Weight Maximum Score

    9.3 10

    3. Evidence-based Assessment & Solution 9.4 33.33% 10

    4. Ex ante Economic Analysis 10.0 33.33% 10

    5. Monitoring and Evaluation 8.4 33.33% 10

    Overall risks rate = magnitude of risks*likelihood

    Identified risks have been rated for magnitude and likelihood

    Mitigation measures have been identified for major risks

    Mitigation measures have indicators for tracking their implementation

    Environmental & social risk classification

    The project relies on the use of country systems (VPC/PDP criteria) The project uses another country system different from the ones above for implementing

    the program

    The IDBs involvement promotes improvements of the intended beneficiaries and/or public

    sector entity in the following dimensions:

    Gender Equality

    Labor

    Environment

    Additional (to project preparation) technical assistance was provided to the public sector

    entity prior to approval to increase the likelihood of success of the project

    The ex-post impact evaluation of the project will produce evidence to close knowledge

    gaps in the sector that were identified in the project document and/or in the evaluation plan Yes

    h h f f f ( ) h h d d l f h f f h l b l h l

    The project plans to do a quasi-experimental impact evaluation

    using double differences. The evaluation aims at providing

    evidence on: (a) The effect of a community health care model on

    the general health status of the population of Guaina, and (b)

    The impact of family care model in the Guaina department on

    the resolution and mortality rates.

    Low

    Yes

    III. Risks & Mitigation Monitoring Matrix

    IV. IDBs Role - Additionality

    Yes

    Yes

    B.13

    Infant mortality ratio.

    Individuals (all, indigenous, afro-descendant) receiving a basic package of health services.

    Aligned

    Enhance health system quality and sustainability.

    The intervention is included in the 2013 Country Program

    Document.

    Development Effectiveness Matrix

    Summary

    Aligned

    Lending for poverty reduction and equity enhancement.

    I. Strategic Alignment

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    21/22

    Annex II

    Page 1 of 2

    POLICYMATRIX

    Component

    Issue

    Policy Measures

    Programmatic loan I (2013) (Policy Conditions) Programmatic loan II (Triggers)

    1. Macroeconomic framework:Stable, sustainable macroeconomic and fiscal framework to support the viability of program objectives.

    (1.1) Maintain a stable macroeconomic framework

    consistent with program objectives.

    (1.1) Maintain a stable macroeconomic

    framework consistent with program objectives.

    2. Redefinition of the General Social Security Health Care System (SGSSS): Strengthening of the SGSSS by reorganizing service delivery and introducing incentives for risk

    management in health.

    The systems current structure does not include clear incentives forprevention and health promotion, thus making it difficult to achieve

    the desired health outcomes. The prevailing service delivery model is general, with no specific

    guidelines for care and for service delivery in areas with dispersed

    populations.

    (2.1) Preparation and presentation to the Congress of a

    bill redefining the SGSSS that lays out the structure of

    health services delivery, the role of the variouspersonnel involved, and the incentives for achieving

    health outcomes, with an emphasis on prevention.

    (2.1) Definition by MINSALUD of the model of

    incentives for achieving positive health

    outcomes.

    (2.2) Identification by the Ministry of Health and

    Social Protection (MINSALUD) of general guidelines

    for service delivery in regions with dispersed

    populations, through a technical document that

    establishes a model for health services, with a

    differential approach.

    (2.2) Operational model for health care, with a

    differential approach for regions with dispersed

    populations, declared legally viable.

    3. Greater efficiency and equity in the administration of health care resources: Promote efficiency and equity in the collection and administration of health care resources, along

    with rationalizing the use of health-related technologies.

    Fragmentation of public financing into multiple budgetary categorieswith separate, inflexible and uncoordinated financing, leading to

    inequities in allocating resources among various population groups.

    (3.1) Preparation and presentation to the Congress of a

    bill redefining the SGSSS that calls for the creation of

    a management unit with administrative, financial, and

    budgetary autonomy, in order to provide unified

    management of the resources for financing the system.

    (3.1) Preparation of technical specifications for

    the structure of the information system to be used

    by the management unit in providing unified

    management of system resources.

  • 8/12/2019 Documento Bid Colombia Apoyo Reforma Al SGSSS

    22/22