Public Disclosure Authorized August 2011 REGIONAL INITIATIVE ON PRIORITY SETTING, EQUITY, AND CONSTITUTIONAL MANDATES IN HEALTH Creating a Sustainable Platform for Multi-stakeholders to Coalesce and Address the Progressive Realization of the Right to Health PROGRESS REPORT | ARGENTINA, BRAZIL, CHILE, COLOMBIA, COSTA RICA, PERU, AND URUGUAY The Regional Initiative on Priority Setting, Equity, and tial actions that maximize the benefits and minimize Public Disclosure Authorized Constitutional Mandates in Health was launched in the limitations of the current use of PSS and JRH; and 2010, by the Health Systems Practice of the World Bank (iv) support participating countries in strengthening Institute. Seven Latin American countries—Argentina, leadership, building consensus, and establishing Brazil, Chile, Colombia, Costa Rica, Peru, and Uru- sustainable multi-stakeholder coalitions for the design guay—are currently participating in the Initiative. and implementation of policy actions to increase and The ultimate goal of this multi-year program is to enforce sustainable and equitable progressive access contribute toward the creation of a sound process to to healthcare. achieve a sustainable, equitable and progressive real- The Initiative has four phases structured around ization of the right to health. To achieve this objective, regional and country level priority setting, equity, and the Initiative supports a capacity building and leader- constitutional mandates issues. ship program for multiple stakeholders from several Public Disclosure Authorized sectors, including the executive, judiciary, health The Challenge authorities, physicians, and civil society. This process The number of health rights litigation cases in Latin intends to: (i) create awareness of the existence of Pri- America has increased dramatically since the 1990s. ority Setting Strategies (PSS) and judicialization of the This has occurred despite the fact that Latin American right to health (JRH) mechanisms to improve health- countries have improved access to health care, and care access; (ii) establish a sustained dialogue across that aggregate health indicators have shown steady countries in the region to contribute to a collective improvements in the last two decades. During this understanding of the nature, uses, and limits of the period, governments have also increased the allocation status-quo of these mechanisms; (iii) enhance national of public resources to deliver health care to its citizens, and regional capacity among branches of the govern- reducing in some cases the financial burden of health- ment and other key stakeholders, to develop poten- related shocks on households, especially the poor. It is Public Disclosure Authorized important to note, however, that large inequalities still This resource constraint is being further exacer- persist in these countries. bated in the region by epidemiological and demo- While these lawsuits may provide individuals access graphic transitions, and the spiraling costs triggered to health services, the judicialization of the right by the rapid incorporation of new medical technolo- to health can collide with the limited availability of gies. As a result, countries face increasingly hard resources faced by the health systems, and may even choices on how best to use available funds. increase inequality in healthcare delivery and access. As This scenario implies that the challenge of the recognized by the 2010 World Health Report, pooled full realization of the right to health for all cannot be funds will never be able to cover all the costs of all ser- achieved immediately, but it is instead a continuous vices needed for all the population. process in which countries have an obligation to Chart 1. The Four Phases of the Initiative Regional National National National National PHASE 1 PHASE 2 PHASE 3 PHASE 4 Identification Consensus building Implementation of Monitoring and diagnostics national plans and evaluation DESCRIPTION DESCRIPTION DESCRIPTION DESCRIPTION `iÌviÃÊV >i}iÃÊ>`Ê`iÌvià Õ`ÃÊÕÌÃÌ>i `iÀÊV>«>VÌÞ >ViÃÊÃÌ>i `iÀÊV>«>VÌÞÊÌ ii«iÃÊÕÌÃÌ>i `iÀ iÞÊÃÌ>i `iÀÃÊ>ÌÊÌ iÊVÕÌÀÞ ÌÊivviVÌÛiÞÊÌÀ>Ã>ÌiÊi >Vi` «iiÌÊÌ iÀÊ>Ì>Ê>VÌ i}>}iiÌÊÌÊv>VÌ>ÌiÊÀivÀ >`ÊÀi}>ÊiÛi Üi`}iÊÌÊ>VÌÊ«>à «>à >ÌÊÌ iÊVÕÌÀÞÊiÛiÊ>`ÊÃÕ««ÀÌ ÌÀ} FOCUS FOCUS FOCUS FOCUS UÊ Üi`}iÊiÝV >}iÃÊ>` UÊ ÃÌ>Là iÌÊvÊÕÌ UÊ «iiÌ>ÌÊvÊVÕÌÀÞ UÊ ÃÌ>Là iÌÊvÊ>ÊÀi}>ÊL`Þ Ê ÃÌ>i `iÀÊVÃÕÌ>ÌÃ Ê ÃÌ>i `iÀÊVÕÌÀÞÊV>ÌÃ Ê >VÌÊ«>à UÊ ÌÀ}ÊvÊÀiÃÕÌÃÊÌ UÊ *ÌV>Ê>««}Êv UÊ iÛi«iÌÊvÊ>Ì> UÊ -Õ««ÀÌÊvÀÊÌ i>ÌVÊÜi`}i Ê ÃÌÀi}Ì iÊivvV>VÞÊvÊ i>Ì Ê ÃÌ>i `iÀÃ Ê >VÌÊ«>Ã Ê iÝV >}iÃ Ê «Vià UÊ Õ`}ÊVÃiÃÕÃÊÊÃÃÕià UÊ ÃÌ>Là iÌÊvÊ>ÊiiVÌÀV UÊ -Ì>i `iÀÃÊV>iÃViViÊv UÊ ÕVÌ}ÊvÊÃivÃÕvvViÌ Ê >`ÊV >i}iÃÊ>ÌÊÌ iÊVÕÌÀÞ Ê ÀiÃÕÀViÊViÌiÀ Ê ÀiÃÕÌÃ Ê >Ì>Ê>`ÊÀi}>ÊiÌÜÀÃ Ê iÛi move forward in an effective, equitable and sustain- UÊ Knowledge Exchanges: Since the inception of able way. the Initiative, eleven knowledge events have been delivered via video conference using the The Four Phases of the Initiative at the National and Global Distance Learning Network (GDLN). Regional Level More than 60 high-level decision makers of This Initiative has a national and a regional focus. While client countries participated in these exchanges. the Initiative relies on country-level knowledge and stake- The objectives of these events were to foster holder involvement, its major strength rests on its regional dialogue, create a better understanding of the focus. At the national level, multi-stakeholder coalitions main challenges and advances in the protec- will be formed to spearhead country efforts to champion tion of the right to health from a health systems the development of strategies and the subsequent imple- perspective. Other subjects were the evolution mentation of action plans to address this issue. These of the right to health jurisprudence, as well as coalitions will play a critical role in providing oversight and its impact on the performance of national health monitoring progress at the country level. systems in delivering equitable, efficient, and At regional level, the Initiative relies on dialogues sustainable health care. and knowledge exchanges among key stakeholders in UÊ Analysis of the evolution of the right to health the same region. The activities under each phase are jurisprudence carried out in all seven participating also expected to be coordinated at the regional level, countries: This comparative analysis facilitated with the support of different regional partners, such as more robust knowledge exchanges and will be a the Inter-American Court of Human Rights. By levering milestone for future coalition-building activities. In regional collaboration, this Initiative can contribute addition, a quantitative analysis of litigations was to planned and/or ongoing efforts at national level to also undertaken in Brazil and Colombia for which address regional solutions for the progressive realiza- draft reports on key findings are being prepared. tion of the right to health (see chart 1). UÊ Political Mapping: In collaboration with the Coali- The Initiative has successfully completed Phase 1. tion Building Research and Support Unit of the Its activities were aimed at the identification of key Governance Practice of WBI, the first political stakeholders at the regional and national level, and mapping exercise was carried out in Uruguay. It at the characterization, by these stakeholders, of the included an analysis of stakeholders’ perception issues and challenges around priority setting, equity, of health litigation and the progressive realization and the progressive realization of the right to health. of the right to health. It also gathered information Activities of Phase 1 were a political mapping exer- on health care access, the governability of priority cise, the launching of a web-based platform and the setting strategies, and the financial and technical establishment of first regional coalitions (see table 1). sustainability of court decisions. The draft report Table 1. Knowledge Exchange and Coalition-Building Activities during Phase 1 Activities of the Regional Initiative Date Participants Sharing experiences of a regional June 2010 Governments of Argentina, Brazil, Chile, Colombia, Peru, and Costa Rica phenomenon Understanding the concepts of October 2010 Constitutional Tribunal of Peru and Governments of Argentina, Brazil, reasonability and proportionality Chile, Colombia, Peru, and Costa Rica in the Peruvian right to health jurisprudence Understanding a multi- December 2010 ACAMI, OSDE, Universidad Nacional del Cuyo, and Supreme Court of stakeholder dialogue experience and March 2011 Mendoza in Health in Argentina Learning from the use of right to February 2011 PRODISA–Fiocruz and Ministry of Health–Brazil, National Resources health litigation to ensure access Fund–Uruguay, NICE–UK to health services: experiences of Uruguay and Brazil Political Mapping Exercise of March 2011 Ministry of Public Health, Supreme Court of Justice, National Resources stakeholders’ perception towards Fund, Center for Judicial Studies, Health Services Administration health litigation in Uruguay Services, Republic University, Montevideo University, Physician unions, Insurers, and Patients Understanding court decisions April 2011 PRODISA–Fiocruz–Brazil, Pan American Health Organization and in Latin America: legal, academic institutions in Guatemala, Argentina, Colombia, Chile, and economic and medical/sanitary Uruguay characteristics and their impact on developing and implementing health policies Understanding the evolution of May 2011 Cuyo University,