HEALTH POLICY AND HEALTH SYSTEM

in Chile 2008

Professor Jorge Jimenez MD MPH

Departamento de Salud Pública

Pontificia Universidad Católica de Chile

CHILE

• An Independent Nation since 1810

• Close to Bicentenary• Politically

– Republican– Unitarian– Democartic (mostly)

• Socially Progresive and Sensitive

BRIEF SOCIAL HISTORY

• From Independence to late 1890, mainly based on– Agrarian Society with Charitable interventions– But with

• Early Separation of Church and State, • Mandatory Public Education, Charity Hospitals• Few social unrest: disciplined society?

• From 1890 on– Science and State or Public Policy takes the

scene: Rationalism and Social Justice

INSTITUTIONS AND POLICIES

• 1892 Institute of Hygiene• 1893 Board of Vaccinations• 1918 First Code of Public Health• 1924 Social Insurance for Workers:

» Pensions and Widows

» Health

• 1924 Ministry of Health• 1936 Preventive Medicine and MCH Laws• 1952 National Health Service

HEALTH POLICY & HEALTH SYSTEMS

• POLICY: A set of criterias, procedures and resources to intervene in a certain health problem– VG: TB Program: Early Diagnosis and guaranteed

free treatment, MCH:Mothers prenatal care and professional delivery and well baby control

• SYSTEM: a coordinated set of Institutions jointly oriented to health prevention and cure in a given population and territory, with policies and resources, periodically evaluated for improvement and change

MULTIPLE LAYERS IN DEVELOPMENT

BASIC POLICIES 1936-1952

• 1936: Preventive Medicine Law allocated funds and designed strategies to deal with TB, Syphillis and Hypertension

• 1937: Mother and Child Law established a National Council for Nutrition, agreed with the Private Sector to produce and distribute powdered milk to combat malnutition, expand preventive services for reproductive mediceine and child care.

• 1940: A project was sent to Congress for the unification of institutions and policies. It took ten years of debate: Behind the project was an idea of Health System. Integrated, Unified, Egalitarian, Universal

NATIONAL HEALTH SERVICE

• 1952 After 10 years of parliamentary debate, the institution came to life.

• Few technocrats beleived in it

• Doctors were against

• Workers were skeptical

• Employers were afraid of more taxes

NHS. SLOW INCREMENTAL DEVELOPMENT

• 1953 to 1960: Search for institutional cohesion, dificult merger of 20 autonomous entities

• Algorythms for interventions were in preparation and population based experiences

• Examples in Child Care: main problems were Malnutrition, Diarrhea, Infectious diseases: the case of Professor Meneghello and his team:

• Academics with Social Sensibility Plus the Public Service Opportunity were crucial

INFANT MORTALITY: the Mother of Battles

GOOD RECORDS HIGH PERFORMANCE: IMR FALL

y = -0,0001x3 + 0,0311x2 - 3,5661x + 144,63

y = 0,0005x3 - 0,0782x2 + 1,3804x + 115,92

0

20

40

60

80

100

120

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1917

1921

1925

1929

1933

1937

1941

1945

1949

1953

1957

1961

1965

1969

1973

1977

1981

1985

1989

1993

1997

2001

YEARS

RA

TE

x 1

.000

LB

Neonatal mortality

Posneonatal mortality

Polinómica (Neonatal mortality)

Polinómica (Posneonatal mortality)

BETTER SERVICES MAY DETERIORATE YOUR FIGURES

y = -0,0001x3 + 0,0311x2 - 3,5661x + 144,63

y = 0,0005x3 - 0,0782x2 + 1,3804x + 115,92

0

20

40

60

80

100

120

140

160

YEARS

IMR DETERIORATES AFTER NHS 1953-58

INFANT MORTALITY RATE BY SELECTED CAUSESCHILE 1950-2000RATES PER 1.000 LIVE BIRTHS

YEAR 1950 1960 1970 1980 1990 2000

Number of live births 208.092 287.063 251.231 247.013 307.522 261.993

Infant Mortality Rate 136,2 119,5 82,2 33,0 16,0 8,9

Neonatal Mortality Rate 50,4 34,6 31,7 16,7 8,5 5,6

Post Neonatal Mortality rate 85,8 84,9 50,5 16,3 7,5 3,3

Certain conditions originating in the perinatal period 38,7 47,8 17,45 12,86 5,528 3,4

Pneumonia and bronchopneumonia 44,4 31,0 19,5 4,2 2,4 0,66

Diarrhea and gastroenteritis of presumed infectious origin 29,0 16,0 15,2 2,0 0,24 0,038

Congenital malformations, deformations & chromosomal abnormalities

1,45 2,0 3,4 4,0 3,7 3,0

Selected infectious diseases (*) 5,9 4,9 1,6 0,3 0,1 0,07

LOWER IMR, BIGGER PROPORTION OF NEONATAL DEATHS

MALNUTRITION IS PRSENT IN 40% OF INFANTDEATHS

TABLE: Percentage of malnourished children 0-6 years, Chile 1960-2000

YearTotal Mild Moderate Severe

1960 37.0 31.1 4.1 1.8

1970 19.3 15.8 2.5 1.0

1980 11.5 10.0 1.4 0.2

1990 8.0 7.7 0.2 0.1

2000 2.9 2.6 0.2 0.1

Source: Monckeberg F: Prevention of malnutrition in Chile, experience lived by an actor and spectator, Rev Chil Nutr Vol 30, Supp nº 1, Dec 2003, with Annual Reports of Ministry of Health Chile

INFANT MORTALITY DUE TO PNEUMONIA AND BRONCHOPNEUMONIA

YEAR Number of deaths Rate per 100000 LB % of total infant deaths

1990 735 239 15

2000 174 66·4 7·4

% reduction1990-2000

76·3 72·2

NEONATAL MORTALITY DUE TO RESPIRATORY DISTRESS SYNDROME

YEARNumber of deaths Rate per 100000

LB% of neonatal deaths

1990 187 64·4 7·2

2000 87 33·2 6

% reduction1990-2000

53·5 48·4

TECHNICAL ISSUES FOR CHILD SURVIVAL(Jamison et als,2004)

CHILD SURVIVAL IS ALWAYS A MATTER OF CONCERN

• In the presence of a renovated effort to curb the unacceptable number of 10 million infant's deaths occurring every year in the world, certain regions and countries face a second stage in the child survival effort. Latin America and especially Chile have done very well and have rates of infant mortality of under 50 per 1000 live births. (Bellagio Child Survival Group, 2003)

CHILD SURVIVAL SECOND PHASE Contribution to Policy from Chile

• This represents a second phase in the effort, with different components and causes of these deaths. Mainly perinatal conditions, including congenital defects, respiratory infections and some residual infections with effective vaccines available

•

CHILD SURVIVAL STILL BENEFITS FROM PUBLIC INTERVENTIONS

• . While keeping its traditional free and universal access public services for the last 50 years, Chile has reached a figure of 8.9 infant deaths per 1000, with a set of interventions that represent an increase in the provision of services related to perinatal risks, acute respiratory diseases, congenital heart conditions and certain vaccine preventable infections.

CONCLUSION: WE CAN DO WELL WITH LESS MONEY

• With an income per capita of US$ 4,500, Chile has a level of child survival that compares with countries with income over US$ 20,000.

DEMOGRAPHIC TRANSITION

EPIDEMIOLOGIC TRANSITION

2000 A NEW SCENARIO IN HEALTH

• An older population

• Life expectancy closer to 80

• Prevalence of Chronic Diseases

• Need to develop new strategies to cope with the emerging challenges

• Policy and System have to accept and adapt

• And of course: “The economy, stupid”

HEALTH SYSTEM CHILE

• A Basically Public System with Private Sector with different functions

• Insurance:– National Health Fund 80% – Private Insurance Funds 12%– Other or non insured 8%

• Provision:– Public PHC & Hospitals 70%– Private 25%

PUBLIC & PRIVATE GOODS

• Public Goods, Free Universal Access:– Preventive Interventions as Vaccines– Care of Environment– Health Education

• Private Goods, according to Insurance– Medical Care, BUT

• Universal Access with Guarantees for a list of conditions: AUGE

THE WHO MODEL FOR HS

Respuesta Expectativas Legítimas

Respuesta Expectativas Legítimas

Financiamiento JustoFinanciamiento Justo

Mejor Salud

(nivel y distribución)

RectoríaDiseño del sistema; Evaluar; priorizar; Promoción intersectorial; Regulación Protección del consumidor

Provisión

Servicios personales y no personales

Financiamiento

Recolectar, agregar, comprar

Desarrollo recursos

Invertir Capacitar

STRUCTURE, PROCESS & OUTCOMES

• Infrastructure: Hospitals, Technology, Human Resources: in permanent change, progress is uneven

• Financing: Private 450 US per capita, Public 250 per capita

• Provision of Services: Private receive more amount than Public but results are similar

• Quality concerns

Muchas Gracias