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HEALTH POLICY AND HEALTH SYSTEM
in Chile 2008
Professor Jorge Jimenez MD MPH
Departamento de Salud Pública
Pontificia Universidad Católica de Chile
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CHILE
• An Independent Nation since 1810
• Close to Bicentenary• Politically
– Republican– Unitarian– Democartic (mostly)
• Socially Progresive and Sensitive
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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
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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
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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
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MULTIPLE LAYERS IN DEVELOPMENT
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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
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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
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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
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INFANT MORTALITY: the Mother of Battles
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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
140
160
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)
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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
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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
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LOWER IMR, BIGGER PROPORTION OF NEONATAL DEATHS
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MALNUTRITION IS PRSENT IN 40% OF INFANTDEATHS
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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
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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
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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
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TECHNICAL ISSUES FOR CHILD SURVIVAL(Jamison et als,2004)
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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)
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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
•
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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.
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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.
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DEMOGRAPHIC TRANSITION
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EPIDEMIOLOGIC TRANSITION
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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”
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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%
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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
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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
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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
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Muchas Gracias