Dr. Nelly Baeza Tapia. Division of Primary Care
Better health, with your participation
Primary Health Care
SOCIAL DETERMINANTS ANDSOCIAL DETERMINANTS AND PUBLIC POLICYPUBLIC POLICY
Ref: Modified Briefing paper: Health inequalities: concepts, frameworks and policy authors H. Graham , M P. Kelly 2004, NHS.
LABOR MARKET
EDUCATIONAL SYSTEM
WELFARE STATE
SOCIAL STRUCTURE
Socioeconomic
status
Gender
Ethnicity
SOCIAL STATUS OF THE
INDIVIDUAL
MEDIATING FACTORS
Living Conditions
Working Conditions
Behavior
Health and Social
Services
Health and well-being
EQUITY IN HEALTH
Mediating Determinants Structural Determinants
POLITICAL-INSTITUTIONAL
GLOBALIZATION
Environment
Social Cohesion
HEALTH: PILLAR OF SOCIAL PROTECTION
Health as the engine and result of an individual’s quality of life
Based on the ability of people to obtain education, work, create a family, and be happy in their environment.
Result of education, work, family relations, and quality of the environment.
THE CONTEXT OF OUR ACTION
Epidemiological and
Demographic Changes
Epidemiological and
Demographic Changes
InequityInequity
User
Dissatisfaction User
Dissatisfaction
Principles of the
Reform
Principles of the
Reform
Objectives of the
Reform
Objectives of the
Reform
R
E
F
O
R
M
R
E
F
O
R
M
HealthObjectives
Model•Emphasis on health promotion and disease prevention
•Integration of the social services network
•Strengthening primary health care
•Improve performance in meeting health objectives
•Face up to the challenges of aging
•Reduce inequalities
•Meet the needs and expectations of the population
POPULATION STRUCTURE. Chile: POPULATION STRUCTURE. Chile: Population pyramid-1950, 2005, 2050.Population pyramid-1950, 2005, 2050.
• Pop.: 16,432,674 (2006)• IMR: 8.4 (2004)• GMR: 5.4 (2004)
• LEB: 77 (74/80)
Source INE
NEW CONCEPTSNEW CONCEPTSChile: Trends in life expectancy at birthChile: Trends in life expectancy at birth
by age and sex. 1950-2050 (observed and by age and sex. 1950-2050 (observed and projected). projected).
Save Lives
Quality of Life
Source INE
Poverty trend,1990-2006. Casen Survey, MIDEPLAN
GRADUAL ELIMINATION OF POVERTY
38.6
32.6
27.5
23.221.7 20.5
18.8
13.8
0
5
10
15
20
25
30
35
40
45
1990 1992 1994 1996 1998 2000 2003 2006
Per
cent
age
Pop
ulat
ion
268268 Urban and rural communes
5252 Fixed-fee (F.F.) Communes
2626 Communes with PC dependent on
the Health Services
Source: www.minsal.cl/DEIS. 20/09/2007
PRIMARY HEALTH CARE (PHC) NETWORK
Municipal
CESFAM 144
CGR 142
CGU 214
ST CENTERS 500
POSTS 1,168
Growth of Municipal Beneficiary Population2000 - 2007
6798956 7490508 8031075 8484199 8823191 9365626 9742047 9976716
1.00
1.18 1.25
1.30 1.38
1.43 1.47
1.10
0
2000000
4000000
6000000
8000000
10000000
12000000
2000 2001 2002 2003 2004 2005 2006 2007
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
Beneficiary Population Variation
RESOURCES FOR HIGH-QUALITY PRIMARY HEALTH CARE
150,348
0
42,014
179,252
3,347
41,277
197,665
2,471
46,334
235,461
2,402
45,319
269,271
2,422
47,551
313,688
19,166
51,984
354,121
22,006
52,687
416,359
32,799
56.421
463,492
44,202
58,233
0
100.000
200.000
300.000
400.000
500.000
600.000
2000 2001 2002 2003 2004 2005 2006 2007 2008
11.9%
MUNICIPAL AND NONMUNICIPAL PHC-- INVESTMENTS IN PHC PUBLIC HEALTH PROGRAMS
% OF PRIMARY CARE IN HEALTH SERVICES BUDGET
U$: 1,021,000,000
2008
TREND - MONTHLY PER CAPITA AMOUNT PER TREND - MONTHLY PER CAPITA AMOUNT PER PERSONPERSON
1997-2007
Source: Department of Primary Care D.I.G.E.R.A. /MINSAL, Year 200 7
U$: 3 per person/month (2007)
$ 563$ 721
$ 793 $ 841 $ 877 $ 922 $ 950 $ 973
$ 1,336$ 1,429
$ 1,500100%
128%141%
149% 156%164% 169% 173%
237%254%
266%
500
1.000
1.500
2.000
2.500
3.000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
-30%
20%
70%
120%
170%
220%
270%
Monthly Per – Capita value/person (in pesos)Growth
Source: DIVAPS/2007.
Figure: Total Resources 2007
by Funding Line
PER CAPITA
CONTRIBUTION
57%EXPLICIT
GUARANTEES
17%
LAW 19,813
4%
STRENGTHENING
PROGRAMS
22%
Infrastructure for Primary CareFAMILY HEALTH CENTERS AND COMMUNITY FAMILY HEALTH CENTERS
Linchpins of the Model’s transition
Curative approach Promotional andpreventive
Biomedical approach Biopsychosocial
Social services delivery Community approach approach to health
Hospital-based approach Primary CarePrimary Care
Levels approach Networks concept
Integrated Health Care ModelIntegrated Health Care Model
Health Care Model
Emphasis
User-centered carePromotion and preventionFamily approachIntegratedOutpatient careParticipatoryIntersectoralQualityAppropriate technologyCommunity management
Health Care Model
OBJECTIVE: Ensure that each individual and family has a primary care team and health care facility nearby, allowing them to feel protected and accompanied to stay healthy, and the necessary referral mechanisms for dealing with more complex problems
NationalReferralCenters
Organized family and community
HEALTHYNEIGHBORHOOD
INTERSECTORAL
Family HealthCenters
SecondaryCare Centers
Hospitals
Integrated health care model with a family and community approach
Prehospital careEmergency Care Network
Health Team
• Doctor• Nurse• Midwife• Social Worker• Dentist
• Nutritionist• Physical/respiratory
therapist• Psychologist• Paramedic • Administrative
support staff
Conceptual Model
• People-centered • Flexible to needs• Biopsychosocial approach (integrated)• Population served and continuity• Emphasis on rights and responsibilities
• Promotion and prevention emphasis • A preventive approach at all levels.
• Family health approach• Consider the context and the individual and
family life cycle
Conceptual Model
• Integrated• At PHC centers• In the health care delivery network
• Emphasis on outpatient care• Prioritize open care
• Participation• In community action and management
monitoring
Conceptual Model
• Intersectoral Approach• Activation of priority sectors
• Quality• Technical and in terms of user perception
• Appropriate technologies• Procurement and purchasing
• Workforce• Specific competencies
MAIN TRENDS
We continue to have major progress in health, but:
– Moving forward requires cultural changes that must be manifested in individual behaviors that can only be improved collectively.
– Inequities in health status persist, depending on the geographical location, socioeconomic and household situation, ethnicity, and gender.
– Greater social and economic development is needed, together with the implementation of public health policies that have a significant impact on the population, with a new social rights approach.
MAIN TRENDS
• Low growth and aging of the population.
• Increase in chronic diseases--high degree of
harm from accidents and violence: visibility and
emergence of new health problems
• Greater concern about well-being and not simply
preventing death or disability.
• Citizens and users who increasingly demand
better health conditions and health care in a
growing spiral of expectations.
Guarantees in Acute Respiratory Infections
• ARI (Acute Respiratory Infections)
•ARD (Acute Respiratory Diseases)
Guarantees in Acute Respiratory Infections
• ARI (Acute Respiratory Infections)- As of the mid-990s. - Childhood ARI. - Respiratory therapist, drugs (inhalers),
oxygen therapy, monitoring with x-rays. - Health monitors. - Epidemiological surveillance
Guarantees in Acute Respiratory Infections
• ARD (Acute Respiratory Diseases)- Began in 1999. - Elderly. - Respiratory therapist, drugs (antibiotic
treatment), oxygen therapy, monitoring with x-rays. 2007: Pneumococcus Vac.
- Epidemiological surveillance
EPIDEMIOLOGICAL EPIDEMIOLOGICAL SURVEILLANCESURVEILLANCE
•Morbidity in Sentinel Centers
•Emergency Morbidity Services
•Etiology
•Climate and Pollution
PMF, ODP/ MINSAL Respiratory Health Unit PMF, PAO/ Respiratory health unit, MINSAL
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 5 9 13 17 21 25 29 33
Epidemiological week
TOTAL ARI NON-RESP.
Proportion of Pediatric Respiratory ConsultationsSentinel Centers of the Metropolitan Region, 2007
PMF, PAO. Respiratory Health Unit, MINSAL
ARI DECLINE IN CHILDREN UNDER 15, 2007ENDEMIC CHANNEL 1998-2006 SENTINEL CENTERS
PRIMARY HEALTH CARE - METROPOLITAN REGION
PAO/PMF/MJP. ARI PROGRAM, MINSAL
0
5
10
15
20
25
30
35
40
45
50
55
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Epidemiological week
% o
f to
tal p
edia
tric
con
sulta
tions
2007 med under max. Over min.
OBSTRUCTIVE BRONCHIAL SYNDROME IN CHILDREN UNDER 15 - 2007
ENDEMIC CHANNEL 1998-2006 SENTINEL CENTERS PRIMARY HEALTH CARE - METROPOLITAN
REGION
PAO/PMF/MJP. ARI Program, MINSAL
0
5
10
15
20
25
30
35
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Epidemiological week
% o
f to
tal p
ed
iatr
ic c
on
sulta
tion
s
2007 med under max. over min.
PNEUMONIA IN CHILDREN UNDER 15, 2007 ENDEMIC CHANNEL 1998-2006 SENTINEL CENTERS
PRIMARY CARE - METROPOLITAN REGION
PAO/PMF/MJP. ARI PROGRAM, MINSAL
0
1
2
3
4
5
6
1 6 11 16 21 26 31 36 41 46 51
Epidemiological week
% o
f t
ota
l ped
iatr
ic c
on
sult
atio
ns
2007 med under max. over min.
CONSULTATIONS FOR DIS.OF LOWER RESP. TRACTAGES 65 AND OVER
SENTINEL CENTERS – METROPOL. REGION, 2003-2007 -
0
5
10
15
20
25
30
35
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Epidemiological week
% o
f to
tal co
nsu
ltati
ons
for
peop
le 6
5 a
nd
over
2003
2004
2005
2006
2007
CONSULTATIONS FOR PNEUMONIA AGES 65 AND OVER
SENTINEL CENTERS-METROPOLITAN REGION.. 2003-2007
0
1
2
3
4
5
6
7
8
9
10
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Epidemiological week
% o
f to
tal c
onsu
ltat
ion
s b
y p
eop
le a
ged
65
and
ove
r
2003
2004
2005
2006
2007
WEEKLY CONSULTATIONS FOR RESPIRATORY ILLNESSCHILDREN’S EMERGENCY SERVICES - METROPOLITAN
REGION,APRIL - SEPTEMBER 2003 - 2007.
14 16 18 20 22 24 26 28 30 32 34 36
Statistical week
0
2000
4000
6000
8000
10000
12000
14000
16000Number of consultations
2007 2006 2005 2004 2003
WEEKLY HOSPITALIZATIONS OF CHILDREN WITH RESPIRATORY ILLNESS
METROPOLITAN REGION, APRIL - SEPTEMBER 2003 - 2007.
14 16 18 20 22 24 26 28 30 32 34 36
Statistical week
0
200
400
600
800
1000
1200Number of hospitalizations
2007 2006 2005 2004 2003
WEEKLY CONSULTATIONS FOR RESPIRATORY ILLNESS ADULT EMERGENCY SERVICES. REGION METROPOLITANA.
APRIL - SEPTEMBER 2003 - 2007.
14 16 18 20 22 24 26 28 30 32 34 36
Statistical Week
0
1000
2000
3000
4000Number of consultations
2007 2006 2005 2004 2003
Gr‡fico 1: Tasa de Notificaci—n de Influenza. Vigilancia Centinela. Chile, 2004- 2007 (semana 1-35)
0
20
40
60
80
100
1 5 9 13 17 21 25 29 33 37 41 45 49
Semana Epidemiol—gica
Tasa
de N
otific
aci—
n x 10
0.000
2007 2006
2005 2004
Fuente: EPIDEMIOLOGìA -MINSAL
Figure 1. Influenza Notification RateSentinel Surveillance. Chile, 2004-2007 (weeks 1-35)
Notification
rate
X
100,000
Epidemiological week
Source: EPIDEMOLOGY-MINSAL
RSV CASES.METROPOLITAN REGION 2001-2007 --
050100150200250300350400450
1 4 7 101316192225283134374043464952
weeks
n c
as
es
2001
2002
2003
2004
2005
2006
2007
Average Weekly Temperature
Tem
pera
ture
oC
Weeks
Average Weekly Comparison of 2007 with 2002-2006 Historical Levels of Suspended Particulate Matter Fraction Under 1010
)
0
20
40
60
80
100
120
140
160
WEEKS
WE
EK
LY
GL
OB
AL
AV
ER
AG
E (
"g/m
3N)
Maximum 63 61 68 64 74 61 68 71 70 73 84 101 90 98 107 127 114 120 146 116 120 137 98 128 143 100 104 138 107 113 117 99 98 81 93 83 75 59 73 62 57 60 55 62 67 59 64 58 58 60 67 58
Average 55 58 60 54 65 59 61 63 62 67 70 80 74 82 76 88 95 98 118 87 100 101 81 93 106 80 90 88 91 74 76 75 75 63 64 63 64 52 61 50 48 55 48 53 53 51 52 50 51 53 58 54
Minimum 46 55 54 46 48 56 53 51 57 59 59 68 59 60 49 61 83 61 63 54 82 64 50 48 91 56 73 64 70 56 52 54 45 46 39 44 54 42 48 39 39 52 39 48 42 44 42 45 46 46 52 52
2007 60 61 54 41 58 56 44 46 59 65 68 70 53 67 66 72 105 90 131 129 120 99 117 92 70 123 74 85 93 82 83 70 53 58 87
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Average Weekly Comparison 2007 with 2003-2006 Historical Levels of Suspended Particulate Matterunder 25 microns (MP2.5) Stations L-M-N-O
0
10
20
30
40
50
60
70
80
weeks
WE
EK
LY
GL
OB
AL
AV
ER
AG
E (
µg
/m3N
)
Max. 28 26 28 29 38 29 32 32 28 32 33 43 35 39 42 53 51 52 67 61 53 74 58 58 53 53 57 49 52 57 53 49 58 43 46
Ave. 23 24 24 23 32 26 26 26 25 28 28 35 30 33 33 39 46 47 55 52 50 57 50 43 50 47 49 39 44 42 40 39 37 34 32
Min. 19 23 22 19 23 22 22 22 23 24 24 30 23 27 23 29 39 30 31 29 46 46 34 28 45 27 33 30 33 32 26 25 24 25 19
2007 25 23 21 14 20 21 17 19 22 25 26 29 25 32 30 29 43 39 58 64 66 53 62 46 41 59 41 43 46 38 45 36 26 29 41
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
RESOURCESRESOURCES
No. of ARI and ARD Rooms. Chile 2004 - 2007
PMF, ODP/ MINSAL Respiratory Health Unit
ARI Rooms ARD Rooms ARI-SAPU Rooms Mixed Rooms
502
165
60
0
523
230
100
0
523
410
170
0
530500
172
100
0
100
200
300
400
500
600
2004
2005
2006
2007
2660
132194 194
230280
350 357 357 357396 402
452502 523 523 530
30
40 45
45
60
100170 172
100
0
100
200
300
400
500
600
700
800
900
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
No. of ARI Rooms. Chile 1990-2007
PMF, PAO/ MINSAL Respiratory Health Unit
No. of Inhalers Distributed - Chile 2006 and 2007 Child and Adult Respiratory Programs
PMF, PAO/ MINSAL Respiratory Health Unit
0
200000
400000
600000
800000
1000000
1200000 2006 2007
SALBUTAMOL` BUDESONIDE` SALM+FLUTIC IPRATROPIO SALMETEROL
MORTALITYMORTALITY
CHILE HAS MADE TREMENDOUS PROGRESS CHILE HAS MADE TREMENDOUS PROGRESS IN REDUCING INFANT MORTALITY IN RECENT IN REDUCING INFANT MORTALITY IN RECENT
YEARS, DUE IN PARTICULAR TO THE YEARS, DUE IN PARTICULAR TO THE SIGNIFICANT REDUCTION IN: SIGNIFICANT REDUCTION IN:
• CHILD DEATHS FROM ARICHILD DEATHS FROM ARI
•NEONATAL MORTALITYNEONATAL MORTALITY
Chile, 1990-2006. No. of ARI Rooms vs. Infant Mortality from ARI
* Estimated rates* Estimated rates
0
100
200
300
400
500
600
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005* 2006*
Nº
roo
ms
0
0.5
1
1.5
2
2.5
Rate p
er 1000 LB
N° ARI rooms I.M.ARI
Deaths from Pneumonia and Other Respiratory Infections All Ages. January-July. Chile 2001-2004 and 2007
2004 2007
PMF, PAO/ Respiratory Health Unit MINSAL Provisional data: Deaths 2006-2007 (DEIS)
2001
2,1391,995
1,453
0
300
600
900
1200
1500
1800
2100
2400
99
63
21
0
20
40
60
80
100
120
Deaths from Pneumonia and Other Respiratory Infections
Children under 1 year. January - July. Chile 2001-2004 and 2007
2004 2007PMF, PAO/ Respiratory Health Unit MINSAL Provisional data: Deaths 2006-2007 (DEIS)
2001
564
498
302
0
100
200
300
400
500
600
Deaths from Pneumonia and Other Respiratory Infections Ages 65-79. 1 January - July. Chile 2001-2004 and 2007
2004 2007
PMF, PAO/ Respiratory Health Unit MINSAL Provisional data: Deaths 2005-2006 (DEIS)
2001
1135
1403
1125
0
200
400
600
800
1000
1200
1400
1600
Deaths from Pneumonia and Other Respiratory Infections Age 80 and over 1 January - July. Chile 2001-2004 and 2007
2004 2007
PMF, PAO/ Respiratory Health Unit MINSAL Provisional data: Deaths 2005-2006 (DEIS)
2001
ADDED TO THIS IS A BREAK IN THEADDED TO THIS IS A BREAK IN THE TREND TREND FOR DEATHS FROM PNEUMONIA IN THE FOR DEATHS FROM PNEUMONIA IN THE
ELDERLY, WHICH REMAINED STATIONARYELDERLY, WHICH REMAINED STATIONARY
Mortality from Pneumonia and Other Respiratory Infections Chile 1990-2006. Children under 1 and adults aged 65 and over
(Rate per 100,000 LB and per 100,000 pop. aged 65 and over, respectively)
PMF, PAO/ MINSAL Respiratory Health Unit Source: DEIS * Provisional data
0
50
100
150
200
250
300
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005*2006*
0
100
200
300
400
500
600
700
Under 1 year 65 and over
Current Challenges
• Progress toward implementing the model
- Identify best practices
– Establish technical quality and treatment
standards
• Covering HR gaps: • Competencies• Supply• HR management
• Improving inefficient or vulnerable processes
• Registration• Access and flow in the care network
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