HEALTH REFORM in CHILE: Facts and

Comments

Professor J orge J iménez MD MPHPontificia Universidad Católica

Chile

HISTORY IS ALWAYS A WISE COUNSELLOR

• HR never appears in a vacuum• There is always something before• We construct over the remainings of

previous era• Others will build upon ours• many times we recycle knowledge

and even architecture, like in Foro di Augusto

FORO DI AGUSTO, ROMA, 35 AC

SYSTEMS DEVELOPMENT

• History overlaps succesive cycles:Power, culture, Values, Beleifs, Politics, etc.

• Revolutions dont exist, changes are incremental and take long periods of time

• Health Reform is a stage in which policy concentrates in certain aspects: health problems, systems organization. It varies

• We never reinvent the wheel or gun powder

HEALTH SYSTEMS COMPONENTS

•Structured Pluralism (Londoño & Frenk):prevaling situation

•Public services and Medical Care

•Financing and Provision •Integrated or Split functions

HEALTH SYSTEMS: Integration vs Atomization

F

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C

I

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CAPTACION

AGREGACION RIESGOS

COMPRA

PROVISION

INTEGRACION DESINTEGRACION

VERTICAL HORIZONTAL

HR: central hypothesis• HEALTH REFORMS ARE THE

CULMINATION OF AN INCREMENTAL PROCESS,

RATHER THAN A RUPTURE WITH THE PAST

• Jiménez and Bossert

THE LATINAMERICAN HEALTH SYSTEMS MIX

COUNTRY PUBLIC+INFORMAL

SOCIALSECURITY

PRIVATE

MEXICO 45% 54% ¿?COLOMBIA 65% 22.4% 12.6%ECUADOR 97% 3%VENEZUELA 90% ¿?CHILE 70% XX 20%

CHILE: Four reform periods

• State responsibility: 1920-1930• National Health Service: 1940-1960• Decentralization and Privatiztion:

1980• Strengthening of mixed system and

Recovery of Public sector 1990

• Jimenez and Bossert, 1995

CHILE: After Charity, the State takes

responsibility(1918-1938)• Basic institutions established by

law:Sanitary Code (1918), Social Security (1924), Preventive Medicine Law (1936), Mother and Child Law(1937).

• Period of Reformist Goverment (1920-1930), but also..

• Right wing Socially Sensible Liberal Right wing Government (1932-1938)

CHILE: After Charity, the State takes

responsibility(1918-1938)2• Period has two economic stages,initially

growth (1915-1929), then crisis and recession(1930-1938)

• Epidemioloy plays an important role via outbreaks of Murine Thyphus and Small pox.The rich under threat, react.

• Debates in Parliament question: who pays??, who will execute the policy

Cruz Coke, a catholic conservative physician,also biochemist and

entrepreneur

• He proposes a special “Preventive MedicineLaw” (1937)

• Project, approved due to his brilliant mathematical calculations on cost-benefit of sick leave versus absenteeism

• SCIENCE:another critical actor• He says: “Medicina Preventiva y

Dirigida”

SCIENCE: another critical actor

• Scientifical method via epidemiological concerns and concepts, aided with primitive cost benfit approaches helped clever politicians to push their ideas to success

• Concept of “Directed or Managed medicine”, appears for the first time in debate about health structure and administration

ALLENDE: free mason, socialist, intuitive politician

• Earthquake in south of Chile, 1939• Sanitary services are all put

together under single united rule• Observations after a year prove

increases in production of services: medical visits, preventive interventions and others

• Conclusion: Unification is Good, Reform the social security, create a single structure(1941)

CHILE:APOTHEOSIS of Wellfare, NHS,1952

• 10 years of parliamentary debates to approve the reform. Several changes to arrive to the prevalent idea: Unify services

• Model was the British NHS, but had many original ideas and strategies.Included only the poor,no employees

• Unification of 20 separate services in only one structure. Dificult and complex operation that took four years to implement

CHILE,NHS,1952• Finance and Provision together: total

vertical integration. Left out pensions• Money from taxes and social security

premiums• Salaried doctors, complex

negotiation, they were afraid of loosing liberal practice.

• Initial opponents, after strong supporters (Medical paradox)

CHILE, NHS 1952-1980• After structure was established,

important sanitary programs were put in place

• Maternal: hospital and professionaly attended deliveries, family planning, pregnancy controls

• Children: neonatal care, routine checkups, immunizations, diarrhea and infectious disease care

CHILE: NHS impact after 50 years

1960 1990 2000• Population (millions)7,3 13,2 15,2• Fertility (%) 3,5 2,3 1,7• Life expectancy (ys) 58 72 74• General mortality (p 1000) 15,5 6,0 6,0• Infant mortality (p 1000 LB) 136 14,4 8,9• Professional deliveries 62% 97% 99%• Children immunized 89% 97% 100%

CHILE: health and dictatorship

• Military coup overthrows socialist regime in1973.

• NHS was under severe criticism from right wing and users due to bureaucratic excess

• Junta adopts neoliberal market model ,1975

• Paralell reforms in health only in 1980, dificult consensus inside government

A public service giant in adaptation to modern times: decentralization &

market,1981• Initial separation of financial and provision

with creation of Health Fund (FONASA) and National Health Services System

• Regionalization and Autonomy for 26 provincial health services

• Primary Health Care to local governments• Privatization: optout to health insurance

plans: ISAPRES.

1980-1990 an imperfect reform

• Reform was initiated with mind in cost reduction more then actual perfectioning

• Public system left with low salaries and no capital investement, time bombs.

• Private insurance plans done in competition with all the defects of similars in US: cream skimming, moral hazard, no cost control (third party payments), etc

• Decentralization mostly in paper, few training, few powers, reconcentration in Subsecretaria de salud

CHILE:DEMOCRACY RESTORED 1990, what about

health??• Dichotomy again: neoliberals and

statalists clash again inside the Basic Policy of new government: a mixed system, public and private sectors must live together and exchange services.

• government, making the reformers/pragmatists life more difficult

• Strong debates, fluxes and refluxes in 12 years of democratic life

1990-2005, some achievements

• Public Health budget doubled• Productivity remains constant: criticism• Renovation of technology and

infrastructure• Improved salaries for manpower• Purchaser Provider split, up-downs• New payment mechanisms: on the move• Public services autonmy: still on paper

CHILE, some conclusions

• In the Chilean case it’s clear that reforms are progresive, incremental and they go in hand with

• Epidemiology, prevaliling diseases, infections, mother and child, transitional, order the policies

• Economy, progress easy when growth, dificult when in recession

• Political context ideologies and pragmatism overcross, some actors are active in defending interests

Chile: the 2002 Reform• In Parliament from May 2002 to December

2004, 5 projects, 3 years:• 1.- Rights of Patients Charter• 2.- AUGE: Universal Access with Explicit

Guarantees• 3.- Sanitary Authority and Health

Management: Function split• 4.- Private Insurance of Health (ISAPRES)• 5.- Financement of the Reform

– www.minsal.cl

AUGE: the big thing• Priority setting according to burden

of disease• Guarantees established by law in

– Opportunity-Time for Access– Financial Protection– Effectiveness in technical solutions– Quality of care

LIST OF DISEASES• 56 conditions in the Plan• Represent 75% of burden and 50%

of discharges from hospitals• Evidence Based research of cost

effectiveneess of each condition• Protocol promotes “Disease

Management”• Evaluation is critical, but not in place.

The Algorythm

MEDICAL ASSOCIATION: NEGATIVE APPROACH

Question for this Reform• Socialist Delirium ? Central

planning of every detail• Neoliberal Abuse? More money for

the rich and less for the poor• “The answer my friend is blowing

in the wind”

CONCLUSIONS• Final indicators for success in HR:

Health outcomes and /or WHO 2000?• So far it’s clear that HR takes many

years to be implemented, be it a up-dowm or a bottom up process.

• Not all the variables go in the same direction, at the same speed, at the same time