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Bull World Health Organ vol.89 n.10 Genebra Oct. 2011
A decade towards better health in Chile
In 1990, after 17 years of dictatorship, Chile started rebuilding its political system with a focus on improving social conditions and health. A recent study of the last 10 years shows some positive results. Irene Helmke reports.
For former Chilean president Ricardo Lagos Escobar, the establishment of the system of universal health-care coverage known as the Plan de Acceso Universal con Garantías Explícitas in 2005 was a huge step forward. It was a step founded on boosting primary health care provision. "If you succeed in establishing effective primary-health-care clinics, you avoid people reaching the emergency status and it is at these centres where you can prevent [more serious health problems]," Lagos says, noting that the budget for primaryhealth-care centres increased considerably during his term (20002006).
Lagos is proud of improvements across several health indicators, notably in infant mortality, which fell between 2000 and 2010 from 10 to 7.5 deaths of children aged up to 12 months of age per 1000 live births. However, within that broad improvement, there are, he says, some disquieting trends.
"Our average infant mortality rate is about 8 deaths per 1000 live births, which is extremely low. But that masks a wide range between, for example, Vitacura, an affluent district in Santiago, where the average is 2 deaths per 1000 live births, and towns such as Puerto Saavedra, 700 km south of Santiago in the Araucanía Region, where infant mortality rises to about 45 deaths per 1000 live births," Lagos says. He blames these discrepancies not on the health care delivered by Chile's universal access system, but on the socioeconomic system as a whole. "It's not really a matter of the kind of facilities you have in Puerto Saavedra," he says, "it has more to do with income distribution."
In other words, poverty and sickness go hand in hand. This assumption that certain social determinants are significant drivers of health outcomes underlies a shift in emphasis in Chilean health care over the past decade a shift that was in part informed by the work of the Commission on the Social Determinants of Health. This was composed of a group of policy-makers, researchers and civil society activists among them Lagos himself who were brought together by the World Health Organization in 2005 to generate ideas on how to tackle the social causes of poor health and avoidable health inequities.
"Based on the Commission's recommendations, Chile adopted an intersectoral approach in its national health policy that emphasizes the need to embrace all key sectors of society, not just the health sector," says Sylvia Santander, from the health ministry's National Health Programme for Adolescents and Young People.
This change in emphasis has found expression in several initiatives, one of the most recent being the so-called 13 Pasos hacia la equidad (13 steps to equity), that ran between 2008 and 2010. According to María Cristina Escobar, head of the Department of Noncommunicable Diseases at the Ministry of Health, this initiative included a review of the Cardiovascular Health Programme, which revealed the main factors underpinning the observed discrepancies in access to care and in people's health. It identified males between the ages of 45 and 64 years with social risk factors such as low education, unstable employment and low income, as well as workers living in poor districts, as the main excluded groups, particularly in terms of access to health care.
"The review also found that the health-care system itself was one of the main barriers to access to health care[under the Cardiovascular Health Programme], mainly because of the inflexible working hours at health-care centres and high staff turn-over," Escobar says. Other barriers included familiar problems, such as living far from health services and unaffordable transportation costs. A national contest was held in November of 2009 to generate ideas for a redesign of the Cardiovascular Health Programme and 18 projects were selected to run as pilots.
Another significant project inspired by the Commission on the Social Determinants of Health is Chile Crece Contigo (Chile Grows with You), an initiative launched in 2007 by former president Michelle Bachelet. Its goal is to provide services to children and pregnant women through the public health facility network. According to Santander, this initiative goes beyond the scope of many public health programes in that it takes an integrated approach by including home visits, education groups on parenting skills and child development, child care, health care, counselling and referral services.
For Jeanette Vega, director of Chile's Universidad del Desarrollo's Center for Epidemiology and Public Health Policy and former vice minister of health under president Bachelet, the strength of the initiative is its multidisciplinary approach to the challenges people typically face. "The programme has been successful not only in terms of early childhood development but also the social transition of the families those children belong to," Vega says. According to a published government report entitled Evaluación Objetivos Sanitarios 20002010, these successes over the 10-year period include a nearly 50% reduction in maternal mortality, from 1.9 to 1.2 deaths per 100 000 live births.
Asked whether recent health improvements have been a direct result of government action on the social determinants of health, Vega says: "It is difficult to say this, because of issues of attribution and you need time to see changes." She adds: "What we can say, though, is that since the 1990s there has been sustained commitment to implementing more equitable social policies and that these have contributed to health indicators that are much better than what one might expect, given the availability of resources in the country."
Today, comprehensive approaches such as Chile Crece Contigo are also key to the work of Chile's primary healthcare centres, which are at the heart of the country's universal health-care system. At the José Alvo health centre in La Florida, one of the most heavily populated districts in the capital, director Paula Álvarez says that an interdisciplinary approach is essential for dealing with challenges as diverse as teenage pregnancy, an ageing population with chronic diseases, unemployment, domestic violence, overpopulation and substance abuse.
"The doctor must take a holistic approach since he has to determine which other professionals are going to assist family members," Alvarez says. Staff at the José Alvo health centre, which opened its doors in August of this year, assess the socioeconomic status of patients and draw on social networks such as work, school, neighbours and other health centres to make their assessments. Meanwhile, at the San Rafael health centre in La Pintana, a Santiago district once plagued by high crime, unemployment and poverty, director Soledad Turra also emphasizes the importance of addressing the socioeconomic factors affecting health in her work. She believes that recent improvements in access to housing and education, resulting from urban development initiatives in La Pintana, have had a positive effect on people's health in that district.
Needless to say, becoming more aware of the way social factors affect health does not make the problems go away. Lagos worries that the issues Chile currently grapples with may soon be overshadowed by others, notably the challenge arising from an ageing population. "In Chile, 12% of the population is in its 'golden years' and our statistics show that in 202025, about 25% of the population will be senior citizens. This presents a tremendous challenge not just from the point of view of health care but also in terms of social security and pensions." He argues that the inter-connectedness of these different problems strengthens the argument that policy-makers need to banish the silo-approach and embrace inter-sectoral dialogue at the highest political level, a dialogue which, as Lagos knows from personal experience, is not easily established. "How do you convince people that some of the problems in the area of health are not only in the domain of physicians, but are also pertinent to other members of the cabinet?" he says.