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EQUITY GAUGE PROFILES: CHILE

Research & Monitoring
Advocacy & Public Participation
Community Involvement
Key People & Partners
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Introduction to Chile:
Many Latin American countries are aware that the region shows huge inequalities within its population and are trying to improve the situation undergoing health sector reforms. Chile, a middle-developed country, with its population of 15 million, is no exception, and the health sector reform in process declares equity as its basic principle.

Despite that global health indicators for the Chilean population are one of the best for the region with expenditures that are not very high (PGB around US$5.000 and health expenditures around US$204 per capita in the year 2000), there are health gaps, mainly in health care situation and access to services for vulnerable groups, like poor population, women, aged population, ethnic groups and rural population.

Chile Gauge Website: www.equidadchile.cl

Summary:
CHEG started in 1999, after several meetings called by Rockefeller Foundation, giving birth to similar groups in Africa, America and Asia. The Chilean team was part of the "Global Equity Gauge Alliance" GEGA, with another 9 initiatives that work allied until now. CHEG was created within the Catholic University of Chile.
The main purpose was to promote health equity in each country, establish a surveillance system to monitor health equity indicators and also, develop advocacy strategies and community participation to intervene the situation effectively. Since 2000, the team accomplished these objectives and also established alliances with national governmental and non-governmental institutions to develop the work. It was also possible to gather national databases for health indicators and determinants, from different sources, in a combination that is unique in the country.

In the ongoing Health Reform, one goal was to set "National Health Objective for the decade 2000-2010". This document includes the National Equity Objectives, developed jointly with the Health Reform Committee.
The National Equity Objectives are the following:

Indicator

Current situation

Specific target

Activities

1. To decrease health inequities

Infant mortality

Rate Ratio: 5 between extreme maternal education level groups since

To decrease by 10% the infant mortality gap between extreme groups.

Address specific health programs to socially disadvantaged groups.
Focus in the most frequent causes with the higher gaps: perinatal, congenital and respiratory.

Temporary life expectancy (e20-69)

Life expectancy in men decreased by 2 years in men without education between 1985 and 1997;
Life expectancy in women decreased by 0,3 years.

To increase by 2 years the temporary life expectancy for the lower two educational quintiles.

Focus in the most frequent causes with the higher gaps:

  • Accidents in young male adults.
  • Hypertension and preventable
  • Cancers in middle age women (Cervical and gallbladder)

PYLL

Gap between extreme regions in 1997: 20 years, (decreasing) 

To decrease the PYLL gap by 30%.

Increase percentage of health resources going to geographical areas with worst PYLL.

2. To improve equity in the financing of health care

Percent of co-payment

Structure of co-payment is progressive in Fonasa.

Structure of co-payment is regressive in ISAPRES

To implement progressivity of co-payment in both systems.
To define a proportional ceiling for all co-payments, according to family income.
To implement mechanisms of financial protection to protect families from going into poverty due to catastrophic health expenditures.

To implement a mandatory Universal Health Package in both systems.
Guarantee of access, financial coverage, opportunity and quality of care for all health problems included in the Universal Health Package.
Implement a maximum ceiling of 20% for co-payments.
Financial insurance coverage for all health events with a cost higher than 8% of annual family income.

Per-cápita expenditures in public and private system

Fonasa 1999 (Public system):$ 120.000 pesos.
Private system: $202.000 pesos
Difference: $82.000

To decrease the gap between both systems

Implementation of a solidarity fund financed by taxes.
Annual growth of fiscal resources allocated to health by more than the GNP annual growth.

3. To increase equity in access to care

Gap by income quintile

Casen Survey 98: opportunity of attention:
Quintile 1: 80,5%
Quintile 5: 91,4%
Difference: 10,9

To decrease the gap between extreme quintiles

To implement a mandatory Universal Health Package in both systems.

Key People:

  • Liliana Jadue, MD, Master in PH: Professor of Public Health, Universidad del Desarrollo.
  • Hernán Sandoval, MD: Coordinator of the National Committee for a Better Health for the Chilean People.
  • Iris Delgado: National Coordinator Encuesta Nacional de Caracterizacion Socioeconómica. Ministerio de Planificación.
  • Jeanette Vega, MD DrPH: Director, Institute of Epidemiology and Public Health Policies, Universidad del Desarrollo.

Key Partners:

  • Support to the National Health Reform Committee, developing the National Health Equity objectives for the decade 2000-2010.
  • Specific studies and other articles published in scientific journals and different media addressed to specialize and general audiences.
  • Technical capacity to analyze all databases from national available data sources (CASEN series, National Institute of Statistics, Censuses, Ministry of Health, governmental and non-governmental data sources). Time series of several databases are available.
  • Enhancement of Health module in CASEN survey including questions on use of health services and self-perception of health. The CASEN survey is the most important national serial coverage survey to monitor social policies, applied every 3 years.

The monitoring will be accomplished from the annual analysis of data to construct the following indicators to be monitored:

  • Infant mortality by educational level: Based on the analysis of the national annual death and live births databases, infant mortality rates by maternal and paternal years of education will be calculated comparing the extreme educational groups.
  • Life expectancy by educational level, using data from the national death registry to provide the number of deaths in persons 20 and older according to educational level and the annual population projection to provide the corresponding number of people at risk according to age, sex, and educational level. Total deaths and general mortality rates for each year will be computed, for four groups of years of education attained (none, 1-8, 9-12, and 13 or more). Based on these mortality rates, probability of dying, life expectancy at different ages, temporary life expectancy between the ages 20 and 69, and adjusted mortality rates for male and female populations, will be computed for persons over 20 years of age.
  • PYLL by regions will be performed using data from the National death registry to provide the deaths by age and regional population projections to provide the denominators by region.
  • The percent of co-payment by income quintile in Fonasa and Isapres will be calculated from the Fonasa and Superintendencia de Isapres databases.
  • Percent of population covered by the National Health Plan will be calculated based on data available from the primary health care clinic adscription and regular information form the Superintendencia de ISAPRES.
  • Per-capita expenditures in the public and private systems will be obtained annually from the FONASA and Superintendencia de Isapres databases.
  • Utilization of services by income quintile and sex will be obtained from the CASEN analysis of 2000 and 2003 surveys. Data are collected about preventive controls, general and specialist outpatient visits, emergency room visits, dental care, laboratory tests, X rays and sonograms and prescriptions associated. For each activity, it is asked about any co-payment required for the service or the prescription.

  • Creation of a Web page to disseminate the studies and publications, and as a window to the community. All documents written by our team are available at the website.
  • Interactive e-Forum on relevant contingent subjects, with the participation of national and local health authorities, politicians from all sectors and experts in each area.
  • Press analysis (specific study to analyze the equity concept in the public agenda in the last decade).
  • Periodic Reports on relevant subjects sent to a selected mailing list. This audience is made by health professionals from clinical and public health areas, academicians, media professionals and health communicators, professional in social sciences interested in social equity.
  • · The "Book of Equity in Chile" will be published in 2004, gathering all diagnostic elements for social equity in our country and covering the arguments and principal research develop in Chile around the subject. The book will be a useful instrument for specialized audience, but also for other social researchers, politicians, students and people in and out the health sector.
  • Dissemination of information to stakeholders.
  • Other interactive activities like workshops and seminars addressed to journalists and media professionals.

  • Field research and intervention in two communities ("2 Communities study") to search for health inequity mechanism in the population and the intervention strategies that would work on Chilean setting.
  • Development of strategic alliances with other related institutions: MINSAL (Ministry of Health), FOSIS (Social Investments and Solidarity Fund), JUNAEB (National Network for Social Support for Students), MINEDUC (Ministry of Education).

Documents of Interest

  1. Jadue L., Delgado I., Sandoval H., Cabezas L., Vega J, Análisis del Nuevo Módulo de Salud de la Encuesta CASEN 2000. Rev Med Chil 2004, 132:750-760.
  2. Subramanian S.V., Delgado I., Jadue L., Vega J., Kawachi I. Income inequality and health: multilevel analysis of Chilean communities. J Epidemiol Community Health. 2003 Nov; 57(11): 844-8.
  3. Vega J., Bedregal P., Jadue L., Delgado I. Equidad de Género en el Acceso a la Atención de Salud en Chile. Rev Med Chil 2003; (131): 669-678.
  4. Subramanian V., Delgado I., Jadue L., Kawachi I., Vega J. Inequidad de ingreso y autopercepción de salud: un análisis desde la perspectiva contextual en las comunas chilenas. Rev Med Chile 2003, (131): 321-330.
  5. Subramanian S.V., Delgado I., Jadue L., Vega J., Kawachi I. Income inequality, income and self-rated health: a multilevel analysis - Abstract. American Journal of Epidemiology 2002; 155, 11:S62.
  6. Sandoval H, Jadue L. La Salud como un Derecho Humano en Chile. www.equidadchile.cl. 2002.
  7. Vega J., Jadue L., Delgado I., Burgos R., Brown F., Marín F., Zúñiga V. Disentangling the Pathways to Health Inequities. The Chilean Health Equity Gauge. http://www.paho.org/English/HDP/Equity-Chile.pdf. 2002. Presentado en: Participación en International Society for Equity in Health Conference and Regional Consultation on Policy Tools, Equity in Population Health. Canadá 2002
  8. Jadue L. Módulo: Introducción a la Promoción de la Salud: Marco Conceptual y Políticas Públicas en Promoción de la Salud. "Equidad, Calidad de Vida y Promoción de la Salud: La Perspectiva de la Salud". Diploma en Promoción de la Salud, INTA, Versión 2002.
  9. Colaboración en: Manual para la aplicación del Sistema Auge en las redes de atención del Sistema Nacional de Servicios de Salud Santiago, Julio de 2002. Ministerio de Salud, FONASA. www.minsal.cl
  10. McCoy D, Bambas L, Acurio D, Baya B, Bhuiya A, Chowdhury AM, Grisurapong S, Liu Y, Ngom P, Ngulube TJ, Ntuli A, Sanders D, Vega J, Shukla A, Braveman PA. Global Equity Gauge Alliance: reflections on early experiences. J Health Popul Nutr. 2003;21:273-87.