News 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 system as a whole. “It’s not really a matter Health Programme, which revealed the Lagos Escobar, the establishment of the of the kind of facilities you have in Puerto main factors underpinning the observed system of universal health-care coverage Saavedra,” he says, “it has more to do with discrepancies in access to care and in known as the Plan de Acceso Universal con income distribution.” people’s health. It identified males be- Garantías Explícitas in 2005 was a huge In other words, poverty and sickness tween the ages of 45 and 64 years with step forward. It was a step founded on go hand in hand. This assumption – that social risk factors such as low education, boosting primary health care provision. certain social determinants are signifi- unstable employment and low income, as “If you succeed in establishing effective cant drivers of health outcomes – under- well as workers living in poor districts, as primary-health-care clinics, you avoid lies a shift in emphasis in Chilean health the main excluded groups, particularly in people reaching the emergency status and care over the past decade – a shift that terms of access to health care. it is at these centres where you can prevent was in part informed by the work of the “The review also found that the [more serious health problems],” Lagos Commission on the Social Determinants health-care system itself was one of says, noting that the budget for primary- of Health. This was composed of a group the main barriers to access to health health-care centres increased considerably of policy-makers, researchers and civil care[under the Cardiovascular Health during his term (2000–2006). society activists – among them Lagos Programme], mainly because of the Lagos is proud of improvements himself – who were brought together by inflexible working hours at health-care across several health indicators, notably the World Health Organization in 2005 centres and high staff turn-over,” Escobar in infant mortality, which fell between to generate ideas on how to tackle the says. Other barriers included familiar 2000 and 2010 from 10 to 7.5 deaths of social causes of poor health and avoid- problems, such as living far from health children aged up to 12 months of age per able health inequities. services and unaffordable transportation 1000 live births. However, within that costs. A national contest was held in broad improvement, there are, he says, November of 2009 to generate ideas for some disquieting trends. How do you a redesign of the Cardiovascular Health “Our average infant mortality rate is convince people that Programme and 18 projects were selected about 8 deaths per 1000 live births, which “ to run as pilots. is extremely low. But that masks a wide some of the problems Another significant project inspired range between, for example, Vitacura, an in the area of health by the Commission on the Social Deter- affluent district in Santiago, where the -av are not only in the minants of Health is Chile Crece Contigo erage is 2 deaths per 1000 live births, and domain of physicians, (Chile Grows with You), an initiative towns such as Puerto Saavedra, 700 km launched in 2007 by former president south of Santiago in the Araucanía Re- but are also pertinent Michelle Bachelet. Its goal is to pro- gion, where infant mortality rises to about to other members of vide services to children and pregnant 45 deaths per 1000 live births,” Lagos says. the cabinet? women through the public health facility He blames these discrepancies not on the Ricardo Lagos Escobar network. According to Santander, this health care delivered by Chile’s universal ” initiative goes beyond the scope of many access system, but on the socioeconomic public health programes in that it takes an “Based on the Commission’s recom- integrated approach by including home mendations, Chile adopted an inter- visits, education groups on parenting skills sectoral approach in its national health and child development, child care, health policy that emphasizes the need to em- care, counselling and referral services. brace all key sectors of society, not just For Jeanette Vega, director of Chile’s the health sector,” says Sylvia Santander, Universidad del Desarrollo’s Center for from the health ministry’s National Epidemiology and Public Health Policy Health Programme for Adolescents and and former vice minister of health under Young People. president Bachelet, the strength of the ini- This change in emphasis has found tiative is its multidisciplinary approach to expression in several initiatives, one of the the challenges people typically face. “The most recent being the so-called 13 Pasos programme has been successful not only hacia la equidad (13 steps to equity), that in terms of early childhood development ran between 2008 and 2010. According but also the social transition of the fami- WHO/Irene Helmke to María Cristina Escobar, head of the De- lies those children belong to,” Vega says. partment of Noncommunicable Diseases According to a published government at the Ministry of Health, this initiative report entitled Evaluación Objetivos Sani- Ricardo Lagos Escobar, former Chilean president included a review of the Cardiovascular tarios 2000–2010, these successes over 710 Bull World Health Organ 2011;89:710–711 | doi:10.2471/BLT.11.041011 News government action on the social determi- the José Alvo health centre, which opened nants of health, Vega says: “It is difficult its doors in August of this year, assess the to say this, because of issues of attribu- socioeconomic status of patients and draw tion and you need time to see changes.” on social networks such as work, school, She adds: “What we can say, though, neighbours and other health centres to is that since the 1990s there has been make their assessments. Meanwhile, at the sustained commitment to implementing San Rafael health centre in La Pintana, a more equitable social policies and that Santiago district once plagued by high these have contributed to health indica- crime, unemployment and poverty, direc- tors that are much better than what one tor Soledad Turra also emphasizes the im- might expect, given the availability of portance of addressing the socioeconomic resources in the country.” factors affecting health in her work. She Today, comprehensive approaches believes that recent improvements in ac- such as Chile Crece Contigo are also key cess to housing and education, resulting to the work of Chile’s primary health- from urban development initiatives in care centres, which are at the heart of the La Pintana, have had a positive effect on country’s universal health-care system. At people’s health in that district. the José Alvo health centre in La Florida, one of the most heavily populated dis- WHO/Irene Helmke tricts in the capital, director Paula Álvarez The doctor says that an interdisciplinary approach is must take a holistic Elderly patient waits to see doctor at the José Alvo “ essential for dealing with challenges as primary-health-care centre. The proportion of Chile’s diverse as teenage pregnancy, an ageing approach since he has elderly population is increasing every year population with chronic diseases, unem- to determine which ployment, domestic violence, overpopula- other professionals the 10-year period include a nearly 50% tion and substance abuse. are going to assist reduction in maternal mortality, from “The doctor must take a holistic ap- family members. 1.9 to 1.2 deaths per 100 000 live births. proach since he has to determine which Asked whether recent health im- other professionals are going to assist Paula Alvarez ” provements have been a direct result of family members,” Alvarez says. Staff at 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 chal- lenge arising from an ageing population. “In Chile, 12% of the population is in its ‘golden years’ and our statistics show that in 2020–25, 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 WHO/Irene Helmke people that some of the problems in the area of health are not only in the domain Silvana Clark and baby Samara, beneficiaries of theChile Crece Contigo initiative, at the José Alvo primary- of physicians, but are also pertinent to health-care centre other members of the cabinet?” he says. ■ Bull World Health Organ 2011;89:710–711 | doi:10.2471/BLT.11.041011 711.