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