1999 ILASSA Conference Papers -- Gideon

Primary Health Care Delivery in Chile: Local Level Limitations

Jasmine Gideon, University of Manchester

By Jasmine Gideon

Jasmine Gideon is a social development researcher. She is currently finishing her Ph.D. at Manchester University, UK, which focuses on a gendered institutional analysis of health sector reform in Chile. Her research interests include gender and economic issues, health reform, social policy and NGOs. She has conducted research in both Central and South America.

Jasmine can be contacted at the address below:

Department of Government, Oxford Rd, Manchester M13 9PL, UK.

Jasmine.Gideon@man.ac.uk

Introduction

This paper is an overview taken from part of my doctoral thesis. The central tenet of my thesis is an assessment of the process of municipalisation of primary health care delivery in the public sector in Chile. Since the mid 1990s attempts have been made to develop a more holistic model of primary health care delivery, oriented towards users’ needs. This has resulted in the introduction of family health centres, in which providers are expected to consider not only the medical symptoms in a patient, but also the extent to which the family situation of the patient may be a contributory cause of their symptoms.

Overall I spent nine months in Chile carrying out field work. This consisted of around four months collecting documentation from the Ministry of Health and other key institutions in Santiago in order to understand how the system worked and identify key questions for my thesis. This was followed by five months 'at the local level' in El Bosque, a low income neighbourhood in the south of Santiago. Here I spent time at the five health centres and interviewed the director and sub-director of each centre as well as other local level actors. In addition I carried out a series of household interviews in an attempt to determine how people really used the health service and to assess the extent to which the supply of services met their demands. A discussion of these interviews has not been included in this paper.

The paper begins with a brief discussion of the reform of the health sector, in particular the process of decentralisation and an overview of the system today. The focus of the discussion is the factors at the local level which limit the positive effects of the adoption of elements of good international practice. These are exemplified by the use of case study evidence from El Bosque. The paper concludes that the placing of the new model of primary health care delivery within a broader neo-liberal framework has limited the effectiveness of the reforms.

Neo-liberal Reform in Chile

In accordance with neo-liberal ideology that was being pursued in Chile by the Pinochet government, steps were taken to privatise the health service. Social sector reform was carried out in all areas of social welfare (education, health, housing, nutrition programmes, social security). The Pinochet government adopted a typical neo-liberal stance vis-à-vis their approach to poverty: targeted assistance to the poorest to meet basic needs was seen as the solution. Other pivotal ideas that were incorporated in social reform programmes included new financing mechanism and the decentralisation of service provisions. Under Pinochet, financing for social services became based on the services provided, rather than on historically determined budgets. In accordance with the belief that municipalities and the private sector were closer to service users than central government, responsibility for service provision was decentralised to the local level (Castañeda, 1992). The most fundamental change in the health sector was implemented in 1981 with the introduction of private health insurance companies (ISAPRES) following the implementation of Decree 3,626.

These developments had a number of implications. Graham argues that within the neo-liberal agenda, poverty alleviation is considered within a very narrow and limited context (Graham, 1991). Subsequently, programmes implemented under Pinochet failed to provide any links between different areas of social welfare policy or to use programmes as a means of longer term social development. Instead, the approach of the military government redefined citizen’s rights to social services. Usage of state services became a social stigma and rather than enhance equity in any way, subsidies to the poor merely resulted in an increased dependence on the state. Indeed, income distribution worsened and the number of those living in poverty increased.

Despite this, through the targeting of basic services to the poor, Graham argues that the government was ‘remarkably successful at protecting the social welfare of the poorest during a time of severe economic crisis and reduced fiscal expenditure’ (ibid.: 27). In addition, many of those who had been marginalised from benefits under previous governments were now incorporated under the new measures. However, at the same time, many people at the margins of the poverty line lost access to critical services such as health insurance. Although there was improvement under Pinochet in certain areas, such as infant mortality and levels of child malnutrition, this occurred at the expense of considerable deterioration in other areas. Critics have suggested that the Pinochet government concentrated on improving indicators in politically sensitive areas such as child health (Scarpaci, 1986).

The reform of the health sector has been continued by the civilian government since 1990. Coalition (Christian Democrat-led) governments have recognised the need to increase public expenditure in social welfare, including the health sector. Attempts have been made to consolidate the reforms and in particular attention has been given to the financing mechanisms both at the primary and the secondary levels. In addition, considerable attention has been given to primary health care delivery and attempts have been made to implement a more equitable and participatory model.

Decentralisation

The decentralisation process was central to the Pinochet reforms in the health sector. Prior to 1974 the municipalities only had limited responsibilities and incomes and were primarily political institutions rather than providers of services (Castañeda, 1992: 198). In 1974-75 legislation was introduced which assigned the municipalities new responsibilities, including some degree of financial and administrative responsibility. Municipalities were now bound to provide a variety of services, including primary education and health care, transport and public highways, sport and recreation, sanitation, local planning and development, and to administer employment programmes, such as the Minimum Employment Programme (PEM). These responsibilities were ratified in 1988 with the passing of the Municipal Government Law. In order to carry out these functions, the municipality had to produce an annual neighbourhood development plan and budget proposal; the available budget was then to be allocated to different sectors.

Municipal funds are derived from three principal sources: regional government funding, participation in a Common Municipal Fund (FCM) and self-generated funds. Regional government funding comes from the National Regional Development Fund, and is distributed for specific projects and programmes which have been prioritised according to regional sectoral investment priorities. The FCM is a mechanism used to distribute funding more evenly across the country, transferring funds from richer municipalities to poorer ones. However, municipalities must specifically apply for funds and eligibility is determined according to criteria set up by the Interior Ministry (Rosenfeld, 1993:6). Funds in the FCM are collected from each neighbourhood and are composed of money collected from a number of sources; principally sixty percent of the ground taxes imposed in all neighbourhoods (this tax is applied to businesses in the neighbourhood), and fifty percent of the sale of traffic licences. Finally a special contribution is made by the three wealthiest neighbourhoods in the country. In addition, municipalities can generate their own funds in a number of ways: these include land and business taxes, traffic licences, fines, municipal patents, advertising and duties for rubbish collection and other local services. It is therefore clear that municipalities with large numbers of shops and businesses are able to generate more funds than smaller municipalities with fewer businesses and cars.

The Municipal Government Law of 1988 is somewhat ambiguous, since it does not actually give the municipalities responsibility for the overall administration of public health institutions. Article Four asserts that they can develop, either directly, or with other State bodies, public health-related functions. This leaves central government free to set up mechanisms to transfer resources for the functioning of the service, with the amount of resources open to some negotiation, leaving municipalities responsible for making up the financial shortfall for the overall functioning of the service (Materiales para el desarrollo local y regional: 1992, cited in Rosenfeld, ibid.). As we will see below, this creates a number of problems in the primary health care sector.

In 1980 legislation was passed (Decree Law 1-3) which implemented the transfer of primary level care to the municipalities and in 1981 local level delivery began. All health professionals at the primary care level were now to be contracted by respective municipalities, who would take control of the establishment of primary ambulatory care and operate complementary programmes in conjunction with the regional Health Service. The military government believed that municipalisation would improve the control and regulation of local level facilities and to ensure that local health needs were reflected in health provision, as well as channelling municipal level rather than national funds into the improvement of local facilities and infrastructure. The government also argued that municipalisation would improve local participation and allow more inter-sectoral integration to take place, especially with other key sectors such as housing, education and sanitation (Miranda, 1988:91).

The Chilean Health System Today

Chile now has a mixed health insurance system with active participation by both public and private sectors in the financing as well as supply of services. Chilean workers can choose between public and private insurance institutions to contract their mandatory health insurance (a deduction of seven percent of their salary). The seven percent gives users a basic health plan, and they must make additional payments for other services. Workers' coverage includes health care for their dependants, but definitions of this vary between FONASA and ISAPRES. Indigents (the destitute) are entitled to free care directly from the public health system, but are only eligible for a basic package of services. Around sixty five percent of the population is registered with FONASA; twenty five percent are registered in an ISAPRES and the remaining ten percent are covered by other systems operated by entities such as the armed forces, which have their own health service. The private system is made up of private health insurance companies (ISAPRES) and private providers. The Superintendency of the ISAPRES, a decentralised, public institution, is responsible for the registration and regulation of the ISAPRES (Aedo, 1997: 9).

FONASA is the principal financing institution in the public system. It is a decentralised body responsible for the collection, administration and distribution of financial resources. FONASA resources are derived from a number of different origins: the mandatory contributions, additional co-payments made by users and taxation. Within FONASA users can opt between public or private providers under an agreement with FONASA. In the public system, services are provided via the twenty seven regional Health Services. These are autonomous bodies, with their own legal status and assets. Secondary and tertiary care is offered to users through a network of one hundred and eighty eight public hospitals, which are dependent on the Health Services. Primary care is delivered through the Primary Care Centres (329 clinics and 996 health posts); the majority of these are administered by the municipalities.

Financing mechanisms

In 1994 the per capita financing mechanism was introduced. A basic package of services – called the Family Health Plan - is provided by the state to FONASA users. The cost of providing these services is calculated in order to determine the amount per capita that will be contributed by the State. The per capita system is based on the idea of a pre-payment per beneficiary population assigned to each municipal health clinic. Providers are then paid a negotiated sum per month for each person who chooses to register with them for primary care, whether that person uses the service or not. The per capita system is based on a number of principles and in theory creates demand for educative and preventative health care - where doctors think it will save them time in the long run - and supports increased equity in resource distribution (Fuenzalida, 1995). Abel-Smith argues that under a capitation system doctors and patients are likely to be reasonably content, and if not there is a simple answer to a dissatisfied patient, which is to switch doctor (Abel-Smith, 1994: 198).

As noted above, a set payment is made to each municipality according to the number of FONASA beneficiaries registered in each clinic. The transfer per beneficiary varies according to each municipality's urban/ rural and poor/ non-poor status (Larrañaga, 1997: 57). However, Fuenzalida (op.cit.: 126) argues that this approach is problematic since methodologically the Ministry of Health defines poverty from the perspective of the capacity of each municipality to contribute resources to the management of health (i.e. municipal poverty), rather than the poverty of the users. Municipalities are classified from low- to high levels of poverty, based on their level of dependency on the Common Municipal Fund and capacity to generate their own resources. Rural municipalities are defined as those in which over thirty percent of the population are rural, according to the 1992 census. The classification of municipalities according to rural or urban status began in July 1994, accompanied by announcements of the amount of transfers to each neighbourhood and the calculations of the beneficiary population according to figures from the latest census and CASEN survey (national household survey).

Two factors are pivotal to the per capita system: the calculation of the cost of a Family Health Plan, in order to determine the amount per capita that will be contributed by the State and the effective registration of all FONASA beneficiaries in order to maximise income. In addition costs are affected by the negotiation of management contracts between the State and municipalities (Fuenzalida, ibid.; Aedo, 1995).

Primary Health Care Within the New Model

Since the early 1990s, as part of a more widespread process of reform, attempts have been made to reformulate health programmes and to develop a new model of primary care delivery. This has a number of objectives: to ensure that the supply side of the programmes meet the needs of the population; to incorporate increased levels of quality in the services; to orient actions towards priority areas; to prioritise the most cost-effective actions, to develop promotional and preventative actions; and to increase the amount of social participation in the health sector (Minsal, 1997: 143). These objectives have led to the development of a new model of care, which aims to meet the needs of communities and families through a more holistic and humanised approach, based on a number of principles which include user-centredness, equity, quality, accessibility, and social participation, and are intended to enable people to feel protected and reassured in terms of meeting their health needs (ibid.: 144).

From health centre to family health centre

Attempts have been made to improve the service provided at the local level via the health centres (consultorios) and an important recent initiative has been the introduction of new-style family health centres (centros de salud familar). These are staffed by teams of health professionals and non-professionals who have been given specific training in the new holistic approach – the Family Health Focus (el Enfoque Familiar en Salud). The central idea of the approach is that staff will not just treat the medical symptoms in a patient, but will also consider ways in which the family situation may help or hinder the patient's recovery and may be a contributory cause of the symptoms.

This process was first initiated in 1990 with the democratisation process. The Ministry of Health argued that the health centres had been developed to respond to a restricted notion of intervention, one based on a bio-medical model primarily oriented towards illness prevention and cure (Minsal, 1993:45). In contrast the health centres were intended to work with a bio-physico-social model which incorporates other factors into the notion of health - social, cultural, environmental and psychological -and thus provides a much broader approach (ibid.: 40). This uses a more integrated approach to people, considering as well their own environment and the changes which affect them through their life-cycle. In order to work with this new approach, the Ministry of Health argues that it was necessary to move from health clinics to health centres (ibid.: 45).

According to the Ministry, the creation of family health centres is the last phase of this transformation (1997: 145). This final stage was initiated in 1997, and in 1998 there were around forty family health centres. While it is too early to make a final judgement, a preliminary assessment of the cumulative impact of reform is possible.

Local level limitations in primary health care delivery

Financing

One area where limitations are apparent and have provoked much conflict between the municipal and government level is in the area of the financing of primary care, via the per capita system. One problem is that many municipalities do not know the real costs of each health action in terms of cost of hours of personnel, medical inputs, and general costs (Molina, 1997: 7). A number of health centres are currently implementing cost centres, and, until this is done the necessary information is not available and the appropriate level of the per capita transfer payment remains subject to much debate.

One consequence of this has been that many of the health centres continue to operate with deficits. Although the per capita is supposed to cover the full cost of each health action, many argue that in reality it does not even cover the cost of the necessary personnel (Molina, ibid.: 6). It is the responsibility of the municipality to make up the shortfall.

Critics have suggested that the key problem here is that the Ministry of Health did not consider sufficient variables in the calculations to determine the per capita and under-estimated the number of users registered in each health centre, and therefore failed to allocate the funds to provide each user with the services they require (interviews with key informants[i], June - July 1998). There is also considerable debate, even at the local level, about the administration of the per capita transfer payment. Although it is generally accepted by people working in all aspects of the public health sector that there is a lack of funds, especially at the primary care level, some would argue that the key problem is mis-management of resources in the health centres. This may be an issue of local administrative capacity, and in the end (because of underfunding at this level) an issue of resources.

In turn this can place an additional strain on the general municipal budget. The problem is most acute in municipalities which administer neighbourhoods with higher levels of poverty, since the population is more dependent on the public health system (Molina, 1997: 7). In reality, this means that where the health budget comes from municipality, health must compete with other sectors. This can produce tensions since the municipality may have to cut funds in other sectors in order to increase funds in the health sector, but those sectors, such as sanitation, paving, recreation, often contribute to health prevention. In addition, funds may be granted to a particular sector favoured by the mayor or other key players in the financial sector of the municipality. In some poorer municipalities it has been necessary to apply to other sources, such as special project funds offered by Ministry of Health, in order to pay for basic but vital physical improvements to the health centres, even to carry out maintenance work such as painting.

Registration of Users

The introduction of the per capita transfer payment has raised an important contradiction at the local level. On the one hand the per capita payment implies that the municipality has a fixed amount of expenditure per user; on the other hand it also implies that each registered user can demand full use of all the services that are offered in the health centres. This has made it difficult for the municipal administration to find a point of equilibrium between the demand for services, and the supply and financing available (Asociación Chilena de Municipalidades, undated: 3). This creates problems for both users and primary health care providers. While the health centres must meet targets of registered users in order to maintain current levels of per capita funding, they do not have the funds to meet the demand placed upon the services by increased use. In effect they cannot afford to treat the number of users they need to achieve level funding.

One factor contributing to the problem is the use of the public system by non-registered users, most notably those registered in the ISAPRES. This has been a major problem in the public sector and efforts have been made to eradicate it. Software is now in place in parts of the public health system that can identify beneficiaries by their identification number (RUT) and therefore people in an ISAPRES will be excluded from the public system, or prevented from passing themselves off as indigents. The system links all different databases, including those concerned with the pension system (AFP and INP), FONASA and ISAPRES as well as different credit databases, so that if someone applies for indigent status or tries to use the public health facilities all their data can be cross checked. In addition, when entering a public hospital or health centre, the identification number of the user is cross-checked to confirm the level of their FONASA plan. Until the system is fully in place, abuses of the system will continue to occur.

The system at the local level: the case of El Bosque

This section draws on evidence collected during my fieldwork in El Bosque to illustrate some of the limitations highlighted above and point to some contradictions in the model of health sector reform that is currently being implemented in Chile. El Bosque is a low income neighbourhood in the south of the Chilean capital, Santiago, and is classified as a poor urban neighbourhood. According to the CASEN (household survey), thirty percent of households in El Bosque are poor. The area has a population of around 170,000, and around twenty four percent of households are female headed. El Bosque has four health centres: Laurita Vicuña, Cisterna Sur, Condores de Chile and Santa Laura; in addition there is a new health facility, designed as a family health centre, the Orlando Letelier. Each health centre works within a clearly defined geographical area of the neighbourhood (Dirección de Salud de el Bosque, 1997: 21). In theory all inhabitants of El Bosque should have access to a public health centre in the neighbourhood. In addition there is a mental health centre and two emergency service posts. While many of the issues discussed below are relevant to all of the health centres in El Bosque, most of the material here will focus on the family health centre.

The family health centre approach

A key element of the family health centre model is to provide users with a more personalised and humanised service on site (Minsal, 1998: 5). This has been an important principle in the Orlando Letelier, and attempts have been made to ensure this happens. Since it is a newly constructed building, which was purpose built to serve as a family health centre clinic, the objectives are echoed in the design of the building. In terms of its physical attributes, in comparison with the other health centres in El Bosque, it is much more welcoming, clean, light and user-friendly. Areas are colour-coded, so users can clearly identify the areas they need to wait in and where they will be attended. Separation into distinct zones is also important for a number of other reasons. For example users who come for mother and baby clinics do not need to mix with users who have come for treatment of illnesses. In addition, users who require more privacy, for example for gynaecological patients, now have separate areas which meet this need and allow patients to wait in a women-only section.

While to an extent these improvements are in part because it is a much newer building compared to the other health centres, much can be attributed to the fact that the needs of users were considered in the actual design - this does not seem to have occurred in the older buildings. This is an important issue and in household interviews conducted in El Bosque many people cited the physical appearance of the other health centres as reasons for not using them, or indeed for changing to the private sector. Furthermore it was also an issue that was taken on by a number of local women's groups, since women were often forced to change their clothes or attend to their children in highly insanitary conditions. Furthermore improvements were also made to conditions for the staff, for example, each consulting room has a phone installed, so that staff can communicate between themselves without having to shout for each other in the corridors, as often occurs in the other health centres. In addition, the public toilets are very clean and some are equipped with baby-changing facilities, which is also an important need that has often been overlooked in some of the health centres.

Resources

Although the family health centres receive a twenty five percent increase in terms of the per capita per user, in real terms this is only a limited increase of resources. However, since the Orlando Letelier receives a bigger per capita transfer payment than other health centres, the municipality in El Bosque has refused to top up its funds, as it is obliged to do for other health centres. In addition, the family health centre approach requires a higher number of professional staff than in the other health centres, meaning that running costs are higher as more money is spent on salaries. According to the director of the Orlando Letelier (interview, May 1998), this is not taken into account in the resources that go to the family health centre. Therefore in overall terms the Orlando Letelier does not receive more funds than the other health centres, and this is an important limitation on its ability to implement the new model of attention.

The lack of resources in the Orlando Letelier has had a number of consequences. While, unlike the other health centres in El Bosque, it is well equipped at one level, some of the more expensive equipment cannot be used for lack of funds to pay for running costs and necessary inputs. For example, there is a dental x-ray machine, but insufficient money to buy the plates or the chemicals required to process the x-rays, or the chair needed for patients to sit in. Nor are there even sufficient instruments available to measure patients' blood pressure. In terms of the daily functioning of the centre, despite the attractive physical appearance, the Orlando Letelier faces the same problems as the other health centres in terms of lack of basic equipment for both staff and patients.

Another integral part of the Family Health Plan, which outlines the services which must be included in the basic package provided by the family health centre is a home visit and family advice service (Consejería Familiar) (Minsal, 1998: 17). This is intended for families who are at greatest risk in terms of the bio-physico-social factors recognised in the holistic approach of the family health centre model. According to the Ministry of Health the home visit is to be carried out by the appropriate health team and the contents and objectives of the visit are decided by the team, according to the needs of the family concerned, within the holistic framework. The home visit helps the health team to determine the extent to which the family situation may contribute to the causes of a particular illness suffered by a patient.

However, interviews with the director and sub-director of the Orlando Letelier suggested that it is not always easy to carry out home visits. According to them, one of the main problems, as noted above, is that despite the increased role medical staff are expected to play in this model of attention, the family health centre does not have the money to employ additional staff. This is especially problematic in winter when demand increases considerably, both because of normal winter problems, and because the problem of the increased respiratory problems Santiago residents in particular face due to high levels of urban pollution. In a family health centre visited in a neighbouring community, there were not even sufficient funds to buy a vehicle for staff to use when they carried out home visits. Furthermore, in the Orlando Letelier they have no staff who are specifically trained to work in mental health, which is designated as one of the key components of the new 'horizontally oriented' family health centre model. Although mental health is one of the priority areas stressed by the Ministry of Health in health priorities for Chile, it is not included in the basic package of services. Moreover, both respondents felt that the assignation of resources did not take into account the cost of home visits, field work and other non-health centre based activities. For lack of funds the health centre was only able to provide curative health care, yet the family health centre model is expected to promote prevention and health promotion as well. The sub-director suggested that this limitation in turn affected the quality of human resources. She felt that added strains are being placed upon staff who were obliged to work extra hours to meet the needs of patients, without being paid.

Conclusions

Many public health care providers believe that the municipalised health model in itself is a positive one, and does, at least in theory, allow more local level participation and autonomy, but that the insertion of this model within the broader neo-liberal framework which has guided the reform process has resulted in a number of limitations.

A significant concern is the apparent inconsistency between the promotion of family health centre, which encourages a more holistic, preventative, promotional and participatory approach to primary health care delivery and the concurrent introduction of the basic package of services provided to users at the primary level, which is very "medicalised" and mainly includes curative-oriented services. Furthermore, while certain services in this package are targeted towards women, it does not consider gender inequality in health i.e. the role of gender relations in the production of vulnerability to ill health or disadvantage within the health care system (Standing, 1997: 4).

Finally, the current model of primary health care delivery raises important questions regarding state obligations in health care. It provides a very individualistic approach to health care and places users in charge of their own health. The health centre or family health centre, as an agent of the State, no longer has a role in this process, as the state is no longer responsible for health care. Yet evidence from El Bosque suggests that the private sector (i.e. the ISAPRES) is not able to meet the needs of low income households and in many cases the users return to the public sector. Where this demand cannot be met it is left to households to make up the shortfall, thus transferring labour costs for providing services from paid work in the public sector to unpaid work in the household and neighbourhood, where it is largely carried out by women (Elson, 1991, Moser, 1991). There is abundant evidence of this in Chile, but gendered institutional biases prevent equitable, efficient and accountable delivery of services since the system fails to value, recognise or accommodate unpaid, reproductive work and treats the household as an undifferentiated unit and women as dependants of men within the household (Elson and Evers, 1998).

While much of the Chilean health sector reform is a consequence of the neo-liberal framework, some elements draw on good international practice. Improvements have been made in health service delivery and there is a genuine commitment to development among health sector workers, and particular enthusiasm amongst the staff of the family health centres. Yet despite the reforms, including processes of decentralisation, low income groups, and most notably low income women, remain marginalised. Notwithstanding efforts to increase participation and accountability in the health sector, the public sector remains a hierarchical structure and the local level health centres remain at the bottom of this structure, where they continue to be far removed from key resources. The insertion of the primary health care model within a neo-liberal framework places limits on its effectiveness.