WCSDH in Rio: Chile: Steps forward and backward equity

Live from Rio, Cristobal Cuadrado, former president of IFMSA-Chile and member of the IFMSA Delegation to the WHO World Conference on Social Determinants of Health, writes about the Chilean experience in fighting health inequities and acting on social determinants of health. This October, IFMSA-Chile, with Cristobal as general coordinator, organized the First Congress on Health and Poverty in Santiago. The conference was graced by Professor Sir Michael Marmot, head of the 2008 WHO Commission on Social Determinants of Health.

In the context of the World Conference on Social Determinants of Health at Rio de Janeiro, we are having a wide discussion about evidence and experiences of different countries into this field. This entry talks about the Chilean situation on Health Equity from the perspective of the Social Determinants of Health. Dr. Jeannete Vega, past Health Minister Deputy of Chile during the government of Michelle Bachelet, had summit a draft paper (nº25) entitled “Steps towards the health equity agenda in Chile”, this represent a summary and reflection of this paper.

Generalities about Chile and its Health System.

US$ 14,300 in 2010; the minimum wage rose to US$ 350 in 2010 and the current inflation and unemployment rates are 1.4% and 8.6% respectively. Chile scores high in several health indicators, such as life expectancy at birth (81.2 years for women and years for men), infant mortality (8.3 per 1000 live births). The Health System in Chile it is decentralized with 29 local Public Health Services that serve approximately 75 % of the population. The other 25% of the population is covered by a private insurance and provision scheme administered by a number of private insurance institutions (ISAPRE) that provide mainly curative services mostly to those with the highest income, and of younger ages.

As a little history, the actual shape of the Chilean health system is related with the undertaken by the Pinochet military government following the coup d’état in 1973, establishing competition between public and private health insurers and promoted private health services, following neoliberal principles. These principles have changed very little since the early 90ths were the democracy had come again to our country.

The employee mandatory contribution accounts for 7% of the salaries and goes to either the public insurance (FONASA) or the private insurance companies. The National Health Fund (FONASA, Fondo Nacional de Salud) manages public health insurance. All citizens in Chile are insured by Fonasa unless they choose to contribute to a private insurer (ISAPRE). Individuals covered by FONASA may receive health services from either public facilities or a preferred private provider. The Ministry of Health manages vertical programs, public health interventions, and the health care personnel from public facilities. The focus on Primary Heath is location of the health centers and the income level of the municipality, where a health center located in historical context leading to action on Social Determinants and Health Equity

Timeline on Health&Equity issues during the past 20 years

1990-2000

Two streams of social policies were developed during the 1990’s. Firstly, sectoral policies, such as education, health and housing, centered on guaranteeing an adequate level of services and benefits for all the population in an equal opportunity perspective. Secondly, specific programs directed towards disadvantaged vulnerable groups to ensure access to the opportunities available through the sectoral policies, economic growth and development in general.

2000 -2010

Between 2000 and 2006 the emphasis was put in introducing programs to improve structural social determinants: improving neighborhoods conditions (Chile Barrio), diminishing extreme poverty (Chile Solidario) and others. All these programs had in common a policy and programmatic approach centered on the perceived needs of the person, in a family and in a community, rather than on the supply based normative needs, with services built around them on an integrated (intersectoral) manner.  The landmark social program of the last government of this period is Chile Crece Contigo, a program with deep roots on the perspective of SDH, so we will go a little bit further on this experience.

 

Chile Crece Contigo (Chile Growth with you): an intersectoral approach to tackle inequities from the beginning.

The central principle on this program is “Equity from the beginning”. Chile Crece Contigo initiative for action included the Rights of Children and the State’s responsibility to ensure them as a universal principle, creating a integrated system based on rights during the life course. The Ministries of Planning and Finances leveraged funding to investigate policy alternatives, systematize and evaluate innovative local projects and develop possible interventions, including pilot experiences. The evidence base of effective interventions, that the Ministry of Planning and other sectors were building, also looked at international experience

After a long work, in October 2006 President Bachelet announced the creation of the integrated and integral social protection system for early child development, called Chile Crece Contigo. Its social equity goal was ambitious and aimed to eliminate socioeconomic differences in achieving maximum development potential across the social gradient.

The system would accompany children and their families from gestation until they entered the school system in pre-kinder, age 4 years. Chile Crece Contigo would provide all boys and girls access to universal benefits and services to take care of their necessities and support their development in each stage of the life cycle, during early childhood. Additionally, it would contribute to induce basic conditions in the psycho-emotional and physical environment in order to favor harmonious and integral development, in accordance with the evolution of their life course. During 2007 new programs were introduced that required integrated action by two or more sectors: Support for Biopsychosocial Development (Ministry of Health, Ministry of Development, the Fund for initiatives to support local child development initiatives (Ministry of Planning– municipalities) and Fund for Childhood Initiatives (Ministry of Planning – public, private and community agents).

Chile Crece Contigo offers different levels of support and guaranties for all boys, girls and their families. To each according to his/her specific needs.

  1. Strengthened legislation and standards of protection for maternity and paternity for all population.
  2. Free Nursery and Preschool access for the 60% of more vulnerable families
  3. Improved quality in prenatal care.
  4. Humanized birth (with participation of the father)
  5. Improved well child care, especially for the first 2 years (Biopsychosocial support)
  6. Strengthened access to health care for all boys and girls from the first prenatal control until entry into the school system
  7. Increased support and guarantees for boys and girls from the 60% of homes with lesser income or in special situations of vulnerability.

The process of implementation of Chile Crece Contigo to date includes the action in all the Municipalities within the Country through generation of the local intersectoral networks in charge. Since 2007:

  • More than 649.132 pregnant women have enter the program
  • Almost 75% of eligible births (non-emergency) have occurred with the presence of the father since 2009.
  • More than 90.000 visits to the households of pregnant women with social risk.
  • More than 1.000.000 educational sessions to promote early child development (ECD) with families of children at risk.
  • More than 270.000 visits to the household of families with children at risk in their development.
  • Since September 2009, every child born in Chile receives a set of basic implements for initial child care including a cradle, a baby carrier, massage oil, diapers, and much information on first care needed by babies and infants.

The decree that accompanied the Law established a Committee of 9 Ministers, headed by the Minister of Planning and including Health, Education, Justice, Women’s National Service (SERNAM), Finance, Presidency, Labor, Housing. The national technical committee has also been expanded to include all the public services related to children. The preeminence of Health for early child development is expressed in a permanent working group.

The principles of intersectorial approach, equity as a key social goal, focus on education and early childhood, high political commitment and social participation are remarkable aspects of this program that probably will produce outstanding results on the future development of the Chilean society.

National Agenda on SDH. And some lessons of the Chilean experience.

Given the presidential mandate to improve Equity in health as part of the broader objective of improving social Equity, in early 2008, the Chilean Ministry of Health decided to create the Executive Secretariat on Social Determinants of Health, as part of the Subsecretariat of Public Health, within this area an special plan had been create: the “13 pasos hacia la Equidad” (13 steps towards Equity – www.equidad.cl) initiative, aimed at improving the level and distribution of health within the population of Chile. As part of the agenda, six objectives were defined, each of them involving concrete actions aimed at contributing to equity in health in Chile:

Specific objectives of the agenda:

  1. To contribute to the reduction of social inequalities which generate health inequities
  2. To reduce inequities which restrict and limit access to health and health services
  3. To implement actions for the “social inclusion” of excluded groups and territories
  4. To develop competencies on equity and social determinants of health within the Ministry of Health staff
  5. To generate tools for planning, monitoring and evaluation of the SDH and equity in the health sector
  6. To establish bodies and mechanisms for the coordination and integration of various sectors to develop the necessary actions to reduce health inequities

The first of these objectives had been addressed partially through the Chile Crece Contigo that we had already talked about. Another example is the objective 3 had become practical with the implementation of the programs “Vulnerable Counties” and “Vulnerable Neighborhood” focusing on the 96 most vulnerable counties and 68 neighborhood of the country with the goal to promote the reduction of inequities in health in the most communities, by means of interventions aimed at the main barriers of access to health services and to the social protection system, which were identified and prioritized by the community itself.

This Secretariat and his worked until March 2010 promoting a work agenda. We had to make the point that one of the first actions of the new central right party Goverment was to close this important secretariat

Some lessons

The “13 pasos” agenda is also one of few experiences in Chile where the Ministry of Health has been able to play a true leading role. The process of developing and implementing the “13 pasos” agenda influenced the philosophy of people within the ministry of Health but also from other sectors. During the process, we learned some lessons that could be generalizable to others that are involved in similar processes.

  • Lesson 1: In order to strengthen health equity, there must exist explicit political commitment at the highest level
  • Lesson 2: The need for an explicit agenda with incentives
  • Lesson 3: Building trust is a must
  • Lesson 4: Intersectoral relationships are crucial
  • Lesson 5: The community is essential
  • Lesson 6: Training as a strategy for institutionalization

Actual challenges, civil society participation and the future

 

The inequalities in Chile area a huge problem. On income measures for example, the richest 10% earn 36 times more than the poorest 10% and the 20% richest group of Chile share about 50% of the GDP of the country. Taking some health examples, with a very good Infant Mortality Rate of 7.7 as average, there is a 3-fold difference between the less educated and better educated groups. Even more, in life expectancy, the gap increase till 14 and 10 years between the richest and poorest groups, for woman and men respectively. Nevertheless, the worst statistical analysis is that the trends are not diminishing but increasing in the last decades.

In this context we organize and held at Santiago, past 7,8,9 and 15 of October the first Congress on Health and Poverty in Chile, as a voice from the Civil Society to contribute to maintain the health and equity issues and social determinants of health approach into the national agenda. IFMSA was of course involved. It was more concretely, a Health and Equity congress, to widely discuss this issue, the actual policies and problems, gathering civil society, politicians, academicians and other stakeholders with a perspective of future. For Spanish speakers you could enter to our webpage to have more information and access to the presentations. Soon we will have all the conferences online for free access.

At the actual context, the urgent situation and critical inequalities on our country, the civil society is reacting and taking their own responsibility. So different NGOs and young leaders are getting around a platform todiscuss, propose, advocate and create whole society awareness of the needed actions to tackle the terrible inequalities of our country. Heath&Equity will be the future on that. You could check a small presentation with the graphs and a wider analysis and some proposals from the Health&Equity civil society movement in Chile for the future: http://www.saludypobreza.cl/wp-content/uploads/2011/10/Towards-Equity-in-Health.pdf

Do you want to know more about Chilean experience on Health and Equity? Discuss a little bit about? Share your troughs? More than welcome. ccuadrado@saludypobreza.cl

Cristobal Cuadrado

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WCSDH in Rio: Country Case Studies on SDH

One of the members of our delegation, Taavi Tillmann from the United Kingdom, who is also a member of the Small Working Group on Health Inequities, talks about the 28 case studies published online by WHO in commemoration of the World Conference on Social Determinants of Health.

In preparation for the World Conference on the Social Determinants of Health, 26 countries were asked to write short reports about how they have been changing social determinants of health (SDH) in the past. These reports showed an immense diversity in form, highlighting that the boundaries of SDH are very blurry and there is still confusion about what SDH really means for policymakers. Some also appeared to be written in a rush (with spelling mistakes throughout) highlighting that SDH is still largely ignored by many countries. Notably, there are no reports from any European nation.

To save you the 8 hours it took me to read them, I have condensed the key take home examples below.

  1. South Australia appears to be the global leader in incorporating “Health in All Policies” approachinto the entire government. This is somewhat similar to Scandinavian effort, and will compare these two at another point. Nonetheless, the Australian key timeline was:
    • For decades, public health academics interested in health inequalities in Australia had been not only gathering and publishing their data, but working hard to make their conclusions accessible to the public and policymakers. “Policy makers and public health practitioners need simple, precise, easy-to-understand, easy-to-learn, visualize-able information at their constituents’ level.” (Many a global health project comes to my mind which was academically brilliant, but the team was unable to communicate it at constituents’ levels.) Accordingly, the Australians have been publishing “Social Health Atlases” to illustrate and monitor inequalities. This caused health inequality to decrease between 1987-1997. However, between 1997-2007, inequality stagnated.
    • In 2007, the government recruited an external public health expert, Professor Ilona Kickbusch, for a 3-month job where she had to come up with a new health strategy. Her report was essentially a “Health in All Policies” approach.
    • The government approved this approach at the highest level, and all government sectors were publically and formally asked to participate. i.e. there was strong political will to improve health with a long-term perspective, in a cheaper way. This will was largely achieved by economic arguments that said: “if you don’t do “Health in All” (red line), then the alternative is state bankruptcy (blue line)”.


    • Note how the government decided to invest now, and hope for returns 25 years later. I applaud this long-term view, and we should ask other governments to do the same
    • Subsequently, various projects were set up between different government departments to improve SDH that also meet other policy targets. E.g.: an inter-ministerial project to improve mobile broadband access that enables the public to also access health information; an inter-ministerial project to increase use of public transport by 10%; or decrease obesity by 10%; or get more aboriginal people to get a drivers’ license, and therefore reduce RTAs etc. Accountability is strong throughout, so if a project fails, all the participating ministries will be punished.
    • A key side benefit is that it got many policymakers to start thinking about their work through the health lens, thus setting the scene for future, braver SDH changes.

In all, Australia is years if not decades ahead of other countries in integrating the SDH or “Health in all policies” approach throughout its government. This pioneering case maps out how healthy governments could be replicated by other countries.

2. Malaysia’s government got set on reducing inequalities already 50 years ago, back when they inherited a vastly unequal society. They set out to reduce inequalities by giving extra support to the weaker ethnic, rural communities. They were very successful, as seen by increased equality of poverty and health:

However, progress has stagnated since 2000. This is due largely to the East Asian Financial crisis (that the IMF aggravated).

3. Costa Rica did extremely well in raising health with little money (red line), and its life expectancy is now a staggering 80.

The main cause of this success was huge increases in public spending, with a quarter of the county’s GDP being devoted to public social spending. This is in stark contrast to those advocating for strong austerity measures in Greece, UK or other countries whose GDP per capita is already many times that of Costa Rica’s.

4. Brazil gave two interesting case studies: 1) over the past decades, they have been giving cash benefits to very poor families with certain conditionalities: all children must attend 85% of school; no child is allowed to work; and mothers must attend perinatal programmes. Interestingly, the cash was given to the wife of the house. Results show prevention of malnutrition with concurrent improvements in education (as a key social determinants of future health) and improved gender inequality.

2) Brazil‘s second case was a small but beautiful illustration of how to elevate people into communities. A slum area called Morro da Policia was riddled with litter, rats and drug dealers, and the people had no future. A bunch of activists from PHM came in, cleaned up some of the litter and got everyone in the community, including drug dealers, to get excited about making some real changes. They planted gardens and dug water pipes, but the real change was in the faces of the people, who for the first time felt proud to belong to an inclusive, progressive community. A video shows a drug dealer at the end of the programme passionately talking about the benefits of community collaboration. Never before have I seen a drug dealer so positively transformed by anything.

5. Iran gave a completely different story. In Iran, Road Traffic accidents (RTAs) are the single biggest loss of DALYs owing to a bad driving culture. They turned this around not with mass-advertisement, or getting those in power to punish bad drivers. It was done by children. Their programme enlisted 8 million schoolkids to become “Little police officers”. Each child was thoroughly educated about the 8 key aspects of bad driving (Speeding; dangerous overtaking maneuvers; using mobiles whilst driving; chatting away while driving; eating while driving; driving while fatigued; not fastening seat belts; not attending to traffic signs and signals). Kids were issued with various booklets about the topic, as well as little pretend “arrest notepads” as well as other police paraphernalia. They then went about reprimanding their parents and others to improve their driving skills. 85% of parents responded positively to their kids’ notices, leading to a 20% reduction in accidents (about 200 000 accidents) and 10% reduction in road-deaths (about 5 000 lives saved). This is an astonishing feat, given that it was school-age kids who told off their parent governors. Just imagine what medically-educated university students could achieve if we tell off our adult governments. On a personal note, the example resonated a personal note with my childhood. When I was 6, I was convinced that I wanted to become a policeman. I made my own police-belt, complete with arrest-notebook, and went about issuing penalty notices to family for offences like leaving the toilet seat up. Kids have a huge potential resource in that they love to role-play. Tapping into this resource can unleash a wealth of energy, which can be channeled to change unhealthy social norms.

The other countries presented a varied mix of ideas. The Solomon Islands, Kiribati, Vietnam are documenting evidence on domestic violence, in an attempt to address gender inequality as a SDH. In India, an umbrella called “Voluntary Health Association of India” is starting to link together the 4000 health related NGOs that operate in India, in hope of identifying common policy goals to campaign on as a joint civil society initiative. This is similar to what avaaz.org was doing in the UK. Creating short-term unity on one political ask is an indispensable tool in the advocacy toolbelt, so we welcome this promising step by India. In a similar tone, the new government of Egypt spoke passionately about how it was mass social participation in civil society that brought the revolution this sprint, and how social participation in civil society must continue for SDH to be changed.

Chile gave a lengthy account of how it has measured and planned SDH action. Prior to the right wing government taking over two years ago, it had a whole government department dedicated to the topic. The new government dismantled the programme in their first day in office, so the document can be seen as an obituary.  My Chilean colleague, Cristobal, today enlightened me about how Chilean students are still protesting for 6 months to achieve high quality and free education for all. They are even taking their case to the European Parliament, OECD, and UNESCO. This makes me embarrassed at the feeble attempts by UK students against university top-up fees.

Many countries focused on mainstream public health issues, rather than SDH. For example, Jordan spoke about taking initial steps in improving food labeling to prevent obesity, Namibia spoke about how to control a polio epidemic, and Kenya spoke about success in deworming children, and Pakistan spoke about how to give the poor access to healthcare. It seemed these countries had either no active work on SDH, or they were just very pleased with their public health work.

To summarize, various policymakers across the world currently have an incredibly wide, rich diversity in understanding what SDH is, and wide array of experience in what works and what fails, as they take their first, baby steps. The conference will no doubt prove as a useful swap shop for ideas that can then cross-fertilize each other. However, many policymakers are still crawling around in the dark, oblivious to the notion that the SDH will be on the mainstream agenda for the future, and it is in their self-interest to get on the agenda before their competitors do. It is our job, as beacons of medical knowledge, as well as protectors of those in sickness and need, to keep learning and spreading as much as we can about the SDH, so to accelerate this transformation. Thank you for reading this far.

Taavi Tillmann