Chile UHC 17.09.2013

Outline Context Chilean Health System Measurement and Monitoring of UHC Discussion

Context: Chile at a glance 17,5 Millions total population (2013, INE) 21,590 PPP US$ GNI per capita (2012, WB) 14,4% Poverty (2011, CASEN) 87% Urban population (2013, INE) 79 Years Life expectancy at birth (2012, WB) 8 IMR per 1000 live births (2011, WB) 1% Child malnutrition 96% Access to improved water source 99% Literacy of population age 15+ (2009, WB) 0.54 GINI coefficient (2011, CASEN) 9,7% Elderly population 65 years and over (INE, 2013) The main challenge is to tackle inequality. While Chile has made substantial progress in reducing poverty (15% in 2009), the average income of the richest 20% was 14.5 times that of the poorest 20% in 2009. Although Chile has actively invested in social protection programs, middle- and low-income households remain vulnerable to crises. Source: WB World Development Indicators 2011; OECD Statistics 2011

Chile: Economic, social and demographic evolution

Chile: Burden of Diseases Injuries and Risk Factors Source: IHME 2013

Chilean steps towards UHC

Chilean Health System

Measurement and Monitoring of UHC Inputs Outputs Outcomes Prevalence of Risk factors Effective Coverage Impact Finantial Risk Protection Health Status

M&M UHC: Inputs

M&M UHC: Outputs

M&M UHC Outcomes: Coverage of Interventions Indicator Coverage % year source DPT immunization 94 2011 WB WDI Prenatal services 95 1993 Contraceptive prevalence 58 2006 Skilled birth attendance 100 2009 Improved Sanitation 96 2010 TB treatment success 71 HIV-AIDS ART coverage 66 Indicator Public Private year source Depression 56.2% 82.1% 2009-10 MOH – NH Survey High Blood Pressure 40.0% 30.5% 2009-11 Diabetes 54.3% 78.6% 2009-12 Mammography 47.0% 71.0% 2011 CASEN Survey PAP Smear 55.0% 61.0%

M&M UHC Outcomes: Effective Coverage

M&M UHC Outcomes: Prevalence of Risk factors Source: MOH- Chile, National Health Survey 2009-10

M&M UHC Impact: Financial Risk Protection Sources: Cid, C. y Prieto, L., Rev Panam Salud Publica 31(4), 2012 Castillo-Laborde, Villalobos, Rev Médica de Chile , accepted for publication *By income quintiles: over total household expenditure; By system: over total income

M&M UHC Impact: Health Status years of education total urban rural None - 1-3 11,2 12,5 8,5 4- 6 13,6 13,3 14,0 7-9 10,0 10,1 9,8 10-12 7,4 7,1 10,2 13 + 5,8 5,6 8,4 average Ratio 1-3/13+ 1,93 2,21 1,01

Discussion Over the last 60 years the Chilean health system has moved towards UHC, evidenced by the high coverage on primary health care and relative good performance on health indicators on average. However there are structural constraints that prevents further advance and determine the existence of important inequalities in terms of access, but more importantly, in terms of health results (e.g. geographic, socioeconomic, public/private system). For instance, the public expenditure on health (the total expenditure on health), is one of the lowest among OECD countries. Furthermore, an important component of the total health expenditure is financed through out-of-pocket expenditure (i.e. insufficient financial risk protection). At the household level, about 5% of the total expenditure/income is devoted to pay directly for healthcare services (although the % is greater for the better offs) There is important limitation in terms of the inputs. Specially in the public sector (human resources and facilities) On the other hand, the system is fragmented (at the pooling and providers level) Not allowing for a unique pooling of funds (but 1 public fund and 13 private funds). Therefore, there is an unequal availability of funds for the population served in both sectors, as well as unequal access (specially regarding more complex health care services such as surgical procedures and specialist consultation). Besides, there is risk selection (with the poorer, the older and the sicker going to the public fund).

Discussion The geographic characteristics of the country also impose difficulties in reaching the rural and extremely isolated population. There are still some gaps in addressing some increasingly important diseases (groups II and III). For instance, the dementias, enzymatic diseases, secondary preventive strategies (e.g. for some cancers). One of the major limitation in the measurement of indicators related to UHC is the availability of disaggregated data (specially at the health results level). In order to measure the advances in UHC, one possibility is to consider the specific health needs profile of each country according to the burden of disease study, as well as the relative importance of the three different groups (communicable maternal and child health, non communicable and injuries), and use tracer indicators of effective coverage for each group.