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Chile
Index
The state's efforts in the health field began in 1890
with the
creation of an agency in charge of public hygiene and
sanitation.
Despite some subsequent initiatives to prevent and treat
work-
related accidents, it was not until 1924, with the
establishment of
the social security system, that the state assumed an
active role
in providing health care to the population. Between the
mid-1920s
and the early 1950s, state-run programs for health care
were
organized around the pension funds. During the 1940s,
public health
experts argued that the individual pension funds could not
organize
health delivery systems for their affiliates in a rational
way. It
was also argued that a system was needed that would
provide more
comprehensive coverage to the whole population, not only
those who
had accounts in the pension funds, if the country were to
improve
its overall health indexes. The eventual acceptance of
these
arguments by policy makers led in 1952 to the creation of
the
National Health Service (Servicio Nacional de Salud--SNS).
The SNS continued to provide care to all those who held
accounts in the various funds, free of charge to workers
and their
families in the social security system and for a variable
fee to
others. In addition, it extended health care to the
population at
large regardless of ability to pay. Services to those who
were poor
could be slow and often inadequate if a condition was not
life-
threatening, but accidents and other emergencies normally
were
given immediate attention. Moreover, the SNS tried to
identify
specific health problems and focus on providing care in
these
areas, such as giving all women primary prenated and
postpartum
care (and access since the 1960s to contraception),
inoculating the
population against certain diseases, and working to
improve
nutrition and hygiene through extension programs and
publicity. It
is estimated that 65 percent of the national population
used the
state-run system for curative medicine without paying
fees. The SNS
coexisted with private medical practices and hospitals,
which were
preferred by people who could afford them. The military
developed
its own system of clinics and hospitals. In the late
1960s, the
government took the initiative to develop a new program
for white-
collar employees, permitting users to select their
physicians. The
program was funded by payroll deductions but required
users to pay
a fee equal to 50 percent of the cost of their care. The
program
developed its own primary- and preventive-care clinics and
laboratories, although it relied on the hospitals of the
SNS for
backup care of the more serious cases and for
hospitalizations. All
but 15 percent of hospitalizations took place in SNS
hospitals.
All physicians were obligated to work for the SNS for
two years
after graduation; they were usually sent to rural areas
and small
towns where there were chronic shortages of doctors.
During the
rest of their professional lives, physicians were also
obligated to
work a certain number of hours a week for the SNS, for
which they
received relatively small honoraria; in exchange,
physicians took
advantage of many of the facilities of the state system to
treat
and test their private patients.
By the early 1970s, the state-run health programs faced
a
financial crisis. Given that the SNS was intimately tied
to the
social security system, the military government could not
change
the latter without altering the former. Thus, in 1980 and
1981
policy makers redesigned the nation's health care
institutions.
As a result, the Chilean health system in the early
1990s
contained essentially five components. The first is the
main
successor of the SNS, now called the National System of
Health
Services (Sistema Nacional de Servicios de Salud--SNSS).
In 1988
the SNSS employed about 62,000 professionals, including
about 43
percent of the nation's 13,000 physicians, many fewer than
had
worked for the SNS because physicians no longer had any
obligation
to serve the public health system. The SNSS's
administration was
decentralized into twenty-seven regional units, and
control over
its clinics and primary-care centers was transferred to
the
nation's 340 municipal governments. However, the national
government remained the main source of funding for these
various
units, and it continued to control their basic design,
including
staff size and equipment. The SNSS's funding comes from
general
state revenues and from a contribution of 7 percent of
taxable
income (up from the original 4 percent in 1981) from the
employed
population. Access to the SNSS is open to everyone, free
of charge
in the case of indigents and of those whose income falls
below a
certain level; a variable percentage of the cost up to 50
percent
is paid by those with higher incomes.
The SNSS organizes and implements the broad public
health
programs in areas such as inoculations and maternal-infant
care. It
provides periodic preventive medical care to all children
under six
years of age not enrolled in alternative medical plans.
Through
this program, which has broad national coverage,
low-income mothers
can receive supplemental nutritional assistance for their
children
and for themselves as well if they are pregnant or
nursing. As a
result, the incidence of moderate to severe childhood
malnutrition
among those participating in the program has been reduced
to
negligible levels in Chile, while only about 8 percent of
all
children suffered mild malnutrition in 1989. The SNSS is
the
largest health care provider in the country. In the late
1980s, it
served 8.2 million people, or about 64 percent of the
total
population, and its total expenditures on its participants
in 1987
equaled about US$22 per person.
The second component of the health system is the
National
Health Fund (Fondo Nacional de Salud--Fonasa). Fonasa is
part of
the SNSS, except that those who register in the program
may select
their own primary-care physicians, as well as specialists.
In this
sense, Fonasa continues the modus operandi of the program
initiated
in the late 1960s for white-collar employees, except that
anyone
can register in it. Fonasa affiliates direct their payroll
or self-
employment contributions to the fund. Pensioners of the
state-run
system, the INP, may also choose to participate in Fonasa.
The fund
reimburses its users a variable portion of the cost of
medical
attention on presentation of vouchers for services that
have been
performed (an average 36 percent reimbursement in 1989).
In 1987
Fonasa served 2.5 million people, and health expenditures
in it
amounted to US$79 per affiliate.
The Security Assistance Institutions (Mutuales de
Seguridad--
MS) constitute the third element in the health system.
These
consist of hospitals that deal primarily with treatment of
the
victims of work-related accidents. These institutions
house some of
the best trauma and burn centers in the country. The MS
are
financed out of employer contributions equivalent to about
2.5
percent of their total payrolls and completely cover the
medical
expenses of employees of the affiliated enterprises who
are injured
at work. In addition, the MS pay a temporary disability
pension.
The 1.96 million employees who have access to these
institutions
work for 52,000 different enterprises. This program is
among the
better funded, given that its income of US$123 million
amounted to
about US$62 per covered worker, while the rate of
work-related
accidents was only about 10.8 percent per year for all
incidents,
however minor. Safety experts hired by the MS system are
also in
charge of inspecting workplaces and suggesting
improvements to
prevent accidents. The MS are composed of numerous
institutions
administered by boards with employer and employee
representatives.
In 1987 they ran eight hospitals and nineteen clinics,
mainly in
Chile's most important urban centers. The product of
initiatives
taken by some of the country's largest employers in the
late 1950s,
the MS expanded greatly in the 1980s.
Private insurance companies belonging to the Institute
of
Public Health and Preventive Medicine (Instituto de Salud
y
Previsional PrevenciĆ³n--Isapre) constitute the fourth
element in
the health system. People enroll by asking their employers
to
direct their health deduction to these companies, and they
pay an
additional premium depending on the specific insurance
policy.
Medical services are reimbursed to users at a percentage
of cost.
In 1987 about 1.5 million people were enrolled in the
Isapre, with
expenditures of about US$166 per enrollee. Critics of the
Isapre
insurance companies noted that they did not help mitigate
the
nation's highly regressive distribution of income because
they
channeled the deductions of many people with higher
incomes out of
the SNSS. Moreover, as private carriers, the Isapre
companies may
deny enrollment to those who are at higher risk (as a
result of
serious illness or age), and they are prone to drop those
who
become excessive risks. Consequently, the SNSS must take
up the
burden of covering the health care of high-risk
individuals.
The fifth component of the health care system is
private
medicine, which includes private hospitals and clinics.
Most
physicians, dentists, and ophthalmologists maintain a
private
practice even if they work for the SNSS or other systems.
There are
also private health insurers who do not form part of the
Isapre
structure because they do not collect their premiums from
payroll
deductions. In 1987 they insured 500,000 people drawn from
the
population with the highest incomes.
In 1992 Chilean health indicators were much closer to
those of
industrial nations than to those of the developing world
(see
table 14, Appendix). The four leading causes of death in Chile
are
circulatory diseases (27 percent), cancer (18 percent),
accidents
(13 percent), and respiratory illnesses (11 percent).
Medical
visits average about 3.5 per person per year, or about 2
to 2.5 for
the general population and 1 to 1.5 for maternity and
child check-
ups. The SNSS handles 89.1 percent of all these visits
(16.3
percent of them through Fonasa). Fully 98.4 percent of all
births
occur with professional assistance in hospitals or
maternity
clinics. In rural areas, where women might need to travel
longer
distances to give birth, they can spend the last ten to
fifteen
days of pregnancy in special hostels. Inoculations of
infants and
children are virtually universal for tuberculosis,
diphtheria,
pertussis, tetanus, poliomyelitis, and measles.
According to the Pan American Health Organization, the
number
of cases of acquired immune deficiency syndrome (AIDS) was
gradually rising, with 3.8 per million population in 1987,
5.4 per
million in 1988, 6.3 per million in 1989, 8.9 per million
in 1990,
and 11 per million in 1991. As of the end of 1991 in
Chile, 196
individuals with AIDS in Chile had died. According to
Health Under
Secretary Patricio Silva and the National AIDS Commission,
of the
990 individuals who were registered as having been
infected with
the AIDS virus in the country, 630 had become sick and
half of them
had died by the end of 1992. The report stated that 93
percent of
those diagnosed were men and 7 percent were women.
Although the government of President Patricio Aylwin
did not
make structural changes to the health system, it increased
funding
for the portions of the system that most benefited the
poor,
especially primary care services. The salaries of health
workers in
the public sector were increased. The government also
enhanced the
decentralization of authority in the public health sector
by giving
local and regional governments more decision-making power
over the
distribution and equipment of health-care resources and
provisions
within the limits of national government funding
allotments.
Data as of March 1994
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