Chilean Health Reform Challenges

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Chilean Health Reform
Challenges Pitfalls
Rodrigo Castro, PhD(c) Libertad
Desarrollo www.lyd.org
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Outline
Main Issues

• How is Chilean health status?
• Why does AUGE arise?
• What does AUGE mean?
• How much does AUGE cost?
• Will it be worth it?
• What are the main challenges in our health care
  system?

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Since 1990 public health sector have thrown three
times more money with a low productivity
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Expenditure
Public Health Expenditure (mill 2002)
How much to spend?
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Expenditure
Public Private Per capita expenditure
How much to spend?
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How is Chiles health status ?
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Health Status
Basic Health Stats

• On basic health indicators, Chile scores well.
• Infant and maternal mortality are among the
  lowest in LAC.
• Average life expectancy is almost 76 years, up
  from just over 60 years in the early 1970s.
• These achievements are mainly due to investments
  in public goods (child health control),
  sanitation, water and sewage etc.

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Health Status
Statistics
Infant Mortality
General Mortality
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Health Status
Demographic Indicators
Statistics
1970 1982 1992 1997 2000
Life Expectancy 63.6 71.3 72.2 75.3 76.0
Fecundidad 3.4 2.8 2.6 2.5 2.4
Population growth 1.8 1.8 1.6 1.3 1.2
pop. 0-14 39.2 32.2 29.4 28.6 28.1
pop. 65 5.0 5.8 6.6 7.0 7.3
Mortality 8.7 6.1 5.5 5.4 5.5
Infant Mortality 82.2 23.6 14.3 10.0 8.3
Maternal Mortality 1.72 0.4 0.31 0.23 0.2
Source INE
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Health Status
Statistics
Main death causes
1970 1982 1992 1997 2000
Cardiovascular 22.3 27.6 29.0 26.4 27.7
Malignant tumors 12.0 16.8 20.0 21.7 21.8
Injuries 19.0 12.1 12.0 10.6 9.3
Respiratory diseases 17.4 8.5 11.1 12.7 14.0
Digestive diseases 6.9 8.6 6.3 7.5 6.7
Ill-defined causes 4.5 8.8 5.6 4.7 4.5
Infectious parasitic 10.9 3.8 2.9 3.1 2.7
Perinatal causes 5.0 3.5 1.9 1.3 1.1
Others 2.0 10.3 11.2 12.0 12.2
Source INE
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Health Status
International Comparison
Statistics
Countries Health Expend (1) Per capita expend (2) Life exp Infant Mort (3) Physic. (100K hab)
Germany 10.5 2.365 7480 5.0 350
Argentina 8.2 823 7077 19.0 268
Brazil 6.5 428 6371 33.0 127
Chile 6.1 581 7278 8.3 110
Colombia 9.3 507 6773 23.0 116
USA 13.7 3.724 7480 7.0 279
Spain 8.0 1.211 7582 5.0 424
Japan 7.1 1.759 7784 4.0 193
Notes (1) GDP (2) in USD PPP (3) 1998, each
100.000 NB Source World Development Report
2000/2001
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Health Status
Organization

• 2 systems
• Poorly linked
• Population is segmented by risk and income
• Centralism
• Historical public policies
• Big public sector, was design in the 1950s
• Inercy
• There is no leaderships
• Interest groups have important power

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Health Status
Organization

• Poorly management performance due to wrong
  incentives
• Financing does not follow good management
  practices.
• Human Resources policy is poorly defined.
• There is no competition between public hospitals.
• Unfair competition against private sector
  (Chart).
• Public hospitals which must offer free care to
  the poor, are overstretched and grossly
  inefficient Chart.
• Since 1990 have thrown more money three times
  more- with low productivity (Chart).

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Health Status
Public Health System Productivity
Management
Source Rodríguez Tokman, 2000
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Health Status
Management
Outgoing patients per bed
Source Asociación de ISAPRES
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Health Status
Unfair Competition
Subsidy due to fiscal aid
Assumption household of three persons
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Health Status
Private Insurance

• Poor with no access (Chart).
• Different rules of the game law does not
  support integration and competition.
• Information and coverage problems health plans
  aim to ambulatory care and only does not cover
  high cost treatments.
• Health cost increase due to information
  assymetriesbetween users-physicians-insurer, new
  diseases.
• Discrimination by age/gender/diseases (Chart)

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Health Status
Costs by Gender and Age
Risk Selection by gender/ age/illness
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Health Status
No Access to Poor
Health Insurees by income level 2001 (M)
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Health Status
Whats the problem?

• Policy experts believe that current health system
  wont be able to face with reasonable sucess the
  future sanitary challenges.

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Why does AUGE arise?
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AUGEs Philosophy
Causes

• Political issues
• Average conceals glaring inequality
• Population low satisfaction

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AUGEs Philosophy
Political issues

• Improve health for all, lowering life lost
  because of premature mortality or disability
  (DALYS) as well as, lowering health inequalities,
  improving health conditions of riskier groups
• Sanitary Goals 2000-2010

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AUGEs Philosophy
Infant Mortality in local governments
Inequality Gap
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AUGEs Philosophy
Infant Mortality by mothers years of schooling
Health Inequality
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AUGEs Philosophy
Mortality rates adjusted by years of schooling
Inequality Gap
0 1 - 8 9 - 12 13 Average
Women
Cerebrumvascular 108,5 96,1 44,3 26,1 78,9
Heart illness 84,0 87,9 46,7 33,4 75,5
Blister 29,2 26,0 11,9 7,0 21,6
Stomach 15,8 20,9 20,2 18,6 19,8
Breast 22,0 19,6 11,0 5,5 15,3
Uterous cancer 85,2 112,3 87,5 66,3 97,5
Men
Heart illness 101,6 96,4 59,7 35,4 81,0
Cerobrumvascular 72,1 67,1 33,7 12,9 48,6
Cirrhosis 57,2 53,9 27,5 13,4 42,9
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That mirrors our unequal income distribution
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AUGEs Philosophy
Income Inequality
Ratio 20/20 increase from 9 to 13 times
between 1970-00
Source Data 1970-1980, U of Chile. Data 90-2000,
Household Survey, CASEN
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AUGEs Philosophy
Public Opinion about their health condition order
by income quintiles
Low Satisfaction
Source CASEN 2000
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AUGEs Philosophy
Low Satisfaction
Public Hospitals long waiting lists
Hospitals Patients Weeks
San Borja Arriarán 2,377 36
San José 3,327 28
San Juan de Dios 3,440 43
Salvador 2,062 90
Barros Luco 1,298 26
Sótero del Río 5,613 65
Total 18,117 50
Source Altura Management
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AUGEs Philosophy
Low satisfaction
Public Hospital Waiting Lists
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AUGEs Philosophy
Low Satisfaction
Patients in waiting list and weeks
Diseases Patients Weeks
Ext de vesícula 3,489 46
Hernia inguinal 3,089 55
Várices 2,911 73
Amigdalectomía 2,395 73
Adenoma prostático 412 28
Miomectomía 375 32
Endoprótesis cadera 285 62
Source Altura Management
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AUGEs Philosophy
4 Challenges

• Demographic changes
• Inequalities gaps
• Population Expectations
• Solve pending problems and enhance sanitary
  achievements

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AUGEs Philosophy
Why do we need to guarantee?

• Because people need to know what to expect from
  health system and what they should do if their
  expectations are not fulfill.
• It points out an issue health care is getting
  more expensive and current health care system is
  not able to insurance everything to everyone.

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AUGEs Philosophy
What kind of guarantee?

• Ideal total coverage
• Reality set up priorities, direct resources
  where they are most needed, while encouraging
  patients to demand their rights.
• How do we define it?
• Technical criteria
• National Sanitary Goals
• Financial criteria and
• Social and political criteria

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What does AUGE mean?
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AUGE
Definition

• Sanitary instrument which enhance equity and aims
  to achieve sanitary and social protection goals
• Set up health guaranteed plan

• EXPLICIT GUARANTEE
• Access
• Opportunity
• Quality
• Financial protection

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AUGE
Components

• Collective
• Collective and individual actions
• Prevention and promotion
• Individuals
• Current ailments offered by FONASA (Public Health
  Insurance Fund)
• Priorities with maximum or intermediate guarantee

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AUGE
How does it work?

• Ailments set up
• MINSAL has to define ailments every 3 years.
• Advise by Consultive Council
• Approve by joined Supreme Decree of MoH and MoF

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AUGE
How does it work?

• FONASA and ISAPRES would have to offer to their
  beneficiaries
• Guarantee will enhance insurees rights.

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AUGE
What does include?

• Minimum Health Care Plan will offer guaranteed
  free or low-cost treatment for 56 ailments that
  between them are responsible for three-quarters
  of years of life lost because of premature or
  disablement.

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AUGE
What does it include?

• AUGE - Pilot
• Heart disease
• Kidney failure
• Infant cancer
• Pain Treatment
• Uterous cancer

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AUGE
However,....
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How much does it cost?
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Health Care Financing
Cost estimation

• Government says the reform will add an extra USD
  230m to Chiles total spending on health of USD
  4.3billion (or 6of GDP). Most extra money would
  come from the public purse.
• But, likely this reform will cost much more than
  that...

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Health Care Financing
Some bad news

• Is not the only reform that needs financial aid

Rema, no más... Mira que tenemos que pagar el
Chile Solidario, el Auge, las compensaciones por
la baja de aranceles, la descontaminación de
Santiago, las aguas lluvia, la crisis de la
educación, el hoyo de la salud, la compra de
tierras para los mapuches, el Miramar, las
víctimas de los DD.HH., las obras para celebrar
el bicentenario, la plata de los partidos
políticos, las deudas de los municipios, los...
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Health Care Financing
What does it include ?

• AUGE - Pilot
• Heart diseases
• Kidney failure
• Infant cance
• Pain treatment
• Uterous cancer

Millions US 1.84 5.38 0.61 0.61 0.92 Total
9.36
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Health Care Financing
Resources

• Where do we get these resources?

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Health Care Financing
Solidarity Compensation Fund

• Solidarity in health care is rather limited in
  the present Chilean health care system. Money
  does not follow health needs.
• Also, private insurers are not really forced to
  compete on quality and efficiency of health care,
  but rather compete on risk selection
  (cream-skimming) which is a waste of resources.

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Health Care Financing
Solidarity Compensation Fund

• With the introduction of a guaranteed health
  benefit package, the universal premium for which
  will be compensated by the Joint Compensation
  Fund, a contribution to more equity and
  solidarity in health care financing and towards
  more efficiency and quality in health care
  delivery will be achieved.

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Health Care Financing
Solidarity Compensation Fund

• Some issues
• Which risk adjuster? Gender, age,., health
  status
• How many risk groups?, exante or expost
• What to do with outliers? Special subsidies for
  people with high expenditures? special subsidies
  for people with high risk

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Will it be worth it?
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General Comments
Main Highlights

• Main idea is correct
• Set up guarantee with patient rights
• Instrument aims to set up priorities
• Focus on Primary Health Care, emphasis on
  promotion and prevention

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General Comments
However,

• Financial restriction (estimated cost of this
  plan is over USD 300 million, around 1/2 per cent
  of GDP).
• Reform is popular with the public but not with
  health workers. Doctors see standardised
  treatment as a first spet towards managed care
  and therefore as a threat to their income.

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General Comments
However,

• There is no enough technical capacity to
• Design Treatment Protocols
• Training health workers and physicians
• Bottlenecks
• Key to control the evolution of costs granting
  more autonomy to hospitals and moving to more
  prospective and performance related types of
  funding.

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General Comments
However,

• Reform should limit opportunities for cream
  skimming in private health insurance and
  strengthen patients rights.
• Develop a system of indicators to monitor
  improvements over time (e.g patient feedback
  measures, rate of childhood vaccination and
  mortality rates for key diseases)

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General Comments
Proposal

• The current discussion should focus on how
  benefit package will be design, health care
  organize and how this reform will be implemented
  gradually instead of benefit package coverage.

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Concluding RemarksWhat are the main challenges
in our health care system?
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Ideal Health Care System
Main Issues

• Focus on people
• Equity in financing and access
• Efficiency health care
• Accountable
• Empowerment

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Ideal Health Care System
Challenges

• Empower people
• Move towards health subsidy portability
• Reform has to be gradually implemented.
• Trade-off between cost containment and freedom to
  choose
• Trade-off between technical economic efficiency
  and equity
• Enhance institutional policies
• Better design of public choice issues involved in
  this Reform.

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Chilean Health Reform
Challenges Pitfalls
Rodrigo Castro, PhD(c) Libertad
Desarrollo www.lyd.org