Chile UHC 17 09 2013 Outline Context Chilean

Chile UHC 17. 09. 2013

Outline • • Context Chilean Health System Measurement and Monitoring of UHC Discussion

Context: Chile at a glance 17, 5 21, 590 14, 4% 87% 79 8 1% Millions total population (2013, INE) PPP US$ GNI per capita (2012, WB) Poverty (2011, CASEN) Urban population (2013, INE) Years Life expectancy at birth (2012, WB) IMR per 1000 live births (2011, WB) 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) Source: WB World Development Indicators 2011; OECD Statistics 2011

Chile: Economic, social and demographic evolution Poverty and extreme poverty (1990 -2011) 25000 20000 50% 15000 40% 10000 30% 5000 20% 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 0 38. 6% 32. 9% 27. 6% 13. 0% 10% 23. 2% 21. 7% 20. 2% 18. 7% 13. 7% 9. 0% 7. 6% 5. 7% 5. 6% 4. 7% 15. 1% 3. 2% 14. 4% 3. 7% 2. 8% 0% 1990 1992 1994 1996 1998 2000 2003 2006 2009 2011 GDP per capita (current US$) Poverty GNI per capita (PPP) 2013 1950 80+ 75 -79 70 -74 65 -69 60 -64 55 -59 50 -54 45 -49 40 -44 35 -39 30 -34 25 -29 20 -24 15 -19 10 -14 5 -9 0 - 4 600000 Female Male 400000 200000 0 Extreme poverty 200000 400000 600000 80+ 75 -79 70 -74 65 -69 60 -64 55 -59 50 -54 45 -49 40 -44 35 -39 30 -34 25 -29 20 -24 15 -19 10 -14 5 -9 0 - 4 1000000 Female Male 500000 0 500000 1000000

Chile: Burden of Diseases Injuries and Risk Factors 100% 80% 60% 40% 20% 0% 15% 12% 13% 68% 77% 79% 17% 11% 8% 1990 2000 2010 Comm/mater/neonatal/nutr Source: IHME 2013 NCD Injuries

Chilean steps towards UHC

Chilean Health System

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

M&M UHC: Inputs: Chile and OECD countries Nurses and midwives density THE as% GDP Phisician density Nurses and midwives density Hospital beds density PHE as% THE Phisician density THE as% GDP Hospital beds density Chile OECD THE as% GDP PHE as% THE 8% 9% 45% 72% Hospital beds density 220% 480% Phisician density 160% 320% Nurses and midwives density 150% 1110% OECD

M&M UHC: Outputs Health Care Utilization per Income Quintile 2011 . 45 (per capita last three months source CASEN survey) . 40. 35. 30. 25. 20. 15. 10. 05. 00 I II III IV V I II IV V Doctor consultation Specialist consultation. Emergency room visits I II IV Dentist visits V I II IV Lab V I II IV RX-ECO V

M&M UHC Outcomes: Coverage of Interventions Coverage of Intervention for NCD. Comparison public and private sector Coverage of Interventions for Communicable Diseases, Maternal and Child Health Depression DPT immunization HIV-AIDS ART coverage Prenatal services High Blood Pressure PAP smear Tb treatment success Private Public Contraceptive prevalence Improved Sanitation Indicator DPT immunization Prenatal services Contraceptive prevalence Skilled birth attendance Improved Sanitation TB treatment success HIV-AIDS ART coverage Mampograph y Skilled birth attendance Coverage % 94 95 58 100 96 71 66 year 2011 1993 2006 2009 2010 2011 source WB WDI WB WDI Indicator Depression High Blood Pressure Diabetes Mammography PAP Smear Diabetes Public 56. 2% 40. 0% 54. 3% 47. 0% 55. 0% Private 82. 1% 30. 5% 78. 6% 71. 0% 61. 0% year 2009 -10 2009 -11 2009 -12 2011 source MOH – NH Survey CASEN Survey

M&M UHC Outcomes: Effective Coverage Effective coverage of diabetes by educational level, Chile 2009 -10 Effective coverage of HBP by educational level, Chile 2009 -10 HBP Knowledge HBP in treatment HBP compensated Diabetes knowledge Diabetes in treatment Diabetes compensated 83. 08% 70. 02% 75. 93% 66. 10% 64. 98% 63. 56% 55. 13% 41. 90% 34. 91% Low (< 8 years) 17. 40% Middle (8 - 12 years) 37. 91% 34. 86% 16. 78% 16. 67% High (>12 years) 33. 63% 78. 18% 55. 16% 50. 97% 37. 90% 37. 46% 29. 84% 15. 97% 72. 42% 66. 02% Total LOW (< 8 years) Middle (8 - 12 years) High (>12 years) Total

M&M UHC Outcomes: Prevalence of Risk factors Prevalence of Tobacco Consumption 60 50 45. 5 44. 2 50. 3 49. 4 37. 1 40 Prevalence of alcohol risk consumption (AUDIT>8), total, by sex, educational level, area 42. 5 41. 3 35. 7 27. 6 25. 6 30 20 13. 2 25 15 Age Educational level ra 0 Male Female Sex Area Prevalence of high and very high cardiovascular risk, by sex, educational level and urban/rural area 35. 0% 30. 0% 25. 0% 20. 0% 15. 0% 10. 0% 5. 0% 0. 0% 8. 6 10. 9 10. 4 Urban Rural 2. 5 65 Sex 12 l n Ru ba gh Ur Hi dl e w id M Lo e 4 10. 3 an d m or -6 4 45 -4 -2 15 25 al M al 4 5 e 10 0 e 10 Fe m 19. 7 20 Low Middle High Educational level Area Use of barrier methods during the last sexual relation, 2012 (15 -29 years) 70 60 50 40 30 20 10 Male Female Sex Low Middle High Educational Level Urban Rural Area 0 Male Female Sex Source: MOH- Chile, National Health Survey 2009 -10 Low Middle Socioeconomic level High

M&M UHC Impact: Financial Risk Protection Out of pocket health expenditure as % total household expenditure/income*. Chile 2007 8 7. 1 7 4. 3 5 4 3 6. 1 5. 6 6 3. 1 3. 8 2. 1 2 1 0 Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Income Public Private System % of households facing catastrophic payments from out-of-pocket health expenses (>30% household capacity to pay) 5. 7% 4. 3% 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 2. 2% 2. 5% Quintile 1 Quintile 2 Quintile 3 2007 Quintile 4 Average Quintile 5

M&M UHC Impact: Health Status total urban IMR years of education None 1 -3 4 - 6 7 -9 10 -12 13 + average Ratio 1 -3/13+ total 11, 2 13, 6 10, 0 7, 4 5, 8 7, 4 1, 93 rural 8, 5 14, 0 9, 8 10, 2 8, 4 10, 2 1, 01 13 + 10 -12 7 -9 4 - 6 rural average urban 12, 5 13, 3 10, 1 7, 1 5, 6 7, 1 2, 21 1 -3 None 13 + 10 -12 7 -9 4 - 6 1 -3 16 14 12 10 8 6 4 2 0 None IMR per 1000 live births IMR according to women education and zone. Chile 2010

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). – • 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) – • 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) 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.