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Dr. Nelly Baeza Tapia. Division of Primary Care Better health, with your participation

Primary Health Care. Dr. Nelly Baeza Tapia. Division of Primary Care Better health, with your participation. Living Conditions. POLITICAL-INSTITUTIONAL. SOCIAL DETERMINANTS AND PUBLIC POLICY. Socioeconomic status. Health and well-being. Working Conditions. LABOR MARKET. Gender.

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Dr. Nelly Baeza Tapia. Division of Primary Care Better health, with your participation

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  1. Primary Health Care Dr. Nelly Baeza Tapia. Division of Primary Care Better health, with your participation

  2. LivingConditions POLITICAL-INSTITUTIONAL SOCIAL DETERMINANTS ANDPUBLIC POLICY Socioeconomic status Health andwell-being Working Conditions LABORMARKET Gender EQUITY IN HEALTH Environment EDUCATIONAL SYSTEM Ethnicity Behavior Health and Social Services WELFARE STATE Social Cohesion GLOBALIZATION SOCIAL STRUCTURE SOCIAL STATUS OF THE INDIVIDUAL MEDIATING FACTORS Structural Determinants Mediating Determinants Ref: Modified Briefing paper: Health inequalities: concepts, frameworks and policy authors H. Graham , M P. Kelly 2004, NHS.

  3. HEALTH: PILLAR OF SOCIAL PROTECTION • Health as the engine and result of an individual’s quality of life • Based on the ability of people to obtain education, work, create a family, and be happy in their environment. • Result of education, work, family relations, and quality of the environment.

  4. THE CONTEXT OF OUR ACTION • Improve performance in meeting health objectives • Face up to the challenges of aging • Reduce inequalities • Meet the needs and expectations of the population Epidemiologicaland Demographic Changes R E F O R M Principlesof the Reform Health Objectives Inequity • Emphasis on health promotion and disease prevention • Integration of the social services network • Strengthening primary health care Model Objectivesof the Reform User Dissatisfaction

  5. POPULATION STRUCTURE. Chile: Population pyramid-1950, 2005, 2050. • Pop.: 16,432,674 (2006) • IMR: 8.4 (2004) • GMR: 5.4 (2004) • LEB: 77 (74/80) Source INE

  6. NEW CONCEPTSChile: Trends in life expectancy at birthby age and sex. 1950-2050 (observed and projected). Quality of Life Save Lives Source INE

  7. 45 38.6 40 35 32.6 30 27.5 23.2 25 21.7 20.5 18.8 Percentage Population 20 13.8 15 10 5 0 1990 1992 1994 1996 1998 2000 2003 2006 GRADUAL ELIMINATION OF POVERTY Poverty trend,1990-2006. Casen Survey, MIDEPLAN

  8. PRIMARY HEALTH CARE (PHC) NETWORK 268Urban and rural communes 52Fixed-fee(F.F.) Communes 26Communes withPC dependent on the Health Services Municipal CESFAM 144 CGR 142 CGU 214 ST CENTERS 500 POSTS 1,168 Source: www.minsal.cl/DEIS. 20/09/2007

  9. 1.47 1.43 1,6 12000000 1.38 1.30 1.25 1,4 1.18 10000000 1.10 1,2 1.00 8000000 1 0,8 6000000 0,6 4000000 0,4 2000000 0,2 6798956 7490508 8031075 8484199 8823191 9365626 9742047 9976716 0 0 2000 2001 2002 2003 2004 2005 2006 2007 Beneficiary Population Variation Growth of Municipal Beneficiary Population2000 - 2007

  10. 11.9% 58,233 600.000 56.421 44,202 500.000 52,687 32,799 51,984 400.000 22,006 47,551 19,166 45,319 300.000 46,334 2,422 463,492 416,359 41,277 2,402 42,014 2,471 354,121 200.000 3,347 313,688 0 269,271 235,461 197,665 179,252 100.000 150,348 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 MUNICIPAL AND NONMUNICIPAL PHC--INVESTMENTS IN PHCPUBLIC HEALTH PROGRAMS RESOURCES FOR HIGH-QUALITY PRIMARY HEALTH CARE

  11. % OF PRIMARY CARE IN HEALTH SERVICES BUDGET U$: 1,021,000,000 2008

  12. TREND - MONTHLY PER CAPITA AMOUNT PER PERSON1997-2007 U$: 3 perperson/month (2007) 266% 254% 3.000 270% 237% 2.500 220% 173% 169% 164% 156% 149% 141% 2.000 170% 128% $ 1,500 $ 1,429 100% $ 1,336 1.500 120% $ 973 $ 950 $ 922 $ 877 $ 841 $ 793 1.000 70% $ 721 $ 563 500 20% -30% 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Monthly Per – Capita value/person (in pesos) Growth Source: Department of Primary Care D.I.G.E.R.A. /MINSAL, Year 200 7

  13. STRENGTHENING PROGRAMS 22% LAW 19,813 4% PER CAPITA CONTRIBUTION EXPLICIT 57% GUARANTEES 17% Figure: Total Resources 2007 by Funding Line Source: DIVAPS/2007.

  14. Infrastructure forPrimary CareFAMILY HEALTH CENTERS AND COMMUNITY FAMILY HEALTH CENTERS

  15. Integrated Health Care Model Linchpins of the Model’s transition Curative approach  Promotional and preventive Biomedical approach Biopsychosocial Social services delivery Community approach approach to health Hospital-based approach Primary Care Levels approach  Networks concept

  16. Health Care Model Emphasis User-centered care Promotion and prevention Family approach Integrated Outpatient care Participatory Intersectoral Quality Appropriate technology Community management Health Care Model OBJECTIVE: Ensure that each individual and family has a primary care team and health care facility nearby, allowing them to feel protected and accompanied to stay healthy, and the necessary referral mechanisms for dealing with more complex problems

  17. Integrated health care modelwith a family and community approach Organized family and community HEALTHY NEIGHBORHOOD INTERSECTORAL National Referral Centers Secondary Care Centers Family Health Centers Hospitals Prehospital care Emergency Care Network

  18. Doctor Nurse Midwife Social Worker Dentist Nutritionist Physical/respiratory therapist Psychologist Paramedic Administrativesupport staff Health Team

  19. Conceptual Model • People-centered • Flexible to needs • Biopsychosocial approach (integrated) • Population served and continuity • Emphasis on rights and responsibilities • Promotion and prevention emphasis • A preventive approach at all levels. • Family health approach • Consider the context and the individual and family life cycle

  20. Conceptual Model • Integrated • At PHC centers • In the health care delivery network • Emphasis on outpatient care • Prioritize open care • Participation • In community action and management monitoring

  21. Conceptual Model • Intersectoral Approach • Activation of priority sectors • Quality • Technical and in terms of user perception • Appropriate technologies • Procurement and purchasing • Workforce • Specific competencies

  22. MAIN TRENDS We continue to have major progress in health, but: • Moving forward requires cultural changes that must be manifested in individual behaviors that can only be improved collectively. • Inequities in health status persist, depending on the geographical location, socioeconomic and household situation, ethnicity, and gender. • Greater social and economic development is needed, together with the implementation of public health policies that have a significant impact on the population, with a new social rights approach.

  23. MAIN TRENDS • Low growth and aging of the population. • Increase in chronic diseases--high degree of harm from accidents and violence: visibility and emergence of new health problems • Greater concern about well-being and not simply preventing death or disability. • Citizens and users who increasingly demand better health conditions and health care in a growing spiral of expectations.

  24. Guarantees in Acute Respiratory Infections • ARI (Acute Respiratory Infections) • ARD (Acute Respiratory Diseases)

  25. Guarantees in Acute Respiratory Infections • ARI (Acute Respiratory Infections) • As of the mid-990s. • Childhood ARI. • Respiratory therapist, drugs (inhalers), oxygen therapy, monitoring with x-rays. • Health monitors. • Epidemiological surveillance

  26. Guarantees in Acute Respiratory Infections • ARD (Acute Respiratory Diseases) • Began in 1999. • Elderly. • Respiratory therapist, drugs (antibiotic treatment), oxygen therapy, monitoring with x-rays. 2007: Pneumococcus Vac. • Epidemiological surveillance

  27. EPIDEMIOLOGICAL SURVEILLANCE • Morbidity in Sentinel Centers • Emergency Morbidity Services • Etiology • Climate and Pollution

  28. Proportion of Pediatric Respiratory Consultations Sentinel Centers of the Metropolitan Region, 2007 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 5 9 13 17 21 25 29 33 Epidemiological week TOTAL ARI NON-RESP. PMF, PAO/ Respiratory health unit, MINSAL PMF, PAO. Respiratory Health Unit, MINSAL PMF, ODP/ MINSAL Respiratory Health Unit

  29. ARI DECLINE IN CHILDREN UNDER 15, 2007 ENDEMIC CHANNEL 1998 - 2006 SENTINEL CENTERS PRIMARY HEALTH CARE - METROPOLITAN REGION 55 50 45 40 35 30 % of total pediatric consultations 25 20 15 10 5 2007 med under max. Over min. 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Epidemiological week PAO/PMF/MJP. ARI PROGRAM, MINSAL

  30. OBSTRUCTIVE BRONCHIAL SYNDROME IN CHILDREN UNDER 15 - 2007 ENDEMIC CHANNEL 1998 - 2006 SENTINEL CENTERS PRIMARY HEALTH CARE - METROPOLITAN REGION 35 30 25 20 % of total pediatric consultations 15 10 5 2007 med under max. over min. 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Epidemiological week PAO/PMF/MJP. ARI Program, MINSAL

  31. PNEUMONIA IN CHILDREN UNDER 15, 2007 ENDEMIC CHANNEL 1998 - 2006 SENTINEL CENTERS PRIMARY CARE - METROPOLITAN REGION 6 5 4 3 % of total pediatric consultations 2 1 2007 med under max. over min. 0 1 6 11 16 21 26 31 36 41 46 51 Epidemiological week PAO/PMF/MJP. ARI PROGRAM, MINSAL

  32. 35 2003 30 2004 2005 2006 25 2007 % of total consultations for people 65 and over 20 15 10 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological week CONSULTATIONS FOR DIS.OF LOWER RESP. TRACT AGES 65 AND OVER - SENTINEL CENTERS – METROPOL. REGION, 2003-2007

  33. CONSULTATIONS FOR PNEUMONIA AGES 65 AND OVER SENTINEL CENTERS-METROPOLITAN REGION. 2003 - 2007 . 10 9 2003 8 2004 2005 7 2006 % of total consultations by people aged 65 and over 6 2007 5 4 3 2 1 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological week

  34. Number of consultations 16000 14000 12000 10000 8000 6000 4000 2000 2007 2006 2005 2004 2003 0 14 16 18 20 22 24 26 28 30 32 34 36 Statistical week WEEKLY CONSULTATIONS FOR RESPIRATORY ILLNESS CHILDREN’S EMERGENCY SERVICES - METROPOLITAN REGION, APRIL - SEPTEMBER 2003 - 2007.

  35. Number of hospitalizations 1200 1000 800 600 400 200 2007 2006 2005 2004 2003 0 14 16 18 20 22 24 26 28 30 32 34 36 Statistical week WEEKLY HOSPITALIZATIONS OF CHILDREN WITH RESPIRATORY ILLNESS METROPOLITAN REGION, APRIL - SEPTEMBER 2003 - 2007.

  36. Number of consultations 4000 3000 2000 1000 2007 2006 2005 2004 2003 0 14 16 18 20 22 24 26 28 30 32 34 36 Statistical Week WEEKLY CONSULTATIONS FOR RESPIRATORY ILLNESS ADULT EMERGENCY SERVICES. REGION METROPOLITANA. APRIL - SEPTEMBER 2003 - 2007.

  37. Figure 1. Influenza Notification Rate Sentinel Surveillance. Chile, 2004-2007 (weeks 1-35) Notification rate X 100,000 Epidemiological week Source: EPIDEMOLOGY-MINSAL

  38. - RSV CASES.METROPOLITAN REGION 2001-2007 - 450 2001 400 2002 350 300 2003 250 2004 n cases 200 2005 150 2006 100 2007 50 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 weeks

  39. Average Weekly Temperature Temperature oC Weeks

  40. Average Weekly Comparison of 2007 with 2002-2006 Historical Levels of Suspended Particulate Matter Fraction Under 10 ) 10 160 140 120 100 80 WEEKLY GLOBAL AVERAGE ("g/m3N) 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 63 61 68 64 74 61 68 71 70 73 84 101 90 98 107 127 114 120 146 116 120 137 98 128 143 100 104 138 107 113 117 99 98 81 93 83 75 59 73 62 57 60 55 62 67 59 64 58 58 60 67 58 Maximum 55 58 60 54 65 59 61 63 62 67 70 80 74 82 76 88 95 98 118 87 100 101 81 93 106 80 90 88 91 74 76 75 75 63 64 63 64 52 61 50 48 55 48 53 53 51 52 50 51 53 58 54 Average 46 55 54 46 48 56 53 51 57 59 59 68 59 60 49 61 83 61 63 54 82 64 50 48 91 56 73 64 70 56 52 54 45 46 39 44 54 42 48 39 39 52 39 48 42 44 42 45 46 46 52 52 Minimum 60 61 54 41 58 56 44 46 59 65 68 70 53 67 66 72 105 90 131 129 120 99 117 92 70 123 74 85 93 82 83 70 53 58 87 2007 WEEKS

  41. Average Weekly Comparison 2007 with 2003-2006 Historical Levels of Suspended Particulate Matter under 25 microns (MP2.5) Stations L-M-N-O 80 70 60 50 WEEKLY GLOBAL AVERAGE (µg/m3N) 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 28 26 28 29 38 29 32 32 28 32 33 43 35 39 42 53 51 52 67 61 53 74 58 58 53 53 57 49 52 57 53 49 58 43 46 Max. 23 24 24 23 32 26 26 26 25 28 28 35 30 33 33 39 46 47 55 52 50 57 50 43 50 47 49 39 44 42 40 39 37 34 32 Ave. 19 23 22 19 23 22 22 22 23 24 24 30 23 27 23 29 39 30 31 29 46 46 34 28 45 27 33 30 33 32 26 25 24 25 19 Min. 25 23 21 14 20 21 17 19 22 25 26 29 25 32 30 29 43 39 58 64 66 53 62 46 41 59 41 43 46 38 45 36 26 29 41 2007 weeks

  42. RESOURCES

  43. 600 2004 530 523 523 502 500 2005 500 2006 410 2007 400 300 230 172 200 170 165 100 100 100 60 0 0 0 0 No. of ARI and ARD Rooms. Chile 2004 - 2007 ARI-SAPU Rooms ARI Rooms ARD Rooms Mixed Rooms PMF, ODP/ MINSAL Respiratory Health Unit

  44. No. of ARI Rooms. Chile 1990-2007 PMF, PAO/ MINSAL Respiratory Health Unit

  45. No. of Inhalers Distributed - Chile 2006 and 2007Child and Adult Respiratory Programs SALBUTAMOL` BUDESONIDE` SALM+FLUTIC IPRATROPIO SALMETEROL PMF, PAO/ MINSAL Respiratory Health Unit

  46. MORTALITY

  47. CHILE HAS MADE TREMENDOUS PROGRESS IN REDUCING INFANT MORTALITY IN RECENT YEARS, DUE IN PARTICULAR TO THE SIGNIFICANT REDUCTION IN: • CHILD DEATHS FROM ARI • NEONATAL MORTALITY

  48. 600 2.5 N° ARI rooms I.M.ARI 500 2 400 1.5 Rate per 1000 LB 300 Nº rooms 1 200 0.5 100 0 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005* 2006* Chile, 1990-2006. No. of ARI Rooms vs. Infant Mortality from ARI * Estimated rates

  49. 2400 2,139 1,995 2100 1800 1,453 1500 1200 900 600 300 0 Deaths from Pneumonia and Other Respiratory Infections All Ages. January-July. Chile 2001-2004 and 2007 2001 2004 2007 PMF, PAO/ Respiratory Health Unit MINSAL Provisional data: Deaths 2006-2007 (DEIS)

  50. Deaths from Pneumonia and Other Respiratory Infections Children under 1 year. January - July. Chile 2001-2004 and 2007 2004 2007 2001 PMF, PAO/ Respiratory Health Unit MINSAL Provisional data: Deaths 2006-2007 (DEIS)

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