MATERNAL-CHILD HEALTH POLICY

1. MATERNAL-CHILD HEALTH POLICY DR. RENE CASTRO S. Regional Forum on Social Protection in Health for Women, Newborn and Child Populations in LAC – Lessons learned to prompt the way forward. Tegucigalpa, 8 -10 November 2006

2. “Maternal and child mortality is one of the demographic facts that can be influenced in a more or less serious way since it depends a great deal on the care that the mother and child receive before, during and after birth.” Dr. Salvador Allende, Minister of Health (1940)

3. LA REALIDAD MEDICO – SOCIAL CHILENA “Chilean Medical – Social Reality”

4. Maternal, perinatal and child health indicators reflect a country’s economic, cultural, social and health development.

5. Risk of death in Latin America and the Caribbean ( compared to USA and Canada) Relative Risk 3 - 4 9 - 10 Child Mortality Maternal Mortality

6. Until 1920, the health situation in Chile qualified as a “savage state”: the highest child mortality in the world. 1952: Life expectancy at birth - 54.9 years – among the lowest at the global level, reflecting the poor living conditions in the country.

7. INFANT MORTALITY PER 1,000 LIVE BIRTHS

8. 1 Life expectancy at birth1 Average Age 2 PERIODS Sex Sex Differential Men Women Men Women 1919-22 30.90 32.21 1.31 28 29 1929-32 39.47 41.75 2.28 44 46 40.65 43.06 2.41 48 50 1939-42 1952-53 52.95 56.83 3.88 62 67 LIFE EXPECTANCY AT BIRTH ANDHALF LIFE 1920-2002 1960-61 54.35 59.90 5.55 63 70 1969-70 58.50 64.68 6.18 66 72 1980-85 67.37 74.16 6.79 72 78 1991-92 71.37 77.27 5.90 75 81 2001-02 74.42 80.41 5.99 77 83 1. The number of years a newborn would live if age-specific mortality rates at time of birth (shown in Table) continued throughout the child’s life. 2. Age at which 50% of the survivors from a cohort of 100,000 live births are still alive; according to mortality observed at the time referred to in the Mortality Table. Infant Mortality3 Years of life lost from birth to age 854 Male Overmortality PERÍODS Men Women Men Women Difference 1919-22 54 53 264.0 248.7 1.1 - 1929-32 46 44 217.5 198.7 1.1 9 CHILD MORTALITY AND YEARS OF LIFE LOST 1920-2002 1939-42 45 42 205.4 188.5 1 1.1 1952-53 32 29 128.0 112.4 1.1 13 1960-61 125.6 108.3 1.2 31 26 2 1969-70 89.2 75.4 1.2 27 21 4 1980-85 25.8 21.6 1.2 18 12 9 1991-92 15.5 13.1 1.2 15 10 3 2001-02 9.4 7.5 1.2 12 8 2 3. Probability of dying under one year of age at the time referred to in the Mortality Table. 4. Number of additional years that people who died should have lived. The difference between one period and another indicates the impact of the change in mortality on human life.

9. MATERNAL-CHILD CARE • 1901 National Children’s Board • 1924 Workers’ Insurance Law • 1942 Health Units (district-level) • 1952 National Health Service • 1980 National Health Service System: • Ministry – Social Security – Regional • Ministerial Secretary (Seremi) • (decentralization) • 2000 Sector reform (ongoing)

10. NATIONAL HEALTH SERVICE (1952–1979) August 1952Law 10.383: creates the SSS and the National Health Service (SNS): “political will” for the search for social balance and institutional justice – new social pact - will allow the working and proletariat classes to be integrated into the system. Wide national agreement; support of the University (School of Public Health) and the Medical Association. Social Medicine: incorporates the fundamental principle of the WHO, created in 1948: health as “a right and obligation of every human being and of countries as a group.”

11. NATIONAL HEALTH SERVICE (1952–1979) • Chile was the second country at the global level (4 years after England); it integrated 6 institutions that addressed different areas of social security and health management. • Objectives: • reduction of maternal and child mortality, • control of infectious diseases, • eradication of malnutrition and, • coordination with other social sectors that have links to health determinants.

12. MATERNAL MORTALITY BY CAUSE CHILE 1951-2000

13. INFANT MORTALITY CHILE 1980 – 2003 * (*) Rates per 1,000 LB

14. WOMEN’S HEALTH PROGRAM Years Prenatal Family Plan. Skilled Care Maternal Mortality Check-Up Coverage at Birth Rate x 10,000 L. B. % % % 1965 50.1 6.0 75.5 27.9 1970 52.0 13.7 81.1 16.8 1975 55.0 23.7 87.4 13.1 1980 57.4 26.7 91.4 7.3 1985 69.2 23.6 97.4 5.0 1990 85.0 17.3 99.1 4.0 1995 92.5 22.2 99.5 3.1 1998 92.6 22.5 99.7 2.0

15. S.N.S.S. CARE NETWORK • PRIMARY CARE General Doctor’s Offices • Urban 250 • Rural 150 • Rural Posts > 1,100 • HOSPITAL-BASED CARE : 162/177

16. FAMILY PLANNING IN CHILE • 1967: POLICY BASED ON HEALTH OBJECTIVES • Reduce Maternal Mortality due to Induced Abortion • (Avoid Unwanted Pregnancy) ; • Reduce Child Mortality associated with high fertility; • c. Promote Family Well-being • (Responsible Parenting)

18. Abortion-related Mortality 1960 - 2000 • Year Number Rate % Maternal • Deaths • 196030210.7 35.7 • 1970 185 7.1 42.1 • 1980 71 2.8 38.4 • 1990 23 0.7 18.7 • 1998 14 0.5 25.4 • 13 0.49 26.5 • 2001 40.15 13.3

19. Foundation for a Family Planning Policy “The Government of Chile recognizes the benefit that the population achieves through Family Planning activities, which allow individuals to have the number of children with the desired spacing and timing. For this reason, it maintains its support for Family Planning activities in order to promote the achievement of adequate comprehensive reproductive health.” October 1990

20. PROFESSIONAL DELIVERY CARE YEAR % 1965 74.3 1975 87.4 1985 97.4 1998 99.6 “ From empiricism to professionalism in delivery care” Prof. F. Mardones-Restat

21. Maternal Mortality and Professional Delivery Care 1950 - 2001

22. MATERNAL-CHILD HEALTH 1960 – 2000Rates per 1,000 LB • 1960 2000 • Birth Rate35.5 17.2 • Total Maternal Mort.2.99 0.2 • M.M. due to Abortion 1.07 0.05 • Infant Mortality 125.1 8.9 • Neonatal Mort. < 28 d.36.2 5.6

23. REDUCTION OF MATERNAL MORTALITY IN CHILE : LESSONS LEARNED 1950-2000 Ministry of Health, CHILE Universidad de la Frontera Pan American Health Organization PAHO/USAID

24. Steps for Reducing Maternal Mortality • Consider M.M. to be a human rights and social justice problem. • Recognize that every pregnancy has some level of risk. • Assure that skilled personnel attend births. • Promote maternal health as a vital economic and social investment : • Postpone motherhood. • Prevent unwanted pregnancy. • Prevent unsafe abortion. • Facilitate accessto maternal health services. • Improve the quality of maternal health services. • Supervise and evaluate changes.

25. ...the decade in Chile...

26. PEDIATRICS, 10 April 2006

27. MATERNAL – CHILD HEALTH SITUATION • Stable health policies during the last 50 years • Institutionalized National Health System • Human resources that are committed to their work • Culture of health among the population

28. “Chile is better - Health Reform”

30. SEXUAL AND REPRODUCTIVE HEALTH “DESIGN AND IMPLEMENTATION OF HEALTH PRIORITIES Chilean Programmatic Reform”

31. REPRODUCTIVE HEALTH PRECON- CEPTION CARE PRENATAL CARE DELIVERY AND POSTPARTUM CARE + + = HEALTHY MOTHERS AND NEWBORNS NEONATAL CARE +

32. Health Objectives: Cornerstone of the Reform • Improve the health objectives attained • Child health, women’s health, infectious diseases • Confront the challenges that result from aging and other changes in society • Determinants of the health situation, primary causes of death and disability • Reduce health inequalities • Living conditions and determinants, health situation, access to health • Provide services according to the population’s expectations • Financial justice, care according to expectations, quality of care “Health Objectives for the Decade 2000-2010”

33. Model for Comprehensive Health Care Primary Care constitutes the strategic axis for Health Reform Community component Inter-sectoral F a m i l y Health promotion Service network Disease prevention Management team PHC Entire life cycle Targeting by risk Humanized Welfare component

34. Unwanted Pregnancies • Health Objectives and Goals for Unwanted Pregnancies • Impact Goals: • Decrease the gap between desired and observed fertility: the gap between desired and observed fertility should be under 20% • By age group, maternal educational level, socio-economic level, experience with use of contraceptive methods (methods used, duration of use) • Reduce pregnancies in adolescents: see Chapter 2 on Risk Factors, Sexual Behavior • Reduce abortion-related maternal mortality by 50% (over the level in 2000) • Counseling on Sexual and Reproductive Health for the population at greatest risk of abortion (detected using predictive instrument) • Coverage for Fertility Regulation: by five-year age groups • Audit of complicated abortions by cause at the level of hospitals and/or primary care establishments

35. Maternal and abortion-related mortality, Chile 1990-2004 Maternal Mortality Abortion-related mortality Rates x 10,000 LB SO 1: Maintain the achievements attained

36. Infant mortality and its components, Chile 1995-2004 Post neonatal Infant SO 1: Maintain the achievements attained Rates x 10,000 LB Salud Infantil con avance

37. Millennium Development Goals Eradicate extreme poverty and hunger GOAL 1 GOAL 2 Achieve universal primary education GOAL 3 Promote gender equality and empower women GOAL 4 Reduce child mortality GOAL 5 Improve maternal health GOAL 6 Combat HIV/AIDS, malaria and other diseases GOAL 7 Ensure environmental sustainability

38. “This is how the AUGE works: explicit health guarantees”

39. “The regime of General Health Guarantees is a health regulation instrument that is an integral part of the Health Services Regime.” 12 September 2004

40. 12 September 2004 “The Explicit Guarantees relate to access, quality, financial protection and timeliness.”

41. What if a boy or girl is born with an operable congenital cardiopathy? What if a boy or girl is born with an operable malformation of the spinal cord? What if a woman needs preventive services for a premature birth? What if a girl or boy is born with a cleft lip and/or palate?

42. Government Program “ A good social protection system accompanies people throughout their life cycle, protecting their first steps, …”

43. “My goal, at the end of the Administration, is that we will have achieved the implementation of a child protection system aimed at leveling the development opportunities of Chilean children in the first eight years of life, independent of social origin, gender, geography or household structure. A task of this magnitude far exceeds the reach of traditional social policy approaches and will require a set of programs and instruments...” Constitution Ceremony of the Presidential Advisor for the Reform of Childhood Policies, 30 March 2006.

44. FAMILY PUBLIC SERVICE NETWORK AND COORDINATED PROGRAMS DEVELOPMENT AND SOCIAL INTEGRATION OF THE BOY/GIRL Comprehensive focus on social determinantsSocial Protection System for Childhood under development Link activities for support and social services, considering childhood to be the final subject of the intervention, including protection networks that favor the role and participation of the family. WHO definition of health BOY OR GIRL Simultaneous approach to the distinct areas of the life of the boy or girl and his/her family, understanding that each one represents a fundamental aspect: Identification, learning, health,family environment, living conditions, income and work.

45. The logic of the intervention The following matrices have been developed for each stage of the boy’s or girl’s life cycle: • Baby from gestation until 3 months. • From 3 months to 3 years. • From 4 to 5 years. • From 6 to 10+ years (4th of basic). The matrices have a logic of continuity: the boy/girl enters the System at the gestation stage and the System accompanies him/her from that moment throughout the different stages of the life cycle.

46. “The future of children is always today Proposals by the Presidential Advisor for the Reform of Childhood Policies”

47. “Chile grows with you” 13.10.06

48. System for the Protection of Childhood Chile Grows With You • Pregnancy control will mark the entrance of women into the public health system. • Automatic one-time family subsidy for the entire gestational period (R.N. Subsidy). • Pregnancy and delivery manual, organized by weeks of gestation. • Program for the integrated development of doctor’s visits (complement to prenatal and healthy child controls). • Humanized delivery care(AUGE 2007)