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HISTORY IS ALWAYS A WISE COUNSELLOR

HISTORY IS ALWAYS A WISE COUNSELLOR. HR never appears in a vacuum There is always something before We construct over the remainings of previous era Others will build upon ours many times we recycle knowledge and even architecture, like in Foro di Augusto. FORO DI AGUSTO, ROMA, 35 AC.

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HISTORY IS ALWAYS A WISE COUNSELLOR

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  1. HISTORY IS ALWAYS A WISE COUNSELLOR • HR never appears in a vacuum • There is always something before • We construct over the remainings of previous era • Others will build upon ours • many times we recycle knowledge and even architecture, like in Foro di Augusto

  2. FORO DI AGUSTO, ROMA, 35 AC

  3. SYSTEMS DEVELOPMENT • History overlaps succesive cycles:Power, culture, Values, Beleifs, Politics, etc. • Revolutions dont exist, changes are incremental and take long periods of time • Health Reform is a stage in which policy concentrates in certain aspects: health problems, systems organization. It varies • We never reinvent the wheel or gun powder

  4. HEALTH SYSTEMS COMPONENTS • Structured Pluralism (Londoño & Frenk):prevaling situation • Public services and Medical Care • Financing and Provision • Integrated or Split functions

  5. HR: central hypothesis • HEALTH REFORMS ARE THE CULMINATION OF AN INCREMENTAL PROCESS, RATHER THAN A RUPTURE WITH THE PAST • Jiménez and Bossert

  6. THE LATINAMERICAN HEALTH SYSTEMS MIX

  7. CHILE: Four reform periods • State responsibility: 1920-1930 • National Health Service: 1940-1960 • Decentralization and Privatiztion: 1980 • Strengthening of mixed system and Recovery of Public sector 1990 • Jimenez and Bossert, 1995

  8. CHILE: After Charity, the State takes responsibility(1918-1938) • Basic institutions established by law:Sanitary Code (1918), Social Security (1924), Preventive Medicine Law (1936), Mother and Child Law(1937). • Period of Reformist Goverment (1920-1930), but also.. • Right wing Socially Sensible Liberal Right wing Government (1932-1938)

  9. CHILE: After Charity, the State takes responsibility(1918-1938)2 • Period has two economic stages,initially growth (1915-1929), then crisis and recession(1930-1938) • Epidemioloy plays an important role via outbreaks of Murine Thyphus and Small pox.The rich under threat, react. • Debates in Parliament question: who pays??, who will execute the policy

  10. Cruz Coke, a catholic conservative physician,also biochemist and entrepreneur • He proposes a special “Preventive MedicineLaw” (1937) • Project, approved due to his brilliant mathematical calculations on cost-benefit of sick leave versus absenteeism • SCIENCE:another critical actor • He says: “Medicina Preventiva y Dirigida”

  11. SCIENCE: another critical actor • Scientifical method via epidemiological concerns and concepts, aided with primitive cost benfit approaches helped clever politicians to push their ideas to success • Concept of “Directed or Managed medicine”, appears for the first time in debate about health structure and administration

  12. ALLENDE: free mason, socialist, intuitive politician • Earthquake in south of Chile, 1939 • Sanitary services are all put together under single united rule • Observations after a year prove increases in production of services: medical visits, preventive interventions and others • Conclusion: Unification is Good, Reform the social security, create a single structure(1941)

  13. CHILE:APOTHEOSIS of Wellfare, NHS,1952 • 10 years of parliamentary debates to approve the reform. Several changes to arrive to the prevalent idea: Unify services • Model was the British NHS, but had many original ideas and strategies.Included only the poor,no employees • Unification of 20 separate services in only one structure. Dificult and complex operation that took four years to implement

  14. CHILE,NHS,1952 • Finance and Provision together: total vertical integration. Left out pensions • Money from taxes and social security premiums • Salaried doctors, complex negotiation, they were afraid of loosing liberal practice. • Initial opponents, after strong supporters (Medical paradox)

  15. CHILE, NHS 1952-1980 • After structure was established, important sanitary programs were put in place • Maternal: hospital and professionaly attended deliveries, family planning, pregnancy controls • Children: neonatal care, routine checkups, immunizations, diarrhea and infectious disease care

  16. CHILE: NHS impact after 50 years 1960 1990 2000 • Population (millions) 7,3 13,2 15,2 • Fertility (%) 3,5 2,3 1,7 • Life expectancy (ys) 58 72 74 • General mortality (p 1000)15,5 6,0 6,0 • Infant mortality (p 1000 LB)136 14,4 8,9 • Professional deliveries 62% 97% 99% • Children immunized 89% 97% 100%

  17. CHILE: health and dictatorship • Military coup overthrows socialist regime in1973. • NHS was under severe criticism from right wing and users due to bureaucratic excess • Junta adopts neoliberal market model ,1975 • Paralell reforms in health only in 1980, dificult consensus inside government

  18. A public service giant in adaptation to modern times: decentralization & market,1981 • Initial separation of financial and provision with creation of Health Fund (FONASA) and National Health Services System • Regionalization and Autonomy for 26 provincial health services • Primary Health Care to local governments • Privatization: optout to health insurance plans: ISAPRES.

  19. 1980-1990 an imperfect reform • Reform was initiated with mind in cost reduction more then actual perfectioning • Public system left with low salaries and no capital investement, time bombs. • Private insurance plans done in competition with all the defects of similars in US: cream skimming, moral hazard, no cost control (third party payments), etc • Decentralization mostly in paper, few training, few powers, reconcentration in Subsecretaria de salud

  20. CHILE:DEMOCRACY RESTORED 1990, what about health?? • Dichotomy again: neoliberals and statalists clash again inside the Basic Policy of new government: a mixed system, public and private sectors must live together and exchange services. • government, making the reformers/pragmatists life more difficult • Strong debates, fluxes and refluxes in 12 years of democratic life

  21. 1990-2005, some achievements • Public Health budget doubled • Productivity remains constant: criticism • Renovation of technology and infrastructure • Improved salaries for manpower • Purchaser Provider split, up-downs • New payment mechanisms: on the move • Public services autonmy: still on paper

  22. CHILE, some conclusions • In the Chilean case it’s clear that reforms are progresive, incremental and they go in hand with • Epidemiology, prevaliling diseases, infections, mother and child, transitional, order the policies • Economy, progress easy when growth, dificult when in recession • Political context ideologies and pragmatism overcross, some actors are active in defending interests

  23. Chile: the 2002 Reform • In Parliament from May 2002 to December 2004, 5 projects, 3 years: • 1.- Rights of Patients Charter • 2.- AUGE: Universal Access with Explicit Guarantees • 3.- Sanitary Authority and Health Management: Function split • 4.- Private Insurance of Health (ISAPRES) • 5.- Financement of the Reform • www.minsal.cl

  24. AUGE: the big thing • Priority setting according to burden of disease • Guarantees established by law in • Opportunity-Time for Access • Financial Protection • Effectiveness in technical solutions • Quality of care

  25. LIST OF DISEASES • 56 conditions in the Plan • Represent 75% of burden and 50% of discharges from hospitals • Evidence Based research of cost effectiveneess of each condition • Protocol promotes “Disease Management” • Evaluation is critical, but not in place.

  26. The Algorythm

  27. MEDICAL ASSOCIATION: NEGATIVE APPROACH

  28. Question for this Reform • Socialist Delirium ? Central planning of every detail • Neoliberal Abuse? More money for the rich and less for the poor • “The answer my friend is blowing in the wind”

  29. CONCLUSIONS • Final indicators for success in HR: Health outcomes and /or WHO 2000? • So far it’s clear that HR takes many years to be implemented, be it a up-dowm or a bottom up process. • Not all the variables go in the same direction, at the same speed, at the same time

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