Abstract

The project ‘Learning from Promising Primary Care (PC) Practice Models for the USA’ seeks to identify and describe promising PC practice models and approaches that have relevance to application in the United States (US) and to inform policy and practitioner dialogues on models and measures that could be adapted or adopted in the USA. This report provides an overview of PC in the Chilean context, focusing on areas where the Chilean PC system is performing well, the challenges, opportunities and leverage points for improvement and considers new policy initiatives underway. The report is a narrative analysis, synthesising evidence of key features of PC practice in Chile from a desk review of published and grey literature and findings from 18 key informants, including central policymakers, local PC managers, frontline providers (physicians and others), community representatives, a representative of a PC professional association, and academics with first-hand knowledge and experience. Structured around the domains of the project’s conceptual framework for analysing PC, the report presents findings on the general and health system context, the PC model and process, the social roles, health outcomes and issues in management of change in the Chilean system. Chile is a South American country facing profound social and cultural challenges associated with rapid economic growth, societal changes and population aging. A combination of sustained economic growth in a freemarket economy, increasingly robust institutions and innovative social policies has yielded an upward spiral of developmental progress. Social and health policies in Chile emphasise fulfilling rights, with rights-based, social guarantees (including a minimum standards equity concept) and intersectoral approaches to integral social protection, such as Chile Solidario, focused on indigent families, and Chile Crece Contigo, an early child development system, whose entry point is PC. Nevertheless, continuing social inequities in Chile are profound, generating social discontent and fuelling social mobilisation and demands for more structural reforms. Changes in health risks associated with population aging and modern living, including environmental pollution, stress, social isolation, substance abuse and unhealthy behaviours, are reflected in Chile’s burden of disease. Non-communicable diseases (NCDs) account for 83% of total disability-adjusted lifeyears (DALYs). Injuries count for 12% and communicable, maternal, perinatal and nutritional diseases are only 4%. Chile’s early commitment to universal health coverage (UHC), independent of contributory capacity, has been consistent despite dramatic political changes. The dual legacy of a National Health Service (SNS) and a private health insurance market configured the current complex health system of public (FONASA) and private insurance (ISAPRES) and provision. Overlying it is a system of additional guarantees for priority health conditions (AUGE), established in the 2005 health reform. However, the Chilean health system is predominantly public (80% of the population is enrolled in FONASA, 90% in poorer regions of the country) and organised into 29 health services, responsible for coordinating territorial healthcare networks. The main entry point to the health system is the public PC system, covering almost 12 million FONASA affiliates (three-quarters of the population) with a network of PC facilities, including rural health outposts, developed over decades and reaching almost every corner of the country. It is mostly municipal and publically financed through capitation (70%) and activity-based special programmes for reinforcing PC capabilities to resolve specific health problems. The PC delivery model is based on interdisciplinary health teams working in PC centres to resolve 90% of health problems at this level, with referral to other levels of care. With a biopsychosocial family and community health model (MSF), it builds on the strengths of the maternalchild preventive care model. Until now there has been less emphasis on adult preventive programmes that move teams out of centres to work with communities and families to halt the growing prevalence of NCDs and related risk factors. This is partly due to increasingly complex medical demands from the accumulated burden of chronic disease that need to be resolved by the system, requiring a combination of robust clinical capacity, communication skills and community work. Primary care, however, has also had difficulty in attracting and retaining physicians and family medicine specialists, related to salary levels, perceptions of inadequate professional challenges, working conditions and prestige. Through AUGE, Chile has tried to provide additional guarantees for health priorities, largely delivered in PC. The guarantees have been extraordinarily positive for people whose conditions are covered. At the same time, meeting guarantees has also distorted the idea of integrated coverage for the entire population and created financial and administrative burdens. Nor did implementation adequately address critical structural PC constraints, such as underfinancing. The mainly curative focus of AUGE benefits is at odds with the PC family and community health model, but aligns with the demand from the health system and the population for more technology and specialised care. In recent years, increasingly hospital-centric and market-oriented policies have limited progression of the PC model. PC development has differed across municipalities, depending on local vision, resources and capacity. Nevertheless, the underlying strength and commitment of PC health teams has also led to a proliferation of ‘good practices’, although with little evaluation. The holistic approach to family and community health of MSF, defined as the road map for PC in Chile, encourages a strong social role for families and community organisations. Social participation goals are linked with results-based incentive mechanisms. Transforming discourse on participation into practice, however, has not been easy. Factors relating to the general political context (participation as consultative, power asymmetries, paternalism and lack of funding) and local problems (validity of representatives, authoritarian leadership and resistance to change on the part of health teams) constrain effective participation and development of social roles. At the national level, the Ministry of Health has a leadership role in developing a conceptual, legal, and management framework to produce and leverage substantive changes in the national health system. It sets national health objectives, providing the basis for planning and programming linked with management control and results-based budgeting. Commitment of PC workers is crucial. Specific collective workforce incentives and institutional controls are oriented towards achieving the system’s goals. In addition, change is informed by evidence from epidemiologic, social preference and cost verification studies. Universities and PC communities of practice, play pivotal roles in knowledge sharing and learning to generate and sustain PC transformation by engaging municipal directors, frontline providers and community leaders. Our findings indicate that the Chilean PC system is at a critical juncture in terms of the transition towards a transformative PC model. New policy proposals to reposition PC within the health system and the broader social protection system, including increased financing, incentives for family medicine specialists, doctors and specialists in training, closing gaps in electronic health records and integrated information systems, and a more integral chronic care model, are promising but may not be enough to redress structural deficiencies. Strengthened monitoring and evaluation of new interventions are crucial. Nevertheless, several models of Chilean PC practice are informative, including: multiprofessional family and community health teams; the biopychosocial model, based on intersectoral action on social determinants, whose maximum expression is Chile Crece Contigo; the AUGE health guarantees model; results-based budgeting and performance incentives linked to national health objectives; private university clinical excellence and family health practice; and an innovative public health equity agenda experience.