Data updated for 2001

CHILE

GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

Chile has a surface area of 756,626 km2. The most recent census, conducted in 1992, showed the population to be 13,348,401, with an inter-census growth rate of 1.6%. The projected population in June 1996 was 14,418,864 of which 84.7% is urban. The country comprises 13 regions and 341 communes.

The gross domestic product (GDP) has grown steadily since 1960, with a significant rise in the past five years and an average annual growth rate of 7.4% in the 1990–1995 period and of 7.2 % in 1996. Per capita income, estimated at US$ 2,450 in 1990, increased to US$ 4,987 in 1996.

The 1992 census showed the literacy rate in the population over the age of 15 years at 91.2% and in 1995 it is estimated at 94.5%. The educational system comprises the primary (compulsory), secondary and higher levels. In 1995, of 3,533,047 students enrolled: 7.5% were in preschools, 62.3 % in primary schools, 20.9% in secondary schools, and 9.3% in higher learning institutions. These figures indicate enrollment rates of 95.7% at the primary level and 79.3% at the secondary level. The average amount of schooling in 1995 was 9.6 years.

According to the New National Employment Survey, the economically active population increased from 4,550,000 in 1988 to 5,500,000 during the four-month period from January to April 1996. Female participation in the labor force has increased slightly, from 31.8% in 1990 to 33.7% in 1996. The unemployment rate has decreased gradually over the past several years, dropping from 5.7% in 1990 to 4.7% in 1995. It rate was higher among women, 7.9% than among men, 5.6%. Real wages increased by 4.1% on average for most of the period. As for the structure of the labor force by sector of economic activity, the service sector employed the largest percentage of workers (25.2%), commerce (18.1%), and industry and manufacturing (16.2%).

The socioeconomic surveys (CASEN) conducted by the Ministry of Planning indicate that poverty has decreased, although rates varied from region to region. In 1984, it was estimated that 44.6% of the population were poor; 32.7% in 1992 and 25.0% in 1996.The distribution of poverty by sex shows the proportion of females slightly higher. The same was true for indigence.

In 1995, the birth rate was 19.7 per 1,000, while the fertility rate was 2.5 children per woman.

Mortality and Morbidity Profile

After a sharp decline, mortality has leveled off in recent years. In 1995, the rate was 5.5 per 1,000 population. In 1995, mortality among children aged 1 to 4 years was 0.6 per 1,000 population, maternal mortality was 0.3 per 10,000 live births, and mortality in the group aged 15 to 44 was 1.3 per 1,000 population. In the group aged 45 to 54, the mortality rate was 7.5 per 1,000 population, and among those aged 65 and over the rate was 51.4 per 1,000 population.

The leading causes of death in 1995 were diseases of the circulatory system, with an age specific mortality rate of 149.5 per 100,000 population, representing 27.8% of all deaths; malignant neoplasms, 115.7 and 20.7% of deaths; injuries and poisoning, 63.6 and 11.8% of deaths; diseases of the respiratory system, 61.2 and 11.4% of all deaths.

Life expectancy at birth in 1996 was 78.3 years for women, 72.3 for men, and 75.2 for both sexes.

There were sex differentials in the causes of death. Male mortality from injuries and poisoning was almost four times greater than female mortality; diseases of the digestive system was 1.6 times greater for males; conditions originating in the perinatal period 1.3 times greater; diseases of the central nervous system and sense organs 1.3 times greater. Female mortality is 3.2 times greater in diseases of the musculoskeletal system and 1.9 times greater for diseases of the skin and cellular and subcutaneous tissue. In 1995, enteritis, colitis, and pneumonia (ICD-7, A89, A104, A132) accounted for only 9.2% of all deaths (ICD-9, 008, 009, 480). In 1990 and 1995 no cases of measles were reported. In 1995 only 0.5% of deaths were attributed to tuberculosis (ICD-9, 010–012).

Mortality has decreased in all age groups, but the largest reductions have occurred among women and among children under the age of 5 years. In 1994 this age group accounted for only 5.4% of deaths. The decline in mortality rates in the group aged 55 and older has been comparatively small, where male mortality was 1.3 times greater than female mortality. Analysis of mortality by cause in 1995 reveals that the four most frequent causes of death were acute myocardial infarction (ICD-9, 410), 7.3% of total deaths; bronchopneumonia (ICD-9, 485), 5.9%; acute cerebrovascular disease (ICD-9, 436), 4.4%; and cirrhosis and other chronic liver diseases (ICD-9, 571), 4.2%.

In a Ministry of Health study of the burden of disease using disability-adjusted life years (DALYs), the five leading causes of death were: congenital anomalies 7.5 per 1,000 population, acute lower respiratory infections, 5.2; ischemic heart disease 4.9; hypertensive disease 4.4; cerebrovascular disease 4.2 per 1,000 population.

A total of 1.4 million hospitalizations were registered in both public and private institutions in 1996; most were for causes related to pregnancy, childbirth, and the puerperium. In 1995, the occupancy rate in public hospitals was 69.7, with an average hospital stay of 7.1 days and 33.7 discharges per bed. In private-sector establishments, a total of 371 thousand discharges were reported, with an average stay of 5.7 days, an occupancy rate of 57.5, and 32.1 discharges per bed.

The leading reason for outpatient consultations is high blood pressure. Diseases of the respiratory system account for the largest proportion of health service visits, 24 % and about 40% of all primary care level visits.

SPECIFIC HEALTH PROBLEMS

Analysis by Population Group

Infant mortality has shown a marked decline as a result of the sharp reduction in birth rates and high rates of prenatal care and professional care at childbirth. In 1995, 99.5% of births were attended by trained birth attendants and the infant mortality rate for that year was estimated at 11.1 per 1,000 live births. The neonatal mortality rate was 6.1 per 1,000 live births in 1995, the late infant mortality rate was 5.0 per 1,000, and the early neonatal rate was 4.5 per 1,000.

Better nationwide coverage of the Expanded Program on Immunization (EPI) and the cold chain resulted in fewer deaths from vaccine-preventable diseases in the past decade. The coverage of BCG vaccine in 1996 reached 98% of newborns. In the same year, the coverage with three doses of DTP (diphtheria, tetanus, and pertussis) was 94.2 % of newborns, and coverage with three doses of polio vaccine was 94.3 % of newborns. Mortality from diphtheria fell to 0 in 1992. The measles mortality rate decreased from 0.2 in 1989 to 0 in 1990, and subsequently, none have been reported.

A high-risk approach in obstetric and perinatal care has resulted in a steady decline in the percentage of low-birthweight infants, which fell from 5.7% in 1991 to 5.0 % in 1995.

Some improvement also has been noted in nutritional deficiency indicators among children under the age of 6 years with slight but sustained decreases in nutritional disorders, but with a slight increase in the prevalence of overweight.

In 1996, 60% of hospital discharges of children under the age of 2 years were associated with respiratory causes.

There is no nationwide outpatient consultations tracking system and data are available only for 1990. Medical visits by children under age 15 were comprised of acute respiratory infections, 57%; infectious and parasitic diseases, 18%; skin diseases; 9%.

In 1993 the principal cause of hospital discharge in the group aged 10 to 14 was injury and poisoning, 704.9 discharges per 100,000 population; diseases of the digestive system, 569.3 and diseases of the respiratory system 404.7. As for sex differentials, the most frequent causes associated with hospital discharge among males aged 10 to 14 were injuries, 956.0 per 100,000 discharges; diseases of the digestive system, 625.6. Among females in this age group, the most frequent causes were diseases of the digestive system, 511.4 and injury, 445.4.

The most frequent cause associated with hospital discharges in the group aged 15 to 19 years is childbirth, 2,272 per 100,000, followed by injuries and poisoning, 823.7. In this age group, addiction is a serious problem.

In a 1994, a survey estimated the prevalence of tobacco at 24% in the group aged 12 to 18; the prevalence of alcohol, 24%; tranquilizer use, 1.1%.

In 1994, mortality in the group aged 15 to 59 was 2.2 per 1,000 population; male mortality was double female mortality, with little variation in rates by region. Sex differentials were noted mainly for accidents and violence, 118 per 100,000 males versus 19 per 100,000 females. In diseases of the circulatory system, the rate for males was 43.8 and females 25.0. Mortality in the group aged 15 to 44 decreased slightly from 12.6% in 1984 to 11% in 1995, and the rate in the group aged 45 to 64 decreased to 7.6 per 100,000 persons in this age group. Mortality from infectious diseases decreased for both sexes from 3.6% of all deaths in 1984 to 2.7% in 1995; external causes, 12.4% in 1984 to 11.3% in 1995; diseases of the circulatory system, 28.4% in 1984 to 26.9% in 1995. The proportion of deaths due to malignant neoplasms increased from 16.6% in 1984 to 21.7% in 1995, endocrine and metabolic disorders, 2.3% in 1984 to 3.6% in 1995. Adults over the age of 60 make up 9.7% of the country’s population. Deaths in this age group in 1995 totaled 54,527, 69.4% of all deaths. In 1994 diseases of the circulatory system and malignant neoplasms together accounted for 57.1% of all deaths; respiratory diseases,13.5% and digestive diseases, 6.1%. With regard to hospital discharges, the rate in 1993 was 174.8 discharges per 1,000 population in the over-65 age group. The most frequent causes of hospitalization were diseases of the circulatory system followed by diseases of the respiratory, digestive, and genitourinary systems; injuries; and malignant neoplasms.

Results of the 1992 CASEN survey showed that 75% of the population over 65 years of age is covered by the public health care system, 11% by private physicians, 5% through private health insurance institutions (ISAPREs), and 4% by the Armed Forces health care system.

Maternal mortality increased to 30 per 100,000 live births in 1995 but appears to be leveling-off.

In 1993, domestic violence, physical or psychological abuse, was estimated for one of four women, regardless of socioeconomic level.

In 1993, an estimated 68% of the employed labor force had some of insurance covering occupational risks. Work-related health problems are substantially underreported to the National Health Services System (SNSS). However, most frequent claims were for diseases of the skin, hearing disorders, and musculoskeletal system diseases.

The 1992 census indicates that there were 283,888 persons or 2,1% of the population in Chile with a disability including total blindness, total deafness, muteness, paralysis, or mental impairment. The disability male/female ratio, was 1.2. The most frequent disabilities were was paralysis, 36%; mental impairment, 30%; deafness, 21%; blindness 14%; muteness 5%. Blindness is the only disability that is more frequent among females.

Available but incomplete epidemiological data show that communes with the largest concentrations of indigenous populations have less favorable health indicators than the rest of the country. The infant mortality rate in the period 1988–1992 varied among different indigenous groups: among the Aymará the rate was 40 per 1,000 live births; among the Atacameños, 57; among the Rapa Nui, 32; and among the Mapuche, 34. Health conditions among the indigenous population appear to have deteriorated more in urban areas than in rural ones.

Analysis by Type of Disease

Communicable Diseases

Triatoma infestans is present in Chile between parallels 18°30´ and 38°35´. The population exposed to Chagas’ disease numbers 500,000 persons, distributed among 43 communes. Based on serological studies, 19% of the population is seropositive. In the endemic areas, blood is regularly screened in about 76% of donors. In 1994, the incidence of the disease is estimated at 3.3 per 100,000 population.

Mortality from hydatidosis decreased from 0.5 per 100,000 population in 1981 to 0.2 in 1994 with 34 cases. In 1994 an incidence rate of 2.4 per 100,000 population was reported with 332 cases. The prevalence of hydatidosis in slaughterhouses has remained stable at about 10% of slaughtered animals.

There are no known cases of yellow fever. Eight cases of malaria were reported in 1994. No up-to-date studies exist on Aedes aegypti infestation in urban areas.

The incidence of diphtheria in 1995 was 0.01 per 100,000 (two cases). The rate has decreased slowly but steadily. Fewer than five deaths have been reported every year since 1987, and only 1 case and no diphtheria deaths have been reported since 1991.

Reported cases of whooping cough in the past five years have varied. In 1990, there were 59, with two deaths; in 1991, 61 cases and two deaths; in 1992, 264 cases and four deaths; in 1992, 59 cases and two deaths; in 1993, 517 cases; in 1994, 10 cases; and in 1995, 361 cases, with no deaths.

The last outbreak of measles was in 1988, 45,079 cases with a morbidity rate of 351 per 100,000. In 1989, there were 13,008 cases, but in 1990, cases fell to 1,958, with no deaths; 1991, 2,098 cases; 1992, 397 cases and two deaths; 1993, 2 cases, no deaths. From 1994 to 1996 no cases were reported.

No cases of poliomyelitis were reported during the 1976–1996 period.

Tetanus is under control with incidence rates of 0.1 per 100,000 population in 1994, 11 cases, no deaths. In 1994 1 of the 11 cases of tetanus was neonatal, but in 1995 no neonatal tetanus was reported.

The incidence of rubella has declined, with noncyclical outbreaks; the last occurred in 1988. The rate fell from 54.9 per 100,000 population in 1990 to 16.5 in 1994.

Since the outbreak of cholera in 1991 with 41 confirmed cases and a case fatality rate of 4.8%, the disease has been under control. The last reported case was in 1994.

The number of cases of typhoid and paratyphoid fever decreased by more than 50% between 1980 and 1990. In 1990 the incidence rate was 39.3 per 100,000 (5,172 cases). The reported death rate for that same period was 0.2 per 100,000. The cholera outbreak in 1991 led to the application of a series of control measures, which brought about a spectacular reduction in typhoid fever and hepatitis. In 1994, the hepatitis morbidity rate was the lowest in Chile’s history: 11.2 per 100,000 population (1,565 cases).

Hepatitis A is the most frequently reported sanitation-related enteric disease in the country. The incidence rate between 1980 and 1984 increased from 36.7 to 107.6 per 100,000, subsequently falling to 66.5 per 100,000 in 1990 (11,400 cases). Since the start of the cholera epidemic, the incidence of hepatitis A has declined from 66.6 in 1991 (8,909 cases) to 38.9 per 100,000 in 1992 (5,291 cases). However, in 1994 it increased to 90.8 per 100,000 population (12,732 cases). Hepatitis C, is estimated to have infected less than 1% of the Chilean population. Studies of blood banks in the country indicate antibody prevalence rates of between 0.2% and 0.35%.

Mortality from tuberculosis in 1994 was 2.8 per 100,000 population, but decreased by one-third compared to 1980, 12.2. The prevalence has also decreased from 55.0 per 100,000 in 1985 to 41.1 in 1991 and to 29.5 in 1994 (4,138 cases). In 1994, 6,636 persons were hospitalized for tuberculosis; 81 % had the pulmonary form. From 1989 through 1996, 40,000 cases and 3,800 deaths were reported. In 1994, new cases of tuberculosis totaled 3,646, 60% in males, and 4% of these new cases were in children under the age of 15. In 1994, 75% of cases were pulmonary tuberculosis (62% were smear-positive).

Leprosy cases exist only in Easter Island. No new cases were reported between 1984 and 1993, and six new cases were reported between 1994 and 1996.

Acute respiratory infections were the third leading cause of death in the general population in 1990 and the second leading cause in 1994 (5.2% of total deaths). Among children under 1 year of age, acute respiratory infections accounted for 9.3% of all deaths in 1994. Bronchopneumonia is associated with 9.4% of all discharges in all age groups. Respiratory infections are responsible for between 40% and 50% of all such visits. Among children under 2, respiratory infections are associated with 60% of hospital discharges. Discharge rates for respiratory infections among children under the age of 15 were 2,000 per 100,000 discharges and among adults over the age of 60, 4,000 per 100,000 discharges.

In 1996, one case of human rabies occurred in a child bitten by a vampire bat.

As of March 1996, 1,456 cases of AIDS, males 92% and females, 8%, 909 deaths, and 2,203 carriers of the human immunodeficiency virus (HIV) had been reported. The male/female ratio was 10:1 for the 1992–1996 period, down from 15:1 reported in 1984–1991. As of 31 December 1994, Chile had a cumulative rate of 8.8 cases per 100,000 population. Sixty percent of cases acquired through contact with infected blood are associated with intravenous drug use. Surveillance data indicates that among STD patients monitored from 1992, the prevalence of HIV-positive individuals has remained stable (1% in 1992, 1% in 1993, and 0.7% in 1994). Prevalence of HIV infection observed among pregnant women increased for all sentinel centers, with the rate rising from 0% in 1992 to 0.05% in 1993 and 0.1% in 1994. Systematic screening of blood donors begun in 1987 indicates a slow but steady increase in HIV prevalence. In 1994 the most frequently reported STDs in Chile were syphilis, 33.5 per 100,000 population; gonorrhea 26.1; and nongonococcal urethritis, 5.9. Rates of syphilis have changed little in recent years, following a period of decline that ended in 1989. In 1994 a total of 4,705 cases were reported, with an incidence of 33.5 per 100,000 population. The incidence of gonorrhea has decreased in recent years, from a rate of 114 cases per 100,000 population in 1981 to 26.1 in 1994.

The incidence of meningitis caused by Neisseria meningitidis has increased slightly in recent years, especially in the country’s northern region. The rate increased from 0.6 per 100,000 population in 1971 to 3.4 per 100,000 in 1995. The disease affects mainly children under the age of 5 (55% of all cases). Children aged 0 to 9 years account for 70% of all cases.

In 1995 and 1996, two and three cases, respectively, of laboratory-confirmed Hantavirus infection were reported in southern Chile. Three were fatal. In 1995, two cases of hemolytic-uremic syndrome were reported after consumption of meat contaminated with enterohemorrhagic Escherichia coli.

Noncommunicable Diseases and Other Health-Related Problems

The incidence of child malnutrition, as measured by weight-for-age, was 15% in 1975 and 5% in 1993. Integrated nutritional assessments show that 74.4% of children under 6 are classified as normal. Among pregnant women, the prevalence of underweight decreased from 26% in 1987 to 17 % in 1996, and the proportion of overweight increased to 46% in 1994. The most recent available study of nutritional status in the child population shows that 3.1% of children are at risk of malnutrition and 0.7% are malnourished. Children with normal nutritional status are 74%, while 22% are overweight or obese.

The incidence of anemia, according to studies by the Food Technology and Nutrition Institute (INTA), is 20% among children aged 6 to 24 months and 20% among pregnant women. Although 97% of salt is iodized, studies of localized school populations in 1995 found a 9% prevalence of goiter.

Studies by the National Breast-Feeding Commission, created by the Ministry of Health to promote breast-feeding, reveal that 87% of children are breast-fed during the first month of life. By the fourth month, the percentage drops to 59%, and by the sixth month, to 25%. Other studies in pediatric care services found that 57.1% of the population surveyed was exclusively breast-fed at 120 days of age.

Based on various studies, obesity among females is estimated from 23% to 25%, while males obesity ranges from 13% to 18%. Differences occur between men and women in different socioeconomic strata; for example, obesity is more frequent among females in lower socioeconomic strata and among males at higher socioeconomic levels.

The prevalence of diabetes ranges from 3.0% to 5.6%, according to studies and is the primary or associated cause in a rising number of hospital admissions. In 1990, 11,650 patients were hospitalized for diabetes mellitus, a rate of 8.8 per 10,000 population and 35.8 in the group aged 45 and over.

For the past several years, cardiovascular diseases has accounted for the largest proportion of mortality among Chileans, especially adults. More than one-fourth of all deaths are caused by cardiovascular diseases 20,922 in 1994, or 27.7% of all deaths that year, with a specific rate of 149.5 per 100,000 population. Within this group, ischemic heart disease, hypertensive disease, and cerebrovascular disease occur most frequently. According to information on hospitalized patients, cardiovascular diseases generated a hospitalization rate of 5.2 per 1,000 population in the general population in 1991, a 35% increase with respect to 1975. Ischemic heart disease (ICD-9, 410–414) accounts for the largest percentage of deaths. Myocardial infarction (ICD-9, 410) alone accounts for 25.9% of all deaths attributed to this group of causes.

The mortality trend of malignant neoplasms has been upward over the past decade. In 1980 the rate of malignant neoplasms was 101.6 per 100,000. In 1995, malignant neoplasms were the second leading cause of death in the country, accounting for 16,429 deaths (20.7%). The five most frequent cancer sites are the stomach (16.7%); trachea, bronchus, and lung (10.4%); gallbladder and bile ducts (10%); prostate (6.4%); breast (5.7%); and uterine cervix (4.5%).

In 1994, 10,293 cases of cancer were reported, 73.4 per 100,000 population. The most frequent cancer sites in females were the cervix, 25.6%, breast, 15.8%, and skin 8.7%. Among males, the most frequent cancer sites were stomach, 20.5%, prostate,12.2%, and lung 10.1%. The male/female case ratio is 0.68.

In 1991 the mortality rate from injuries, poisoning, and violence was 69.1 per 100,000 population, and in 1994 it was 63.6. Accidents and violence have become increasingly prominent as causes of both mortality and morbidity. Persons under the age of 65 accounted for 84.8% of all deaths from this group of causes (compared with 44.5% for other causes) and persons under the age of 15 accounted for 16.5%. Thirty-eight percent of the deaths from this group of causes are due to accidents of all types; of these, almost one-fourth are motor vehicle accidents.

According to police records, the number of persons injured or killed annually in traffic accidents increased between 1980 and 1995 from 25,176 to 41,582, an average rise of 9.4% per year. The number of deaths went up from 1,191 to 1,747 over the same period, a 7.4% yearly increase. In 1996, police statistics show 1,925 traffic accident fatalities and 60,093 accidents.

The prevalence of mental health problems has increased substantially in recent years. Several studies—most of them of small groups, specific groups, or both—provide indirect indicators. Of the medical leave certificates issued by the National Health Fund, 5.6% were for neuroses.

Alcoholism is more frequent among males and among persons who are unemployed or irregularly employed. It is the eighth leading cause of disability adjusted life years (DALY: 53,498, with 3.0%). Alcoholism is associated with 38% of hospital discharges. It is the primary cause reported in 4.5 % of hospital discharges and in 7% of deaths, and it is an associated cause in 25% of deaths. Alcohol use is a factor in 48.6% of homicides, 38.6% of suicides, and 50% of traffic accidents.

Specific mortality from cirrhosis of the liver was 20.8 per 100,000 population in 1994, one of the highest rates in the Region. Liver disease remains an important cause of death, especially cirrhosis, which is responsible for a significant proportion of alcohol- and tobacco-related mortality. The death rates from cirrhosis were 27.4 per 100,000 population in 1989, 28.5 in 1990, and 20.8 in 1994.

According to a drug addiction survey, among individuals aged 12 to 64 surveyed, the lifetime prevalence of illicit drug use was 13.4%. The rate was 20.6% for males and 7.1% for females.

According to 1994 survey data, the prevalence of tobacco use is 38% in the male population and 25% in the female population. A slight decrease in prevalence has been noted among males, 47% to 44%, and the prevalence among females has increased from 36% to 41%.

The estimated prevalence of dental caries in the population exceeds 90%. Thirty-four percent of preschool children have dental caries. Another problem is gingivitis, the prevalence of which is estimated at 37.7% in the population aged 6 to 12, and the rate increases with age.

Chile is exposed to earthquakes, landslides, and floods, which have affected the population in the past decade. In 1996, a drought affected at least four regions of the country, including the metropolitan region and agricultural sector. Water reservoirs used to generate electricity as well as the drinking supply were affected. Subsequently, there was excessive rainfall, which produced a state of emergency especially in the northern part of the country where no drainage infrastructure exists to deal with such a situation. Many families with limited resources lost their homes or possessions, and several deaths occurred

In 1992, the city of Antofagasta was flooded affecting the water storage reservoirs serving a large segment of the city. In 1993, a similar phenomenon affected the Macul gorge area in the Santiago metropolitan region. A mass of mud and rocks claimed more than 100 victims.

The last earthquake, one of medium intensity, occurred in 1996 and affected Chile’s central area.

Industrial accidents are a recent phenomenon resulting in the creation of disaster response activities.

RESPONSE OF THE HEALTH SYSTEM

National health Plan and Policies

Under the Constitution of 1980, health is considered a basic human right and it is the State’s duty to ensure that all citizens are able to exercise their right to protect their health and to live in an unpolluted environment. The Constitution recognizes a person’s right to choose whether to receive care in the public or the private health care system. The function of the Ministry of Health is to ensure free and equal access to services for the promotion, protection, and recovery of health as well as rehabilitation services following illness. The Ministry also is responsible for coordinating, overseeing, and, where appropriate, executing activities in these areas.

Organization of the Health Sector

The unified public health care system of 1952, which provided coverage for the entire population has changed substantially since 1980, particularly in establishing the ISAPREs and in transferring responsibility for management of primary health care establishments to the municipal level. These changes have been accompanied by decentralization of the management of the 28 regional health services as of early 1997.

The public subsector comprises agencies that make up SNSS: the Ministry of Health, the 28 regional health services, the National Health Fund (FONASA), the Public Health Institute, the Central Supply Clearinghouse, and the ISAPRE Authority. All of them have been decentralized. The sector also includes governmental institutions and enterprises that provide health care for their personnel. In each region, the Ministry of Health is represented by a regional secretariat. The 28 health services and the Metropolitan Environmental Health Service provide medical attention and health care services for the population in a specific geographic area. Public sector health care personnel include 68,400 SNSS employees and 16,500 primary health care providers at the municipal level.

Health sector reforms have required extensive changes in legislation. The principal legal reforms under consideration are the draft law on professional remuneration and incentives; a series of proposed laws advancing decentralization efforts; a new law regulating the working conditions and compensation of physicians, dentists, and pharmacists; and draft legislation on bioethical issues. Major legislative matters remaining include environmental legislation to clearly define the role of the health sector in environmental issues and expansion of the scope of law governing production and marketing of drugs.

To date no viable proposals have been advanced for health legislation to respond to present and future needs associated with regional integration.

The legal framework for the process of health service decentralization is provided by the reforms of 1980. The population is covered by 28 regional health services, which enjoy autonomy of action, financing, and budgeting. These services form the core of the Chilean health system. Responsibility for primary health care is delegated to the municipios, which coordinate with regional services. The regional as well as municipal health services have financial autonomy and are financed by either FONASA or ISAPRE, to whom they sell services. One of the fundamental aspects of health reform is separation of institutional functions. The Ministry of Health, historically the provider of basic health services in the country, has progressively adopted a governing and regulatory role; FONASA performs insurance and financial functions; and the regional health entities are responsible for providing service.

In the private sector, health insurance is provided by the 21 open ISAPREs and 15 restricted ISAPREs operating around the country. Some ISAPREs have their own outpatient primary care services, but they generally do not provide hospital care. Of the 35.3% of the population that receives care in the private sector, 23.7% are covered by ISAPREs, 2.7% by the Armed Forces health care system, 0.9% by other systems, and 8.0 % cover their own health care expenses.

In 1995 a total of 1.4 million patients were discharged from inpatient care facilities in the country. SNSS registered 1,064,000 discharges, with 33.7 discharges per bed. In the private sector, the proportion was 32.1 discharges per bed. In 1996, the SNSS had 116.2 discharges per 1,000 beneficiaries; the open ISAPREs, 86.4; and the restricted ISAPREs, 139.8. The hospitalization rate (the discharge/consultation ratio) was 4.6% in the SNSS, 2.5% in the restricted ISAPREs, and 2.8% in the open ISAPREs.

Construction of new private health care facilities is regulated by the General Construction and Building Ordinance. Construction of health care establishments is authorized by the regional health services.

In 1981 the 1948 law on professional associations, which made the College of Physicians responsible for ethical oversight of the profession, eliminated mandatory physician membership in the College. This has had serious ethical ramifications, as well as consequences for the control over the practice of medicine, because an estimated 20% to 30% of practicing physicians are not members of the College. Currently there are four proposed laws before the National Congress that seek to correct this situation.

The Chilean drug market generates close to US$ 400 million annually. About half the drugs sold are produced in national laboratories and the other half are imported. Under legislation of March 1997, drug registration falls under the responsibility of the Public Health Institute. Inspections are carried out by the regional health services, and tests and analyses conducted by the Public Health Institute.

Health Services and Resources

The environmental regulatory system was strengthened through the enactment in 1994 of the Basic Law on the Environment and the adoption in April 1997 of regulations for environmental impact assessment in development projects. This system has made it possible to disseminate daily information on levels of pollution in the capital and to declare environmental alerts and emergencies as necessary. The National Commission on the Environment is updating regulations on water use. The Public Health Institute has responsibility for controlling the quality of foods, but the Ministry of Health through the regional health services, authorizes the marketing of foods, monitors food-handling practices, and inspects the sanitary conditions in food establishments. A network of public health laboratories carries out analysis of food samples.

Chile has organized development councils at the level of primary care services and establishments and in hospitals. In 1995, 40 development councils were operating, and by late 1996 the number had increased to 111.

Municipally administered primary care services and the regional health services carry out disease prevention and control activities. More than 95% immunization coverage, 99.5% attended births, and infant mortality of 12.0 per 1,000 live births illustrate the results of these activities.

The regional health services carry out epidemiological surveillance of communicable diseases through various intervention strategies to control and monitor outbreaks.

The national network of public health laboratories is coordinated and controlled by the Public Health Institute through the Program for External Evaluation of Clinical Laboratory Quality (PEEC), which includes eight clinical laboratory sections: clinical chemistry, hematology, parasitology, syphilis serology, bacteriology, immunology, virology, and mycobacteria. In March 1997 a total of 886 clinical laboratories were affiliated: 201 public; 77 municipal; 56 within the health systems of the Armed Forces, universities, or religious entities; and 552 private laboratories. In addition to these laboratories, there are 128 blood banks, 75 public and 53 private. All blood banks are required to screen for HIV, hepatitis B, syphilis, and, in endemic zones, Chagas’ disease.

Ninety-eight percent of the urban population and 67.3% of the rural population has access to safe drinking water. The coverage of sewerage systems is 84.7% in urban areas, although 97 %
of wastewater is disposed of in waterways without prior treatment.

One hundred percent of the population that has drinking water service receives chlorinated water.

Solid waste collection coverage is 98% in urban areas; 74.2 % of the waste collected is disposed of in sanitary landfills. Of the industrial waste generated in 1995 in the metropolitan region, 3.0% was classified as hazardous.

Since the 1920s, Chile has been carrying out supplementary feeding activities through the National Supplementary Feeding Program, which in 1994, accounted for 9.1% of total public spending on health.

The health care establishments affiliated with the regional health services are organized in a network. The municipally administered primary care services are linked to the regional services which coordinate activities through their primary care division, program division, or integrated care divisions.

In 1995, the public health system included 187 hospitals, 15 urban outpatient clinics administered by the SNSS, 215 municipally administered urban outpatient clinics, 146 rural outpatient clinics, and 1,102 rural health posts (without a permanent staff physician). Of the hospitals, 20 (11,855 beds) are high-complexity institutions; 30 are type-2 hospitals, or hospitals with several specialized departments (8,019 beds); 23 are type-3 hospitals, or hospitals that provide care in several basic specialties (4,114 beds); and 105 are operated by general practitioners (5,332 beds).

A network of emergency and prehospital care units operates within several health services in the Santiago metropolitan region, Valparaíso, and Viña del Mar. The prehospital care services are staffed by auxiliary personnel in some cases and by a physician.

In 1996, the Public Health Institute reported that the country had 128 blood banks, 58.5% public and 41.4% private.

In 1994, SNSS had 37 psychiatric establishments with 1,334 beds. The National Mental Health Plan, a comprehensive normative effort, is currently being implemented with the support of multidisciplinary units in the 28 regional health services. Mental health units in these services are concerned mainly with promotion and prevention activities and with the identification of problems that require urgent attention.

Since 1990 the country has had an oral health program oriented toward health promotion and prevention of oral health problems. Thirty-eight percent of the population receives fluoridated water. In regions with no fluoridated water rinses are applied to approximately 900,000 of 2 million schoolchildren. In addition, an oral health education program is carried out jointly by the Ministry of Education and the municipios, which monitor decayed, missing, filled teeth and fluorosis problems.

Inputs for Health

Under legislation of March 1997, the Public Health Institute is responsible for registration and quality control of drugs, foods for medicinal use, cosmetics, and pesticides used for health and domestic purposes. The Public Health Institute also is responsible for the control, authorization, and inspection of establishments that manufacture pharmaceutical products, cosmetics, and pesticides throughout the country. Inspection of warehouses, drugstores, and distributors of these products is carried out by the regional health services. The Public Health Institute does testing and analysis.

Chile’s Public Health Institute is the official producer of biologicals. Production is sufficient to meet domestic demand. The Public Health Institute also produces purified protein derivative (PPD) for detection of tuberculosis, Rotagel for diagnosis of rotavirus, and standard antigen for diagnosis of rabies. Other vaccines are imported and the Public Health Institute is responsible for quality control.

A recently modified law regulates quality control activities for a series of products with a view to ensuring their safety and efficacy. Among the products subject to inspection are instruments, equipment, diagnostic reagents, and articles or elements used in the prevention, diagnosis, and treatment of human diseases, as well as prostheses used for anatomical replacement or modification.

Of the 13,857 physicians practicing in the country in 1966, 66.2% worked in the public sector and 7,831 were affiliated with SNSS; 11.7% of them practiced at the municipal level. Of the 5,817 dentists, 26.1% worked in the public sector and 8.8% at the municipal level. In 1996 the country had 0.54 physicians per 10001, 0.07 dentists, 0.22 nurses, 0.14 midwives, and 1.54 auxiliary personnel per 1,000 population.

Public and private universities throughout the country offer undergraduate training programs for health personnel. As of December 1995, CONACEM had certified 5,127 medical specialists; the majority was in the fields of pediatrics (735), internal medicine (683), general surgery (561), and obstetrics and gynecology (506). The University of Chile and the Catholic University train about 94% of the specialists who graduate from university programs.

Continuing education is also a requirement for those employed by the municipal government. The health services are responsible for approving and supervising the annual training programs developed by each municipal government.

In 1996 a study on the job market for health professionals revealed that the country has sufficient numbers of medical professionals, except in some specialties such as anesthesiology, procedure-related specialties, oncology, and child neuropsychiatry. The country has an insufficient supply of nurses, and most of these professionals are concentrated in the metropolitan region. Of the 5,817 practicing dentists, about 65% work in the metropolitan region, 30% in the SNSS; of these, 45% are specialists.

Research and development in Chile increased ninefold in real terms between 1965 and 1993, although this sector of activity continues to account for only 0.75% of the GDP. Of the resources distributed by the National Board for the Development of Science and Technology (FONDECYT), the principal official source of funding in the area of technology, 13.4% went to the health sciences. In the area of health, two national institutions receive a large share of this funding, University of Chile (Santiago) and the Catholic University of Chile (Santiago).

In 1997, 75 regular publications were identified in the area of health. The Ministry of Health/PAHO Documentation Center registers close to 800 titles of this type each year.

Total spending on health in 1997 was estimated at US$ 3,600 million, of which the public subsector accounted for US$ 2,020 million. Total spending as a proportion of GDP for that year was estimated at 5.0%, of which 2.1% was private. Of the public spending, 10.2% was direct expenditures by municipal governments. In the past five years the proportion of the GDP devoted to health grew by 15.1%. The public component increased 5.7% during the period, while the private component increased by 36.5%. In 1994, tax revenues financed 46.8% of public spending on health and the remainder was financed by the 7% withholding on workers’ earnings. In 1995 SNSS spent a total of US$ 183 per beneficiary on preventive services, while in the private sector, the amount spent was US$ 213 for ISAPREs and US$ 432 for ISAPREs. Of the total institutional spending in the public subsector, 12% was for primary care.

FONASA spent 33.6% of its resources on inpatient care, 19.3 % on diagnostic examinations, 17.1% on outpatient care, 13.9 % on surgical procedures, 5.03% on gynecology and obstetrics procedures, 4.8% on oral health care, 1.3% hemodialysis and other benefits, 0.82% on specific protection activities, and 2.3% on environmental activities. In the ISAPRE subsystem, 46.15% of the resources were spent on outpatient care and related diagnostic services, 48.3% for medical programs, including hospital care, 2.2% on dental care and 0.35% on preventive activities.

The public health budget in 1997 was funded by worker contributions, 33%, fiscal revenues, 48%, operating income, 8%, other income, 9%, and borrowing, 2%. Of the public resources for health, 10.2% came from municipal fiscal revenues. In 1996 investment in the sector totaled US$ 112 million, which represented 6.3% of total public spending in the sector.

In Chile financial cooperation is less important than the joint activities made possible by cooperative projects. Chile participates in a significant amount of cooperation among countries, especially with countries of Central America and the Caribbean, as is the case with Nicaragua and Haiti.

From 1994 through 1995, Chile received extrasectoral resources in the form of loans from the World Bank. Loan for hospital rehabilitation and upgrading projects were US$ 3.3 million; emergency units in the metropolitan region, US$ 23.9 million; institutional development projects, US$ 3.5 million; and investment in eight regional health services, US$ 86.5 million. The Inter-American Development Bank (IDB) extended a loan of US$ 70 million for a project to improve the physical and functional efficiency of the regional services. The Government of Germany granted a loan of US$ 31.75 million for hospital restoration.

As for bilateral cooperation from 1994 through 1995, Chile received US$ 894,000 from Germany for a project in the field of rehabilitation; US$ 10.8 million from the United States for primary care in needy communities; US$ 348,000 from the Kingdom of the Netherlands for AIDS prevention; US$ 10.34 million from Italy for health care in socially high-risk areas; US$ 42,000 from France for AIDS control efforts; US$ 700,000 from Japan for the development of health care units at the secondary level; and US$ 416,000 from Sweden, also for AIDS control. With regard to multilateral cooperation, the European Union provided US$ 986,440 for the prevention of drug addiction.

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