Pan American Health Organization

Chile

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Outlook
  • References
  • Full Article
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Overall Context

Flag of ChileChile is located at the extreme southwest of South America, and shares borders with Argentina, Bolivia, and Peru. Its mainland territory is long (4,329 km) and narrow (average width 177 km), and the total area of its combined mainland and island territories is 756,626 km2, plus Chile’s Antarctic territory of 1,250,000 km2. The country has a rugged and mountainous topography and is vulnerable to natural disasters, such as earthquakes and tsunamis. Chile is a unitary republic with a stable democratic political system, in which the State has three independent branches: executive, legislative, and judicial. The capital is Santiago, and the country’s political-administrative divisions comprise 15 regions, 54 provinces, and 346 communes.

Demographics

Located in southwestern South America, Chile has a population of 17.8 million (2014), of whom 50.5% are women. Life expectancy at birth is 80 years for men and 85 years for women (2014). The national territory includes 15 regions, subdivided into 54 provinces and 346 communes. Most of the population (87%) lives in urban areas, with 40% concentrated in the Santiago Metropolitan Region. Figure 1 shows Chile’s population structure in 1990 and 2015.

Figure 1. Population structure, by age and sex, Chile, 1990 y 2015

Between 1991 and 2015, Chile’s population increased by 36.6%. In 1990, the population distribution showed an expansive trend in the over-25 age groups, with the younger age groups remaining stable. By 2015, the structure had become regressive due to reduced fertility and mortality rates associated with an aging population and greater life expectancy at birth.

Source: Pan American Health Organization, based on data from the UN Department of Economic and Social Affairs. Population Division. 2015 Revision. New York; 2015.

The Economy

Between 1961 and 2014, gross domestic product (GDP) increased by an annual average of 4.3%. During that period the country saw gradual development economically, socially, and with regard to health. Since 2013, the World Bank has classified the Chilean economy as high-income; the per capita gross national income (GNI) in 2014 was US$ 21,290 (PPP). In tandem with economic growth, mean years of schooling also increased, reaching 10.8 years in 2013, though with marked differences between urban and rural areas, as well as between different income quintiles.

The country is close to achieving universal coverage of drinking water and sanitation services in both urban and rural areas. In 2014, 99.9% of households had access to drinking water, 96.7% had access to sanitation services, and there was 99.9% coverage of wastewater treatment in urban areas. Along with increased coverage, there have been improvements in the quality of water and sanitation services. Chile is the only country in the world that has privatized water supply services ().

Leading Environmental Problems

Chile is vulnerable to a wide range of severe natural disasters. Over the last two decades, natural disasters are estimated to have cost the Chilean national treasury more than US$ 200 million per year in disaster relief actions to assist more than 350,000 victims.

Although structural vulnerability to earthquakes is low, due to earthquake-resistant construction governed by a strict building code, until 2010 the country had no systemic regulations concerning disaster risk management. Following the 2010 earthquake, at the request of the Chilean government, the Secretariat of the United Nations International Strategy for Disaster Reduction (UNISDR) conducted a diagnostic assessment that led, in 2014, to the creation, by Chile’s National Office for Emergency, of the country’s National Policy for Disaster Risk Management. As a result, during the September 2015 earthquake (8.4 on the Richter scale) and subsequent tsunami (affecting primarily the regions of Coquimbo, Valparaiso, and the Santiago Metropolitan Region), early warning systems and evacuation planning helped minimize the number of victims and the amount of damage.

Social Determinants of Health

According to the CASEN 2015 survey, Chileans living in non-extreme poverty, as measured by income, constituted 8.1% of the population, while 3.5% were living in extreme poverty. In comparison, the 2011 figures were 14.1% and 8.1%, respectively (Figure 2). Between 2003 and 2014, the average income of the poorest 40% of the population increased by 4.9%, while the income of the overall population increased by 3.3%. The Gini inequality coefficient has remained around 0.55 during the last few decades. The 10/10 ratio increased from 30.5 to 35.4 between 1990 and 2013, taking account only of autonomous income (i.e., not including taxes and transfers), though these figures decrease-from 27.1 to 21.7-if social transfers and taxes are included (Figure 3) ().

Figure 2. Persons living in poverty (%), by indigenous group, by urban or rural residence, and by sex, Chile, 2006 to 2015

Figure 3. Distribution of autonomous income* in households, according to household’s decile of per capita autonomous income

Source: Ministerio de Desarrollo Social, Encuesta Casen 2015. observatorio.ministeriodesarrollosocial.gob.cl/casen-multidimensional/casen/docs/CASEN_2015_Ingresos_de_los_hogares.pdf.
*Autonomous income: sum of all payments received by all household members, excluding live-in domestic servants, from both work and ownership of assets.

Vulnerable Populations

Despite the socioeconomic progress described above, inequality continues to be one of the country’s greatest problems. There have been major improvements in living and health conditions, but significant differences between socioeconomic groups persist (). Social inequalities are reflected in unequal access to, and unequal use of, health care services, with consequences for the health of the population. Infant mortality among children of mothers with less than 3 years of schooling is 3.4 times higher than among children whose mothers have more than 13 years of schooling.

Women’s participation in the labor market increased from 35% in 2000 to 47.7% in 2013. Nevertheless, the full incorporation of women in the workforce, with high-quality jobs and in nontraditional functions, has yet to be achieved. Moreover, the wages women and men receive for performing the same work are unequal, particularly in the lower income quintiles. While the participation of indigenous women in the workforce is comparable to that of nonindigenous women, there is a gap in income between the two groups, with the income of indigenous women being 28% lower than that of nonindigenous women. Law 20.786, which entered into effect in October 2014, changed the rules pertaining to domestic work, which is performed primarily by women. The law regulates the length of the workday, work breaks, and remuneration for domestic workers, and is expected to have a positive effect on their quality of life.

Studies conducted in regions of the country with the highest proportion of indigenous population indicate a higher degree of preventable morbidity in the indigenous population than in the nonindigenous population. The prevalence of tuberculosis, for example, is higher in the indigenous populations of the Arica-Parinacota, Tarapacá, and Los Lagos regions. Moreover, Mapuche children in the Araucanía region have a 250% greater risk of dying in their first year of life than do non-Mapuche children. These inequalities also are seen in access to health care.

With regard to the sexual and reproductive rights of women, all forms of abortion are prohibited in Chile, regardless of the cause. Nonetheless, in 2016 the National Congress agreed to discuss the therapeutic abortion law in Parliament, a debate that took place in July 2017.

The Health System

Chile has a mixed public-private health care system that includes public insurance through the National Health Fund (FONASA), insurance provided by private insurers (known as ISAPREs), and other special insurance schemes, such as those tailored to the Armed Forces. The system is responsible for collecting and pooling funds, as well as for purchasing equipment and supplies. Both public and private providers are responsible for the delivery of health services. Formal workers are required to contribute 7% of their pay to one of the funds, and in 2018 this requirement will also be applied to all self-employed workers who issue receipts for fees paid to them. The health system also receives funding from general taxes to cover the health care needs of those who are unable to pay.

Governance and regulation are overseen by the Ministry of Health, which establishes the regulatory framework. The universal provision of public health services is handled by the health authorities, which include the regional ministerial secretariats of health, the Institute of Public Health, the Ministry of Health, and the Superintendency of Health, all of which are financed by general taxes. The system provides essential public health services and other interventions, such as immunization and the supplementary food program. The National System of Health Services (SNSS) coordinates the functions of public sector providers, comprising 29 decentralized service providers across the country’s 15 regions, along with the primary health care system, which operates principally at the municipal level.

At present, the health system is fragmented with respect to both financing and delivery of services, with unequal availability of resources for serving populations dependent on different sectors within the system. Out-of-pocket health spending represents 38% of total health expenditure, and primarily affects lower-income families. In 2013, 76.3% of Chileans belonged to FONASA, while 8.2% were members of an ISAPRE. The remainder of the population either belonged to the Armed Forces health system (nearly 3%) or had no insurance. An estimated 5% of family income is devoted to health spending, a figure that is on the increase, and an estimated 4% of families are faced with catastrophic expenditures (threshold: 30%) that puts them at risk of impoverishment ().

The public and private systems operate differently: the former is focused on primary health care, including promotion, prevention, and treatment services (medical, dental, and nursing) at the local level, with referrals to secondary and tertiary care. Private sector services, on the other hand, are focused on specialized secondary services and tertiary services.

Leading Health Challenges

Critical Health Problems

Economic development and the gradual increase of health care coverage in recent decades have succeeded in reducing communicable, nutritional, maternal, and childhood diseases. Better hygiene and sanitation, universal coverage of hospital deliveries, establishment of outpatient care facilities for children with acute respiratory infections and for adults with respiratory diseases, along with traditional programs for nutritional assistance and prevention and control of communicable diseases, have improved the indicators associated with these health problems.

These factors, along with demographic, economic, and cultural changes, have highlighted the increasing importance of noncommunicable diseases (NCDs) and mental health disorders as causes of death and years of healthy life lost (YHLL). In 2012, cerebrovascular disease, ischemic heart disease, and cirrhosis were the leading causes of death in the general population. That year, dementia ranked as the fifth leading cause of death. In terms of YHLL, NCDs represented 82% of the disease burden in 2013 as measured by this indicator-19% higher than in 1990, an increase attributable primarily to the aging of the population. Injuries and violence accounted for 11% of the disease burden, while maternal, neonatal, child, and nutritional diseases or disorders, plus communicable diseases, were responsible for 7% of YHLL. A decade after GES/AUGE entered into effect, its impact is beginning to be felt through increased management of diseases prioritized in this regime, resulting, for example, in reductions in heart attack case fatality and cervical cancer mortality rates.

Chronic Conditions

NCDs responsible for the greatest disease burden in 2013 were malignant neoplasms (13.8%), cardiovascular diseases (12.3%), and mental disorders and substance abuse (12.2%) ().

Diabetes Mellitus

In 2011, type 2 diabetes mellitus was responsible for 3,426 deaths, or 19.8 deaths per 100,000 population, with the risk of dying from diabetes being 25% higher for men than for women. This risk increases with age and becomes particularly significant over the age of 60. The prevalence of diabetes in the over-15 population was 10.4% for men and 8.4% for women ().

Cardiovascular Diseases

Cardiovascular diseases were the leading cause of death in 2011 (the most recent year for which information is available), with 149 deaths per 100,000 population. However, the age-adjusted risk of dying from this group of diseases decreased by 25% between 1997 and 2011. Three-quarters of the deaths due to cardiovascular disorders can be attributed to cerebrovascular disease (34%), ischemic heart disease (28%), and hypertensive disease (13%). In 2011, the prevalence of hypertension in the over-15 population was 28.7% for men and 25.3% for women ().

In 2002, the country began including cardiovascular health in its primary care program. Aimed at people age 55 and older, primary care includes prevention and control of atherosclerotic cardiovascular disease, diabetes mellitus, hypertension, dyslipidemia, and tobacco use. Moreover, in light of the high prevalence of cardiovascular disease, from 2005 onward hypertension, acute myocardial infarction, and ischemic stroke were incorporated in the GES regime. Surveillance of chronic NCDs in vulnerable population groups is also being conducted, following the STEPS approach proposed by the World Health Organization (WHO).

Malignant Neoplasms

As a group, neoplasms were the second leading cause of death, accounting for 142 deaths per 100,000 population in 2011, though the risk of dying from cancer was 12.5% lower (age-adjusted rates) than in 1997. The risk of dying from cancer was 2.5 times greater for men than for women. The main cancer sites were the stomach (18.8 deaths per 100,000); trachea, bronchi, and lungs (16.1 deaths per 100,000); and colon, gallbladder and bile ducts, and breast (each accounting for approximately 8 deaths per 100,000 population).

The strategies and activities of Chile’s National Cancer Program include national programs for cervical cancer, adult antineoplastic drugs, children’s antineoplastic drugs, breast cancer, and pain relief and palliative care. Mammography at age 50 and cytological examination of the cervix are part of the preventive care regime, although coverage of these two cancer detection programs is below 60%, and in both cases is lower among FONASA beneficiaries, poor women, and women with low levels of schooling.

Chronic Obstructive Pulmonary Disease (COPD)

In 2011, 9,104 deaths were due to respiratory causes, or 52.8 deaths per 100,000 population. Chronic diseases of the lower respiratory tract were responsible for 34% of those deaths, with chronic obstructive pulmonary disease, or COPD, accounting for 92.1% and asthma for 7.3%. An estimated 24.5% of the population shows symptoms of chronic respiratory disease-11.5% with chronic cough, 10.2% with symptoms consistent with asthma, and 15.3% with dyspnea of respiratory origin. The Ministry of Health has established a national program for the control of adult respiratory diseases, which addresses COPD, asthma, and pneumonia, using an outpatient model that integrates specialized care for these conditions into primary health care.

Mental Health

Mental health disorders representing the greatest disease burden are depression and anxiety disorders, both of which are more frequent among women than among men, followed by disorders due to alcohol and drug use, which are more frequent among men. Schizophrenia affects men and women at a similar rate, representing nearly 1% of the disease burden ().

According to the National Health Survey 2009-2010, 17% of the population had symptoms of depression, and 21.7% reported having been diagnosed with depression at some time in their lives. The Ministry of Health has prepared a national mental health plan; consistent with the National Health Strategy 2011-2020, it includes a national strategy to address alcohol consumption, as well as a national suicide prevention program. Mental and neurological disorders, depression, adolescent depression, epilepsy, schizophrenia, bipolar disorder, Parkinson’s, multiple sclerosis, and adolescent drug and alcohol dependency are covered by the GES regime.

Suicide in the 10-19-year-old age group increased between 2012 and 2014. To improve access to care, a mental health care model was put in place, consisting of community centers established to provide specialized care for these problems as a component of primary health care.

Climate change and human security

Air pollution

Air pollution in urban centers, with its health impacts, is the principal environmental health concern. According to the most recent (2014) national assessment, conducted by the National Air Quality Information System, 10 million people live in areas declared “saturated” (i.e., where the concentration of particulates exceeds national standards). Over 4,000 people are estimated to die prematurely every year from cardiopulmonary diseases associated with chronic exposure to air pollutants. The areas most affected are the Santiago Metropolitan Region and the large cities in the southern part of the country, such as Temuco, Osorno, Valdivia, and Coyhaique.

In attempts to modernize the country’s environmental regulation, ensure its integrity, and make environmental control and recovery more efficient, the Ministry of the Environment, the Superintendency of the Environment, and the Environmental Assessment Service were created in 2010. The published 2014-2018 Atmospheric Decontamination Strategy sets forth plans to implement effective measures to reduce emissions in saturated areas, in addition to some short-term measures for areas shown to have a high concentration of particulates ().

Monitoring of the Health System’s Organization, Provision of Care, and Performance

According to data from the Organisation for Economic Co-operation and Development (OECD), the amount Chile allocated to health funding was equivalent to 7.7% of GDP in 2015. Public spending was responsible for 46.1% of the total, while 33% took the form of out-of-pocket expenditures. Per capita health spending in 2014 was US$ 1,877 in 2015.

The ratio of hospital beds to inhabitants has remained stable, at 2.2 per 1,000 population in 2014, while the numbers of physicians and nurses per 100,000 population were 1.7 and 5.6, respectively, in that year.

Overall coverage of health services exceeds 80% for communicable diseases, maternal health, and child health, but is significantly lower for NCDs, which today represent over 80% of the disease burden in Chile.

The public system has attempted to address these challenges by strengthening the Integrated Health Services Networks (IHSN) and incorporating the family health model as a component of primary care. It is also working to establish telemedicine systems, training personnel for that purpose, and these systems are already operating in some of the country’s hospitals. However, long waiting lists, increased user dissatisfaction, hospital indebtedness, and the movement of specialists to the private sector are ongoing problems that must be addressed in relation to effective management of the networks and the resolution capacity of primary care.

In terms of chronic NCDs, there is concern about the high prevalence of certain risk factors and behaviors in the population, such as smoking, excessive consumption of alcoholic beverages, and malnutrition linked to excessive food intake. To address these issues, a number of strategies have been adopted in line with the WHO Global Plan of Action. These include mass educational campaigns as well as regulations and tax policies to regulate food and beverage advertising and the consumption of tobacco, alcohol, and other substances. The National Health Strategy 2011 -2020 () focuses on risk factors, proposing to develop healthy habits and lifestyles that tend to reduce the risk factors associated with the population’s disease burden. Accordingly, Law 20.670 (), promulgated in 2013, established the “Choose Healthy Living” program, designed to promote healthy habits and lifestyles.

Prospects

The National Health Strategy 2010 -2020, with its health and strategic objectives, remains in effect. Efforts have been ongoing since 2015 to implement the proposed Integrated Health Services Networks (IHSN) in order to consolidate local health teams and ensure that the system has the competencies needed to provide comprehensive care, based on the primary health care model. The aim is to make health services more accessible, equitable, efficient, and of higher technical quality, and thereby meet users’ expectations. Consistent with this goal, in 2015 the Ministry of Health published the document Conceptual Bases for Network-Based Planning and Programming (), with a view to fully consolidating local health teams in 2016 and improving their ability to deal with the various epidemiological situations they may encounter.

In the coming years, the health sector will have to cope with new epidemics associated with risk factors generated by human behavior, such as smoking, alcohol consumption, and malnutrition due to excessive intake (with consequent overweight and obesity). In addition, continuing efforts will need to be made to reverse the course of indicators for maternal mortality and neonatal infant mortality, so that they resume their previous downward trend.

According to the fourth government report on the health-related MDGs (), the overall results have been positive, though much remains to be done. One example of this is the proportion of tuberculosis cases detected and cured, which has remained at close to 80% in recent years, far from the 95% goal set for 2015. The challenges in the public sector include dealing with the shortages of specialized physicians and of infrastructure, improving primary care management and efficacy, and ensuring the adequate provision of medicines. However, the greatest challenge for the coming years will be to reduce the socioeconomic inequalities that stand in the way of more equitable, comprehensive, and inclusive development.

References

1. United Nations Development Programme; Government of Chile. Los Objetivos de Desarrollo del Milenio: cuarto informe del Gobierno de Chile. Santiago: UNDP/GOC; 2014. Available from: http:/www.cl.undp.org/content/chile/es/home/library/mdg/Publicacion4/.

2. Ministerio de Desarrollo Social (Chile). Casen 2015: evolucion y distribucion de ingresos. Santiago: MDS; 2016. Available from: http://observatorio.ministeriodesarrollosocial.gob.cl/casen-multidimensional/casen/casen_2015.php.

3. Aguilera X, Castillo-Laborde C, Ferrari MN, Delgado I, Ibañez C. Monitoring and evaluating progress towards universal health coverage in Chile. PLOS Medicine 2014;11(9):e1001676. doi: 10.1371/journal.pmed.1001676.

4. Institute for Health Metrics and Evaluation. GBD cause patterns. Seattle: IHME; 2015. Available from: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-cause-patterns.

5. Aguilera X, González C, Matute I, Najera M, Olea N. Las enfermedades no transmisibles en Chile: aspectos epidemiológicos y de salud pública. Serie Salud Poblacional. Santiago: Universidad del Desarrollo, Facultad de Medicina, Centro de Epidemiología y Políticas de Salud; 2016. Available from: http://repositorio.udd.cl/handle/11447/1460?show=full.

6. Ministerio del Medio Ambiente (Chile). Planes de Descontaminación Atmosférica: Estrategia 2014–2018. Santiago: MMA; 2014. Available from: http://www.mma.gob.cl/1304/articles-56174_Plan_Descont_Atmosferica_2014_2018.pdf.

7. Ministerio de Salud (Chile). Estrategia Nacional de Salud 2011 –2020. Santiago: MINSAL. Available from: http://web.minsal.cl/portal/url/item/c4034eddbc96ca6de0400101640159b8.pdf.

8. Biblioteca del Congreso Nacional, Ley Chile (Chile). Ley núm. 20.670 [Internet]. Santiago: BCN; 2016. Available from: http://www.leychile.cl/Navegar?idNorma=1051410&idParte=0.

9. González R, Koch E, Poblete JA, Vera C, Muñoz H, Carroll G. Consenso salud materna para Chile en el nuevo milenio. Revista Chilena de Obstetricia Ginecología 2013;78(2):142 –147. Available from: http://dx.doi.org/10.4067/S0717-75262013000200013.

10. Government of Chile. Chile crece contigo [Internet]. Santiago: GOC; 2016. Available from: http://www.crececontigo.gob.cl.

11. Instituto Nacional de la Juventud(Chile). Séptima Encuesta Nacional de Juventud 2012. Santiago: INJUV; 2013. Available from: http://www.injuv.gob.cl/portal/septima-encuesta-nacional-de-juventud/.

12. Ministerio de Salud, Subsecretaría de Redes Asistenciales, División de Atención Primaria (Chile). Salud del inmigrante: Decreto Supremo No. 67 y Circular A 15 No. 4. Santiago: MINSAL; 2016. Available from: http://web.minsal.cl/salud-del-inmigrante/.

13. Ministerio de Salud (Chile). Informe nacional de progreso sobre SIDA en Chile: GARPR 2014 (incluye indicadores de acceso universal), enero de 2012–diciembre de 2013. Santiago: MINSAL; 2014. Available from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0ahUKEwiAv8DQ04HWAhXJyyYKHW7gCG0QFggvMAI&url=http%3A%2F%2Fwww.sidastudi.org%2Fes%2Fregistro%2Fff808181463cc53c014665909473004b&usg=AFQjCNEOiToNDRNulRSJrngYJN7IUH837Q.

14. Pan American Health Organization. Plan of Action for the Prevention of Obesity in Children and Adolescents. 53rd Directing Council, 66th Session of the Regional Committee of WHO for the Americas, 3 October 2014, Washington, D.C., USA. Washington, D.C.: PAHO; 2015. Available from: https://www.paho.org/hq/index.php?option=com_content&view=article&id=11373%3Aplan-of-action-prevention-obesity-children-adolescents&catid=4042%3Areference-documents&Itemid=41740&lang=en.

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Reference/Note:

1. Purchasing power parity, or the sum of goods and services produced in a country at the monetary value of a reference country.

2. In the case of health, the World Health Organization’s Safe Hospitals Initiative has made a significant contribution.

3. An index of inequality that shows the ratio of income received by the 10% of households with the highest autonomous income per capita to that of the 10% of households with the lowest income.

4. 62 public hospitals, 44 of them accredited.

5. In 320 communes these services are administered by the mayors, and in 29 by the Ministry of Health.

6. The Regime of Explicit Health Guarantees, known as GES or AUGE, provides explicit guarantees for health problems defined by law, which must be extended to all residents of Chile. Coverage of these conditions is guaranteed whenever one of the specified pathologies is diagnosed and the relevant criteria are met.

7. AUDIT: Alcohol Use Disorders Identification Test.

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