Country Report: Chile
Chile is located in the southwest of South America, with a continental and insular territory of 756,770 km² and an Antarctic territory of 1,250,000 km2. The country is divided into 15 regions, 53 provinces, and 346 communes. Up to 87% of the population lives in urban areas.
Between 1990 and 2015, the population grew by 36.4%. In 1990, the population pyramid had an expansive structure in the groups over 25 years of age and a stationary structure in younger groups. It has since become regressive as a result of aging and declining fertility and mortality.
In 2014, the population was 17.8 million.
The proportion of older adults (over 60) was 14.5% in 2014. Life expectancy at birth is 80 years for men and 85 years for women.
In 2014, the per capita gross national income was US$21,290 (ppp). Between 1961 and 2014, average annual GDP growth was 4.3%.
- Economic development, a gradual increase in health care coverage, and the efforts of successive governments in recent decades have managed to reduce communicable, nutritional, maternal and childhood diseases.
- Improved hygiene and sanitation conditions, universal hospital delivery coverage, the creation of outpatient care facilities specifically for acute respiratory infections in children and respiratory diseases in adults, and the now-traditional programs for communicable disease prevention and control and nutritional assistance have provided essential benefits to the population.
- In the decade since the launch of the Explicit Health Guarantees program, its effect in terms of increased coverage of care for the priority diseases included in the program (currently, 80 pathologies) is becoming apparent.
- Since 2015, attempts have been made to implement the proposal to establish service networks through the creation of local health teams and to improve system competencies for the delivery of integrated care based on primary health care.
Figure 1. Distribution of the population by age and sex, Chile, 1990 and. 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan American Health Organization and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: UN Population and Statistics Divisions, 1990; PAHO; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- Health and living conditions have substantially improved, but there are significant differences between socioeconomic groups.
- The Gini coefficient, a summary measure of income inequality, has remained around 0.55 in recent decades.
- In 2015, 8.1% of the population lived in poverty and 3.5% of the population lived in extreme poverty. Between 2003 and 2014, the average income of the poorest 40% of the population increased by 4.9%, compared to a 3.3% increase for the population as a whole.
- A sustained increase has been achieved in women's participation in the workforce, which rose from 35.0% in 2000 to 47.7% in 2013.
- In October 2014, Law 20 786, on domestic work (largely performed by women), went into effect. The law, which regulates the work day, time off, and wages of domestic workers, should also have an impact on their quality of life.
- Average years of schooling in 2013 was 10.8 years, but with marked differences between urban and rural areas and income quintiles.
- In 2014, improved drinking-water and sanitation coverage rates were 99.9% and 96.7% respectively. Urban wastewater treatment coverage was 99.9% in 2014.
- In 2015, the country devoted financial resources equivalent to 7.7% of GDP to health, 46.1% of which corresponded to public expenditure and 33% to out-of-pocket expenditure. Per capita health expenditure in 2014 was US$1,877.
- Due to migration in the last decade, policies to facilitate access to medical attention have been implemented for immigrants, especially health care for pregnant women and children under 18.
- The country is prone to major natural disasters of different types. Over the past 10 years, it has been stricken by at least 17 natural disasters, including earthquakes and tsunamis, with grave consequences for the population. The population's vulnerability to natural disasters has been reduced through stringent building codes, early-warning mechanisms, coordination, and assistance.
- Air pollution in urban areas and its impact on health are major environmental concerns.
HEALTH SITUATION AND THE HEALTH SYSTEM
- The maternal mortality ratio declined significantly between 1990 and 2014, from 39.9 to 22.2 per 100,000 live births, respectively. In recent years, the predominant causes of maternal death were indirect obstetric causes and other conditions complicated by pregnancy, which accounted for 25% of total maternal deaths in 2014.
- Universal institutional delivery (99.9%) was achieved in 2013.
- The under-1 mortality rate has been stable over the past seven years at around 7 deaths per 1,000 live births (7.6 per 1,000 in 2006 vs. 7.2 per 1,000 in 2014).
- Post-neonatal mortality has fallen significantly, from 7.5 per 1,000 live births in 1990 to 2.1 per 1,000 in 2012.
- Between 2005 and 2012, mortality in children aged 1-4 fell from 0.34 to 0.28 per 1,000 children. The most common causes of death among these children are accidents and violence (31%).
- In 2014, diseases of the circulatory system and neoplasms were responsible for 27% and 26% of deaths respectively. These two groups of causes account for more than half of all deaths.
- In 2011, mortality from cardiovascular disease was 149 per 100,000 population and mortality from neoplasms, 142 per 100,000 population.
- The leading causes of cancer death by primary tumor site were cancer of the stomach (18.8 per 100,000 population); trachea, bronchus, and lung (16.1); and colon, gallbladder, bile ducts, and breast (around 8.0 each).
- Cerebrovascular disease, ischemic heart disease, and cirrhosis were the leading specific causes of death in 2012.
- In 2011, 9,104 people died of respiratory diseases (52.8 deaths per 100,000 population).
- In 2013, non-communicable diseases accounted for 82% of the burden of disease as measured by years of healthy life lost, and its relative importance increased by 19% between 1990 and 2013, mainly due to the aging of the population.
- Injuries and violence accounted for 11% of the burden of disease, while maternal, neonatal, child, and nutritional disorders, plus communicable diseases, accounted for 7% of years of healthy life lost.
- A high prevalence of some risk factors, especially smoking, is observed in the population. Some 39% of the population smoke (37% of women and 41% of men). In 2014, the prevalence of excessive alcohol consumption (AUDIT test) was 11%, with the figure nearly eight times higher in men (19.7%) than in women (2.5%).
- In 2012, the HIV epidemic was predominantly sexually transmitted (99.2%), particularly among young adult men who have sex with men. The prevalence in pregnant women remains low at close to 0.05%, as does that of the general population (0.35%).
- In 2016, a dengue outbreak occurred, with 27 cases on Rapa Nui (Easter Island).
- By the end of 2016, there had been no reported autochthonous cases of Zika virus infection, although there had been imported cases and one confirmed sexually transmitted case.
- The incidence of tuberculosis was 12.3 cases per 100,000 population in 2014. That same year, there were 15 cases of multidrug-resistant TB (three with HIV coinfection). The non-communicable diseases responsible for the greatest burden of disease were malignant neoplasms (13.8%), cardiovascular disease (12.3%), and mental disorders and substance abuse (12.2%).
- Type 2 diabetes mellitus caused 3,426 deaths, with a rate of 19.8 per 100,000 population in 2011. The prevalence of diabetes in people over 15 was 10.4% for men and 8.4% for women. The prevalence of hypertension in this group was 28.7% in men and 25.3% in women.
- The mental health problems associated with the greatest burden of disease are depression and anxiety disorders.
- The health system is mixed, with both public insurance (the National Health Fund [FONASA]) and private insurance (Social Health Insurance [ISAPRE]) and other specific insurance programs such as that of the Armed Forces.
- In 2013, 76.3% of the population was covered by FONASA and 18.1% by an ISAPRE.
- The Ministry of Health is responsible for system governance and regulation, as well as for the regulatory framework.
- The National System of Health Services (SNSS) coordinates the health delivery functions of the public sector, which is composed of 29 decentralized services, distributed across the 15 regions of the country, and the primary health care system (which is largely municipal).
- The health system is currently fragmented in terms of financing and insurance, as well as service delivery and the unequal availability of resources to tend to the population that depends on each sector. Out of pocket health expenditure accounts for 38% of total health expenditure and primarily affects lower income families.
- In 2015, the country devoted an estimated 7.7% of GDP to health. Per capita health expenditure (ppp) was US$1,689 in 2014.
- In 2014, the ratio of physicians and nurses per 1,000 population was 1.7 and 5.6, respectively. The availability of hospital beds has been stable in recent years (approximately 2.2 beds per 1,000 population).
- To improve access to health care delivery, the National Mental Health Plan of 2015 considers the mental health care model through the creation of community centers to provide specialized care within the framework of primary health care.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- The National Health Strategy 2010-2020 focuses on risk factors, proposing "to develop healthy behaviors and lifestyles that promote the reduction of risk factors associated with the burden of disease in the population." To that end, in 2013, Law 20,670 was passed, creating the "Choose to Live Healthy" program, aimed at promoting healthy behaviors and lifestyles.
- Consequently, in 2015, the Ministry of Health issued the document Conceptual Underpinnings for Networked Planning and Programming, with the object of beginning effective integration of local health teams in 2016 and improving their competencies to address the different epidemiological situations that arise.
- In the coming years, the health sector will have to deal with new epidemics associated with risk factors such as smoking, alcohol, and malnutrition due to excess (this latter with the consequent effects of overweight and obesity).
- Great strides have been made since the last decade, including health-sector policies enshrined in laws on the Explicit Health Guarantees; new rules for the regulation of the pharmaceutical sector; and the Financial Protection Law governing costly diagnostics and treatments.
- Since 2002, the country has had a cardiovascular health program in primary care for people aged 55 and over. This program covers atherosclerotic cardiovascular disease, diabetes mellitus, hypertension, dyslipidemia, and smoking.
- The public system has attempted to tackle these challenges by improving integrated health services networks and implementing the family health model for primary care. A National Mental Health Plan has been implemented that includes a national alcohol strategy and a national program for suicide prevention.
- The challenges in the public sector include addressing the shortage of medical specialists and infrastructure and the need to improve management and effectiveness in primary care, while guaranteeing an adequate supply of medicines. The greatest challenge in the coming years, however, will be reducing the socioeconomic gaps that pose an obstacle to more equitable, comprehensive, and inclusive development.
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