Overall Chile has a well-functioning, well-organised and effectively governed health system and public health architecture. Leadership from different levels of government is ambitious, and all government actors appear to have well-defined roles in delivering public health care. The key building blocks of the public health system are generally in place, and functioning well. However, more could be done to engage non-governmental actors in addressing Chile’s public health concerns. Equally, while ambitious efforts to tackle obesity have been undertaken in Chile, other public health risks – notably smoking and alcohol consumption – merit further policy attention. There is also scope to strengthen public health information system in Chile, notably with more regular administration of the National Health Survey, which is a rich source of epidemiological data.
OECD Reviews of Public Health: Chile
Chapter 1. The Public Health System in Chile
Abstract
The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law.
1.1. Introduction
In the face of considerable public health issues, Chile has a robust and well-functioning public health system. Leadership from different levels of government, and in particular central government, is ambitious. The flow of public health leadership and planning from the central to the regional and local levels appears well thought-out, although more could be done to engage non-governmental actors in addressing Chile’s public health concerns. Equally, while ambitious efforts to tackle obesity have been undertaken in Chile, other public health risks – notably smoking and alcohol consumption – merit further policy attention. There is also scope to strengthen public health information system in Chile, notably with more regular administration of the National Health Survey, which is a rich source of epidemiological data.
Public health issues have gained importance across OECD countries in recent years, as governments grapple with the best way to prevent disease and ill-health, and help their populations live longer, healthier lives. This chapter gives an overview of the epidemiological context and national public health needs in Chile, sets out a summary of the strengths and weaknesses of Chile’s public health system, and where weaknesses are identified makes recommendations for policy strengthening. The description of public health policies in this chapter is structured according to a framework for analysing the public health system detailed in Figure 1.1 below.
Figure 1.1. Appraising Chile’s public health capacity – analytical framework
1.1.1. The health status of the Chilean population presents substantial cause for concern
While Chile has seen improvements comparable to the OECD average in recent decades, the health status of the population nonetheless falls fairly consistently below the OECD average. The average life expectancy in Chile has risen faster than the OECD average in the past forty years, and in 2015 was 81.3 years – 76.5 years for men and 81.7 years for women –, compared to the OECD average of 80.7 years (77.9 for men and 83.2 for women).
Transport accident mortality in Chile should be a cause for concern. Since 1990 mortality due to transport accidents has fallen by more than 60% in the OECD; Chile is the only country where transport accidents have increased, having risen during the 1990s as the number of vehicles on the roads increased (see Figure 1.2).
Figure 1.2. Transport accident mortality 1990 to 2015, or nearest year
Source: OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.
1.1.2. High rates of smoking and obesity in Chile represent significant risks to population health
Health status across a number of key public health areas – tobacco consumption, alcohol consumption, obesity – is mixed in Chile, but worrying. Tobacco consumption, particularly amongst younger Chileans, and obesity, are high. Without an important change to these trends Chile could well expect to see an explosion in the burden of chronic disease in the years and decades to come.
High rates of smoking in general population are reported in Chile; among adolescents and young adults prevalence of daily smoking reached around 50% in the early 2000s, with prevalence for women aged 26 – 34 reached more than 40% daily smoking prevalence during the same period, even if declines were observed. More recent data, which covers a slightly different population, still show concerning high, albeit slightly lower, rates of tobacco use. Tobacco consumption rates in Chile have declined from 45.3% in 2003 to 39.8% in 2009-2010 to 33.3% in 2016-2017, while exposure in the home decreased from 31% to 15.2% in the same period (Encuesta Nacional de Salud, 2017[1]). The heaviest smokers were aged 20-49, with a smoking rate of more than 40%. As in other OECD countries, male smoking in Chile is higher than female smoking; 28.2 of Chilean males were daily smokers in 2016, compared to 23.3% OECD-wide, and 20.9% of Chilean females were daily smokers, compared to 14.1% OECD-wide (OECD, 2018[2]).
OECD-standardised data showed a drop in adult smoking in Chile from 33% of the population as daily smokers in 2000, to 24.5% daily smokers in 2016, a decline of 26% (see Figure 1.3). The daily smoking rate in Chile remains above the OECD average, which is 18.4% of the population, and smoking rates have also declined more slowly. The OECD average rate of decline in smoking rates between 2000 and 2016 was 27%.
Figure 1.3. Daily smoking rate, total population, 2000 and 2016 (or nearest year)
Note: Percentage of the population aged 15 and over who are daily smokers.
Source: OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.
In 2013 24.5% of Chilean youth aged 13-15 reported using tobacco in the previous 30 days, with 27.8% girls reporting tobacco use compared to 19.8% of boys (WHO, 2015[3]; Centres for Disease Control and Prevention, 2013[4]). In 2016 young people (15-24) in Chile were more likely to be smokers than most other OECD countries who could report data by age; 14% of Chilean females and 22.8% of Chilean males aged 15-24 were daily smokers in 2016.
Figure 1.4. Percentage of the population aged 15-24 who are daily smokers, 2016 or nearest year
Source: OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.
Alcohol consumption amongst adults in Chile is lower than the OECD average. However, alcohol consumption increased slightly from 2000 to 2016, bucking the general trend towards lower consumption of alcohol on average across the OECD (Figure 1.5). In Chile alcohol consumption per capita was 6.2 litres in 2000 and rose to 7.9 litres in 2016, while OECD average consumption fell from 9.5 litres to 8.9 litres.
Prevalence of heavy episodic drinking in the population – wherein at least 60 grams or more of pure alcohol on at least one occasion in the past 30 days were consumed – was at 4.9% in 2010, but men were far more likely to be heavy episodic drinkers (9.8%) than women (0.1%) (World Health Organisation, 2014[5]). Chile’s most recent national health survey, the Encuesta Nacional de Salud 2016-17, found that the risky consumption of alcohol fell from 12.7% in 2009-2010 to 11.7% in 2016-2017.
Figure 1.5. Alcohol consumption amongst adults, 2000 and 2016 (or nearest year)
Source: OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.
It is noteworthy that Chile has relatively permissive national guidelines on alcohol consumption: in Chile a ‘standard drink’ contains 13-15.5g of alcohol as nationally defined; hazardous drinking (the limit above which people are at risk for their health) is defined as > 4 drinks per day (52-62 g/day) for men and > 3 drinks per day (29-46.5g/day) for women; and heavy episodic drinking is defined as more than 5 drinks in one occasion (>69g) (Sassi, 2015[6]). In comparison many other OECD countries set lower thresholds for the definition of a ‘standard drink’, of hazardous drinking, and of episodic drinking. For example in France 10g of alcohol is a ‘standard drink’, and hazardous drinking is set above 3 drinks per day (30g) for men and 2 drinks per day (20g) for women. Indeed in all OECD countries where national guidelines exist the hazardous drinking limit as measured in grams is lower than in Chile. Chile’s guideline on heavy episodic drinking is also one of the highest in the OECD (Sassi, 2015[6]).
34.4% of Chilean adults were reported as being obese in 2016, well above the OECD average (OECD, 2018[2]); obesity and healthy diets are discussed in detail in Chapter 2.
1.1.3. Like Chile’s OECD peers, the burden of disease is dominated by non-communicable diseases, though infectious diseases are more prevalent
Like Chile’s OECD peers, the burden of disease in Chile is dominated by non-communicable diseases; diseases of the circulatory system, cancer, and diseases of the respiratory system are the leading causes of death (Figure 1.6). Ischemic heart disease, cerebrovascular disease, Alzheimer’s, Lower respiratory infection, stomach cancer and COPD have been the leading causes of death in Chile for the last decade; lower back and neck pain, ischemic heart disease and cerebrovascular disease are the greatest causes of death and disability combined in Chile (IHME, 2016[7]).
However, infectious diseases, including tuberculosis and HIV/AIDs, do have a higher incidence and mortality rate in Chile than the OECD average. Mortality from infectious and parasitic diseases (ICD A00-B99) is higher in Chile than the OECD average – at 18.7 deaths per 100 000 population in 2015, compared to 14.7 OECD-wide – but lower than both Mexico (19.3 deaths per 100 000) and Brazil (40.1 deaths per 100 000). The incidence HIV/AIDS in Chile was 6.1 per 100 000 population in 2016, above the OECD average of 1.5 100 000 population, and incidence increased by 34% between 2010 and 2016 (UN AIDS, 2017[8]; OECD, 2018[2]). Chile has the fourth highest AIDS mortality rate, behind Latvia, Mexico and Estonia; incidence of AIDS was 6.1 per 100 000 population in Chile in 2016, compared to the OECD average of 1.5 per 100 000 population (OECD, 2018[2]) (see Box 1.1). Hepatitis B incidence is higher than the OECD average – an estimated 6.1 cases per 100 000 in Chile compared to the OECD 2016 average of 1.2 – and again, incidence has increased over the past decade (OECD, 2018[2]).
Figure 1.6. Main causes of mortality by country, 2015
Source: OECD Health Statistics 2017, https://doi.org/10.1787/health-data-en.
Box 1.1. Strategies to reduce incidence and mortality of HIV/AIDS
Chile, along with several other countries in Latin America as seen a recent increase in new HIV infections. However, Guatemala, Costa Rica, Honduras and Panama all saw increases in infection rate of around 10-20%, in Chile infections increased by 34% between 2010 and 2016 (UN AIDS, 2017[8]). Knowledge of status among all people living with HIV is relatively low (69%), only 53% of people living with HIV are on treatment (77% of those who know they have HIV), and 48% of people living with HIV are virally suppressed (UN AIDS, 2017[8]). Key populations affected by HIV in Chile are sex workers (with an HIV prevalence of 1.1%), gay men and other men who have sex with men (with a prevalence of 20.3%) and prisoners (0.4% prevalence) (UN AIDS, 2017[10]).
The Chilean Government has been taking action to reduce the incidence of HIV, and improve treatment coverage. Chile has a National Strategy for the Prevention and Control of HIV/AIDS and STIs (Estrategia Nacional de Prevención y Control del VIH / SIDA y las ITS), and in light of the significant increase in HIV infections launched a further campaign in 2017. The 2017 Government campaign focuses on a ‘combined prevention’ strategy, focusing on encouraging use of condoms and distribution of free condoms, HIV testing, access to care and antiretroviral treatments (ARVs), and STI prevention (Gobierno de Chile, 2017[11]). Treatment for HIV/AIDS, including diagnosis, follow-up, monitoring and access to ARVs, is covered under AUGE, as is the prevention of mother-to-child transmission of HIV.
In Chile more comprehensive education around preventing HIV and other STIs is likely to be a key part of halting the rise in infections. Sex education has only been mandatory – and only in high schools – since 2010, and evidence suggests that knowledge around safe sexual practices amongst young people is poor (Pérez V et al., 2008[12]). Easy access to testing is also key, and the introduction of a self-administered HIV test available for purchase in pharmacies is under consideration in Chile.
Childhood vaccination programmes are in place, even if room for improvement remains, with vaccination rate against hepatitis B slightly above the OECD average, and vaccination against diphtheria, tetanus and pertussis (DTP) and measles just slightly below the OECD average. Vaccination schedules are aligned with global targets, with the exception of Hepatitis A (vaccination at 18 months is not in place nationally), and Chile has a Multi-Year Plan (MYP) for immunisation in place, and coverage for all WHO-recommended vaccinations is close to or above 90% population coverage (WHO, 2017[9]; WHO and Unicef, 2016[10]). A programme of Human Papillomavirus (HPV) vaccination for young girls began in 2014.
1.1.4. Earthquakes are a recurring public health hazard in Chile
Chile faces a number of natural hazards, including 50 active volcanos, significant earthquake activity, tsunamis, and in some parts of the country drought, wildfires, landslides and floods (Center for Excellence in Disaster Management, 2017[11]).
In particular, earthquakes and tsunamis are a recurring public health risk in Chile, which is one of the most earthquake-prone countries in the world, with an average 1-2 major earthquakes (above magnitude 7) hitting the country each year. The population impact of the earthquakes depends on the location of the epicentre. Chile’s disaster preparedness efforts have helped reduce the number of earthquake casualties in recent years.
Tsunamis following earthquakes have also been destructive in recent years, in some cases triggering significant public health responses including mass evacuations, and leading to loss of life and injury. Both the Illapel earthquake in 2015 and the 2016 Chiloé earthquake triggered tsunamis and evacuation of coastal areas, while in April 2017 an earthquake of the coast near Valparaíso led to preventive evacuations in some coastal areas.
1.2. Organisational Structure
1.2.1. The Chilean Health System
Health care coverage in Chile is provided primarily either by the state-funded National Health Fund - Fondo Nacional de Salud , most commonly known as FONASA, or by the private coverage schemes, Las Instituciones de Salud Previsional (ISAPRE). FONASA covers around 78% of the population, ISAPRES cover around 17-18% of the population, while a further 3-4% are covered under an Armed Forces insurance scheme.
Secondary care is delivered through a decentralised network of 29 autonomous health care services which make up the National System of Healthcare Services, coordinated in the Ministry by the Under-Secretariat of Healthcare Networks. Chile’s challenging geography brings with it inherent problems in organising care, and promoting access, especially in the remote northern and southern tips. In general, the government has sought to use the system of service networks to balancing efficiency – for instance centralising specialist centres, e.g. cancer centres – and access, often managed through satellite centres. Primary care provision is decentralised, and overseen by local governments (municipalities) – the comunas, of which there are 346 across Chile. Many comunas provide additional (supplementary) funding to the primary care sector. Consequently, primary health provision can vary significantly, although there is a defined primary care package which includes prevention, health checks and some chronic disease care.
Since 2005 the guaranteed benefit basket under the public health system in Chile has been secured under a system of enforceable guarantees. Citizens are guaranteed access to those treatments defined under the ‘Acceso Universal con Garantías Explícitas’, or AUGE (see Box 1.2).
AUGE coverage is assessed every 3 years by the Ministry of Health, under advice from the Advisory Committee for the GES Plan, who defines the benefits that are covered. The AUGE Advisory Committee has nine members, of which six are named by the country’s main academic institutions and a further three by the President of the Republic. Those named by the President mostly include representatives of scientific societies, universities and professional associations, and sometimes but not always patient groups. A catalogue of goods and services that are covered by public and private insurers (but not guaranteed by FONASA coverage) are assessed by the National Health Fund jointly with the Ministry of Health every year.
While AUGE functions as a way of making coverage guarantees more transparent, some patient groups have reported some confusion around the process by which conditions and treatments are covered, and limited engagement with patient groups by the Advisory committee.
This process may merit some re-examination by the Ministry and the Advisory committee, either to improve communication with patient groups or to increase involvement, or both. Involving patients and service users in decisions about coverage priorities can help promote the legitimacy, transparency, and accountability of the process, increase trust in the system, and decisions can benefit from patient knowledge and experience (Auraaen et al., 2016[12]; Barasa et al., 2015[13]). Indeed, at present AUGE coverage is not always clear to the public, and service users may not fully understand their entitlement, hindering access to health care. According to a national survey called CASEN, about one in four patients who are entitled to AUGE-covered care did not receive care under AUGE. Among those who did not receive AUGE services despite their entitlement, 11.8% did not know that their illness was covered by AUGE and 3.4% found the process involved in accessing AUGE-covered care difficult (Ministry of Social Development (MINSAL), 2015). Along with a move to more consistently involve patients and service users in discussions on AUGE coverage limits, further efforts to inform Chileans about their entitlements, and to improve health care literacy, are likely called for.
In contrast, while the range of conditions covered is more limited, coverage of the Law Ricarte Soto seems generally to be regarded as having a more transparent process by patient groups, and better consultation with patient groups around the listed drugs that the Law covers.
Box 1.2. The AUGE/GES and Ricardo Soto Law guarantees provide clear and comprehensive coverage for some – but not all – conditions
Under the 2005 AUGE (Acceso Universal con Garantías Explícitas) Plan Chilean government reformed the health system, introducing a system of explicit and enforceable guarantees which are legally binding. Applicable to all Chileans, whether covered by FONASA or Isapre, the guarantees cover provisions around access, quality, timeliness, and financial protection. Also known synonymously as GES (Garantías Explícitas en Salud), AUGE guarantees care for a positive list of conditions, often with a waiting time guarantee. Quality of care is assured through registration and accreditation of providers delivering AUGE-covered services, and medical protocols need to be followed for AUGE-covered interventions. Patients are guaranteed care within defined waiting time which is set for each condition and if the public sector is not able to provide care within waiting time guarantee, patients can seek care in the private system and the cost of private health services is covered by FONASA.
80 listed conditions are covered with a 20% co-payment (with a cap), while public health services – antenatal care, child health checks up to 6 years, immunization, TB diagnosis and treatment, and annual preventive exams – are fully covered. Cervical cancer screening is also part of AUGE, and Pap smears taken outside of the Preventive Examination are also provided free of charge. Care for diseases including diabetes (type I and II), a number of cancers, hypertension, depression, Ischemic stroke, COPD, and Hepatitis B and C is included under the current AUGE list.
While conditions listed under AUGE are guaranteed care, those not listed are not necessarily covered. In the case of some conditions which are not covered under AUGE public hospitals may cover treatment using their annual budget, for example lung cancer. However, since non-AUGE covered conditions do not have nationally structured programmes, treatment coverage varies across the countries and waiting times can be long. Those conditions with a waiting time guarantee are reported as being delivered in a more timely way than those without a guarantee.
Introduced in 2015 the Ricardo Soto Law provides coverage for certain high-cost illnesses; in 2017 coverage was further expanded to cover a total of 14 illnesses, for instance treatment-resistant Rheumatoid arthritis or multiple sclerosis, or HER2 positive breast cancer. In 2017, President Bachelet added three new pathologies, expanding coverage to 14 high-cost illnesses. In 2016, an estimated 3 500 people received treatment under the law.
1.2.2. Delivery of essential public health operations in Chile
In addition to those public health functions discussed throughout this chapter and this report, basic essential public health operations typically include population disease surveillance, vaccination programmes, and food and drug safety assurance.
In Chile infectious disease surveillance is undertaken by the Ministry of Health, in particular by the Department of Epidemiology in the Ministry of Health. The Chilean National Institute of Public Health (Instituto de Salud Publica, ISP) is the national reference laboratory. The Department of Epidemiology is also responsible for coordinating the investigation of disease outbreaks, which are run in the field by the epidemiology teams in the Departments of Public Health of each SERMI. Health care institutions alert the Secretaría regional ministerial (SEREMIS), which in turn report to the Department of Epidemiology.
Food safety surveillance is coordinated by the Department of Food and Nutrition in the Ministry of Health, which works with the Department of Sanitary Action in each SEREMI. The ISP is also involved in quality assurance and registration, and laboratory analysis, for food safety purposes.
The ISP is also responsible for laboratory controls, quality control of medicines, control of food safety, surveillance of products subject to sanitary control, the authorisation and registration of medicines and other products, supervising the accrediting entities of the laboratories.
Childhood vaccination programmes are in place, with vaccination rate against hepatitis B, vaccination against diphtheria, tetanus and pertussis (DTP) and measles covering 93% of children in 2018, just below the OECD average rate of 95% in 2017 (OECD, 2018[2]). Vaccination schedules are aligned with global targets, including Hepatitis A vaccination at 18 months which was implemented from March 2018 as part of the National Immunization Programme. Chile has a Multi-Year Plan (MYP) for immunisation in place, and coverage for all WHO-recommended vaccinations is close to or above 90% population coverage (WHO, 2017[9]; WHO and Unicef, 2016[10]). A programme of Human Papillomavirus (HPV) vaccination for young girls began in 2014. 54% of over 65s were vaccinated against influenza in Chile in 2016, above the OECD average coverage rate of 43.6% (OECD, 2018[2]).
1.2.3. Primary, secondary and tertiary prevention
In Chile some key public health functions are delivered as part of core health services, while others are undertaken under dedicated programmes or plans. Ambitious efforts to tackle obesity have been undertaken in Chile, with a comprehensive multi-dimensional strategy in place. This approach, which is further discussed in Chapter 2, is timely, given the concerning high levels of obesity in Chile. However, greater attention may also need to be given to other public health issues. In terms of primary prevention, smoking rates are high while alcohol consumption is low but rising. In terms of secondary prevention a comprehensive set of health checks and screenings are covered, but in the main coverage targets are not being met.
Primary prevention efforts in Chile
As Chapter 2 sets out, efforts to address obesity in Chile – arguably the greatest public health threat in Chile at present – are impressive, even if room for expansion and improvement remains. Policies around preventing smoking could stand to be approached with similar ambition. Chile is a Party to the WHO Framework Convention on Tobacco Control on September 11, 2005, and does relatively well in terms of following the Convention’s guidelines on implementing and managing tobacco control. Smoking is prohibited in the majority of public places, health warnings must cover 50% of all tobacco products, advertising bans are strict and tobacco products cannot be sold or advertised in a certain radius around schools although tobacco companies can still sponsor events and tobacco products can still be displayed at the point of sale. In 2014 taxes on tobacco products exceeded 75% of the retail price, and for the most-sold brand of cigarettes was estimated at 80.81% (World Health Organisation, 2015).
Reducing the prevalence of smokers in the general population from 40.6% to 35.6% was included as part of Chile’s Health Objectives 2010-2020. Chile became a Party to the WHO Framework Convention on Tobacco Control on September 11, 2005, and does relatively well in terms of following the Convention’s guidelines on implementing and managing tobacco control (see Box 1.3).
Box 1.3. Chile’s performance against the WHO Framework Convention on Tobacco Control
In 2015 Chile’s performance against the Convention can be summarised as follows (WHO, 2015[3]):
Monitoring of smoking rates is in place, with recent and representative data available for both adults and children;
Policies to ensure smoke-free environments are strong; Chile has a law prohibiting smoking in public places. The majority of public places – health care and educational facilities, indoor offices and workplaces, eating and drinking establishments, and public transports – smoke-free. However, Chile does not have dedicated funds for the enforcement of smoke-free environments;
Cessation programmes are not cost-covered. While products such as nicotine replacement therapy are available in pharmacies, and other products for instance bupropion and varenicline are available with a prescription, their cost is not covered by insurances. Smoking cessation support is also not widely available, or cost-covered;
Health warnings are displayed on tobacco packages, and must cover 50% of the packaging of all tobacco products. Limits are also placed on the wording that can be used on tobacco products, notably it is prohibited to label ‘light’ tobacco products;
There are bans on advertising tobacco products on TV, radio, in magazines and newspapers, on billboards, and on the internet. Free distribution, promotional discounts, and product placement are also banned. However, as of 2014 tobacco companies could still sponsor events, and tobacco products could still be displayed at the point of sale;
In 2014 taxes on tobacco products exceeded 75% of the retail price, and for the most-sold brand of cigarettes was estimated at 80.81%.
While the range of anti-smoking policies in Chile is adequate, a more ambitious approach could still be envisaged. Further steps could be taken targeting the whole population, as well as populations with high smoking rates. In terms of population-wide policies, Chile should press ahead with the bill that has been before drafted for parliament since 2015 which would introduce plain packaging for tobacco products, as well as limit smoking at beaches and parks, a total ban of display on tobacco products that are on sale, and strengthening the capacity of the SEREMIS to enforce tobacco regulations.
Australia introduced plain packaging in 2012, and as of 2015 the introduction of plain packaging in combination with graphic health warnings on packets was estimated to have contributed to a 0.55% decline in smoking between 2012 and 2015 (Australian Government, 2016[14]). A ban on menthol cigarettes, proposed under the 2015 draft bill, would also be a powerful step in Chile. Menthol flavoured cigarettes are popular in Chile, and while such a measure would apply population-wide it could be expected to have a more significant impact upon female smoking – which for young females is high in Chile – as females tend to a greater preference for flavoured cigarettes (Euromonitor, 2016[15]).
Targeted interventions for population groups with relatively high smoking rates could also be considered. The ban on the sale of tobacco products in a set perimeter around schools is already a good step towards trying to reduce smoking rates amongst children and young people. Chile could consider further mass media campaigns about the dangers of smoking – in general to reduce youth tobacco use, its use in the general population must be de-normalised (OECD, 2017[16]) – which could also be tailored to youth populations, either in their content or in where and when they are displayed.
Chile may also wish to re-consider whether to fund smoking cessation treatments. Smoking cessation services amongst the most cost-effective and clinically valuable preventive measures available in health care, and those with assistance in stopping smoking are associated with greater success rates (Auraaen et al., 2016[12]). Smoking cessation interventions can be provided in the form of pharmacotherapy, most commonly Varenicline and Bupropion, as well as nicotine replacement products such as nicotine patches or chewing gums, as well as through individual or group counselling provided by primary care physician or other authorised healthcare personnel. Often the interventions are combined; participation in support groups or therapy is a prerequisite for receiving smoking cessation coverage in Israel, the Netherlands and Sweden. A number of OECD countries have already introduced coverage for smoking cessation. In Belgium and France eligibility for accessing smoking cessation support (prescription drugs) is tailored to key population groups, notably COPD suffers as well as pregnant women and young people in France. Especially in light of the success of Chile’s Vida Sana counselling and physical activity programme in primary care, expansion of primary-care based services to smoking cessation could be considered. Coverage for such interventions could begin in a stepwise manner, for instance following the example of France and Belgium and starting with vulnerable groups such as COPD sufferers.
The prevention of harmful alcohol use is another area where Chile has made important steps, but which could benefit from further expansion. Alcohol consumption has increased in the last 6 years, with the percentage of people drinking in the previous 30 days increasing from 40.5% to 46% (Observatorio Chileno De Drogas, 2017[17]). The number of days of consumption during those 30 days has also increased slightly, from 4.2 days to 4.4 days. In 2011, a new National Service for Drug and Alcohol Prevention and Rehabilitation (SENDA) was launched to implement the National Strategy on Drugs and Alcohol 2011-2014. The National Strategy promotes the prevention of alcohol use through interventions in schools, workplaces and the community (Ministerio del Interior y Seguridad Pública, 2011[18]). The SENDA’s approach on alcohol consists of three areas of intervention: drink-driving controls, regional action plans, and community prevention plans on risky consumption (SENDA, 2018[19]).
The regional action plans are designed by the regional directorates of the SENDA, together with SEREMIs and local services. The plans aim to identify specific problems with alcohol in the region and tailor the approach to the local situation. Actions under the regional plans include addressing specific neighbourhoods with high alcohol use prevalence, reviewing regional patent fees, and working with local retailers to promote responsible sales (SENDA, 2018[19]). The community prevention plans follow a similar tailored approach, working together with the municipalities and local communities. These plans are then approved by the municipal council, to lend them political support (SENDA, 2018[19]).
In addition to its national strategy, Chile has implemented a range of alcohol policies to reduce alcohol consumption, including excise taxes, minimum drinking age (18 years old), restrictions on sales hours and density, and a maximum legal blood-alcohol level for driving (0.03) (World Health Organization, 2014[20]) (Giesbrecht et al., 2013[21]). However, Chile does not have comprehensive legal restrictions on alcohol marketing, nor legally mandated warning labels on alcohol containers.
While Act No. 19.925 prohibits the advertisement of alcoholic products to children and generally within 100 metres from a school (DLA Piper, 2016[22]), there is no law restricting the marketing of alcohol to the general public. The 2011-2014 National Strategy does recognise the importance of restricting alcohol marketing as a public health intervention, but only discusses plans for a voluntary, self-regulation plan (Ministerio del Interior y Seguridad Pública, 2011[23]). Regulation of advertising during certain times or for specific media is a common approach in many OECD countries, and Chile could consider implementing this alongside voluntary approaches (Sassi, 2015[6]).
Alcohol products in Chile do not require a health warning label. Current regulation exists regarding the labelling of alcohol products, which includes an obligation to display the alcohol content, but there is no requirement to include a specific health warning on the label (International Alliance for Responsible Drinking, 2017[24]). A number of other countries do require alcohol product labels to warn consumers about health consequences of excessive alcohol consumption (Sassi, 2015[6]). For example, in France, alcoholic beverages are required to carry a written warning regarding the impact of alcohol during pregnancy, or to include an icon to this effect (Figure 1.7).
Figure 1.7. Alcohol warning label in France
Source: (Eurocare.org, 2011[25]).
Especially considering the fact that Chile is ahead of the curve with its marketing restrictions and warning labels for unhealthy food and drinks, it may wish to implement similar policies for alcohol products.
Preventive health checks – Examen de Medicina Preventiva
Under AUGE a series of preventive checks, the Examen de Medicina Preventiva or EMP are included as an entitlement for all beneficiaries of Fonasa and Isapres. The EMP are periodic voluntary health assessments which seek to support the detection of high-prevalence diseases in Chile. EMS are targeted at particular populations, defined based on age and sex, for example pregnant women, newborns, or older adults (see Table 1.1). Other tests are undertaken in line with particular risk factors, for example women who have had breast cancer should have more regular mammography (Superintendencia de Salud - Departamento and Estudios y Desarrollo, 2015[26]). EMP tests are delivered through primary care, with funding coming from the municipalities which are responsible for primary care delivery in the Chilean system. Some of the pay-for-performance incentives included in primary care are also tied to the EMP.
Table 1.1. Examen de Medicina Preventiva in Chile – Preventive Health Checks
Source: Adapted from (Fonasa, 2017[27]).
However, uptake of the EMP tests is low, with just eight tests meeting expected coverage targets in 2014-15 (see (Superintendencia de Salud - Departamento and Estudios y Desarrollo, 2015[26]).. For instance, only 0.4% of adults had their height and weight measured, compared to the target 100%, and only 1.1% of people were asked about their smoking habits, compared to a target 100% (Superintendencia de Salud - Departamento and Estudios y Desarrollo, 2015[26]).
The explanation for some of the low rates of EMP checks can be expected to be similar to the drivers of low cancer screening coverage explored in Chapter 3, notably low public awareness of availability and importance of the tests, problems with access and availability of services, poor uptake by providers, and weak monitoring of the rate that the tests are undertaken. The effective approaches for increasing the rate of checks should be focused on improving public health literacy, more targeted and personalised attempts to invite high risk groups for screenings, and ensuring good geographical access. Given the large number of EMP checks for which the targets are missed, it may be that Chile should put particular focus on increasing the uptake of a few key checks, in line with public health priorities. The undertaking of these tests in particular could then be encouraged, both amongst health professionals in clinics and primary care settings and the population. A more focused approach could also mean undertaking some tests on a less regular basis but while aiming for greater population coverage, or targeting only high-risk groups with annual tests.
Tertiary programmes
The aim of the Preventive Health Checks is to provide timely treatment to control the disease. This tertiary prevention is guaranteed under two schemes: the Plan de Acceso Universal de Garantías Explícitas (Plan AUGE) system, which currently provides guarantees on access and timeliness for 80 prioritised problems; and Ley Ricarte Soto (LRS), the financial protection system for diagnosis and high-cost treatment, which provides financial coverage and establishes deadlines for the administration of treatments (Fonasa, 2017[28]).
However, these do not cover early treatment for all conditions included in the Preventive Health Checks – either because the treatment is not guaranteed within a certain time frame, or because the treatment is guaranteed only for specific target groups (Fonasa, 2017[28]). For example, there exists no guaranteed timely treatment for syphilis, UTIs, or tuberculosis. For hyperthyroidism only people over the age of 15 are guaranteed timely treatment, while the Checks include hyperthyroidism in new-borns. In May of 2017, the Ministry of Health established a specific Working Group to address this issue.
People identified as having cardiovascular issues, including diabetes and high blood pressure, are referred for tertiary prevention to the Cardiovascular Health Program (PSCV) (Ministerio de Salud, 2017[29]) (see Box 1.4. Programa de Salud Cardiovascular (Cardiovascular Health Program). Referred patients are counselled and treated pharmacologically by a multidisciplinary team to achieve target values in their blood pressure, HbA1c and LDL-cholesterol (see box for more information).
Box 1.4. Programa de Salud Cardiovascular (Cardiovascular Health Program)
The Programa de Salud Cardiovascular was created in 2002, by the merger of the programmes for diabetes and hypertension. Its aim is to reduce the morbidity and mortality from cardiovascular diseases. It is delivered in the primary care centres by a multidisciplinary team, and financed from the capitated payment paid to primary care providers, with supplements from the Ministry of Health and other funds.
People who are identified as having one or more of the following characteristics are entered into the programme:
Arterial hypertension
Diabetes mellitus type 2
Dyslipidaemia
A history of cardiovascular disease
Active smoker and over 55 years old
In December 2017, over 2.3 million people were enrolled in the programme, of which 80% had high blood pressure, 48% dyslipidaemia, and 37% diabetes.
A patient is admitted to the PSCV programme during a medical consultation where a set of baseline examinations are reviewed. After this intake, patients enter into the first phase of the programme, where they are to achieve specific goals with regards to their blood pressure, HbA1c and LDL-cholesterol levels, according to their cardiovascular risk. To meet these targets, patients receive counselling on healthy eating, physical activity, smoking cessation, and alcohol consumption, in combination with pharmacological treatment.
Once these targets are achieved, patients move into the second, follow-up phase. Depending on their characteristics, the follow-up occurs between 3- to 12-months apart.
Over the last ten years the programme has become more effective, as the percentage of people reaching their target blood pressure increased from 48% in 2006 to 68% in 2017. The number of people with their HbA1c under control increased as well, from 33% to 45%. There are, however, marked differences between sexes, as 63-65% of women achieved their targets goal, compared to only 35-37% of men.
Sources: (Ministerio de Salud, 2017[29]).
1.2.4. Emergency response mechanisms
In Chile, the National Emergency Office of the Ministry of the Interior and Public Security (ONEMI) is in charge of planning, coordinating and executing activities aimed at prevention, mitigation, alert, response and rehabilitation in the face of threats and emergency situations.
Health Sector Response Teams were developed to improve the capacity of Chile to comply with the implementation of the International Health Regulations (WHO, 2003[30]). The first response teams were the rapid response teams (ERR) that were created from the Department of Epidemiology in the Ministry of Health following these recommendations, began their training in 2009. The Health Sector Response are composed of trained and specialised personnel available at all times to travel to disaster areas to perform various emergency response, disaster and epidemic response tasks with the preparation. In addition to the national teams the Regional Authorities (SEREMIS) and the Health Services can work together to establish Local Response Teams, in charge of collaborating in emergencies or disasters within their jurisdiction if the emergency does not exceed the capacity of local response. Local teams have their own training, selection, activation and certification mechanism.
During the year 2014, as a result of the preparation for the possible importation of Virus Ebola into the country, a joint effort was initiated between the Division of Healthy Public Policies and Promotion (DIPOL) and the Division of Health Planning (DIPLAS) to reinforce the Response of these ERRs. The success of the initiative, coupled with the constant emergencies that occurred in the country, led Chile to further expand the capabilities of the teams with the inclusion of health care network officials. In 2015, the Department of Management at Risk of Emergencies and Disasters (DEGREYD) was added to implement a training plan focused on delivering a more comprehensive response through multidisciplinary teams.
During 2016, the departments involved in the initiative, together with the Technical Committee on Emergencies and Disasters of the Ministry of Health, worked together to consolidate progress, generating technical guidelines for the formalisation of equipment, diversification and specialisation, and developing a consolidated strategy to strengthen local capacities to deal with emergencies, disasters and epidemics.
Chile’s disaster response preparations for earthquakes and tsunamis are recognised as robust (Center for Excellence in Disaster Management, 2017[11]). Through a combination of strict building code enforcement to ensure that buildings do not collapse in an earthquake, and tsunami early warning systems, the loss of life from significant earthquakes – most recently a 8.2 magnitude earthquake in 2014 – has been reduced. Chile has also contributed to the development of the Sendai Framework for Disaster Risk Reduction, a global plan for reducing disaster losses.
1.3. Leadership and governance
1.3.1. Key actors in the public health system
High-level public health leadership from within the Chilean Health System comes from the Technical Secretariat for Social Determinants and Health in All Policies (Secretaría Técnica de Determinantes Sociales y Salud en Todas las Políticas), which is responsible for installing the necessary processes within the Ministry of Health in order to ensure the inclusion of the principals of equity, social determinants of health and health in all policies in health actions. The Secretariat is composed of representatives of both undersecretaries of the Ministry of Health, FONASA, CENABAST, ISP and Superintendence of Health.
The organisation of the Ministry of Health into two sub-secretariats, one for Health Networks and the other for Public Health, in itself elevates the importance of public health issues for the government. The Under-Secretariat for Public Health, which is led by a Vice-Minister for Public Health, has oversight over the Regional Health Authorities – which themselves have an important role in public health – over for public and private providers, and has oversight over Fonasa and Isapres (see Figure 1.8).
Figure 1.8. Chilean Health System Governance
Source: Gobierno de Chile / Ministerio Salud.
Indeed, a number of government actors are involved in protecting population health and delivering policies to promote good public health (see also Figure 1.8). They include:
The Ministry of Health is organised through two Subsecretariat: i) the Subsecretariat of Public Health; and ii) The Subsecretariat of Assistance Networks. The Subsecretariat of Public Health ensures all Chileans’ right to health protection, exercising regulatory functions to ensure access and quality, and sustained improvement of population health. The Subsecretariat of Assistance Networks mission is to regulate and supervise the function of health networks which deliver health care services.
The Regional Ministerial Secretariats (SEREMIS) ensures compliance with the national health norms, plans, programs and policies established by the authority, and adapt health strategic plans and programs to the reality of the respective region, within the framework set for this by the national authorities. This role includes, for instance, enforcement of Chile’s Law 20.606 on food sales in supermarkets and schools. The Regional Ministerial Secretariats also ensure the protection of the populations from environmental risk, and also seek to ensure environmental protection measures and compliance with provisions of the sanitary code and environmental laws and regulations.
The Superintendence of Health supervises legal guarantees including those under AUGE, the compliance of health providers with accreditation standards, and the legal and financial obligations of social security institutions;
Fonasa, which is the Fondo Nacional de Salud (National Health Fund), is the national public insurance scheme, which guarantee universal quality, convenient health coverage to the national population with financial protection to the entire insured population, including public health care.
Responsibilities of the Institute of Public Health include laboratory controls, quality control of medicines, medical food and other products subject to sanitary control, the authorisation and registration of medicines and other products, supervising the accrediting entities of the laboratories, and monitoring and reporting to the Ministry of Health around the surveillance of antimicrobial resistance.
CENABAST is Chile’s health procurement agency, which ensures the availability of medicines and medical supplies to health care providers, including the majority of Chile’s public pharmacies. All public procurement is controlled by Chile COMPRA, in the Ministry of Finance. Contracts for the procurement of hospital equipment, for example MRI scanners, do not pass by CENABAST but are controlled by Chile COMPRA.
The leadership of the Ministry of Health on important public health reforms – most notably reforms and programmes to reduce obesity rates – are notable. An ambitious series of reforms to tackle obesity, detailed in Chapter 2, include the introduction of a sugar-sweetened beverage tax, food advertising restrictions, the introduction of food labelling as well as school-based interventions implemented by the Ministry of Education in close collaboration with the Ministry of Health. Indeed, the establishment of a new law on food labelling and advertising, Ley 20.606 Sobre la Composición de los Alimentos y su Publicidad, in June 2016 marks a significant achievement for the Ministry.
Additionally in 2013 a legal architecture was created for a government-wide approach to promoting healthy living and well-being, under Law 20.670 which created “el Sistema Elige Vivir Sano” (a System for Health Living) (Box 1.5). The Law established that programmes under the Elige Vivir Sano system should encompass objectives including promotion of healthy living, of sport, of outdoor activities, of self-care and of family development. The law institutionalised an intersectoral work platform for compliance with the National Health Strategy, and for achieving health priorities set for 2020.
Box 1.5. El Sistema Elige Vivir Sano
Government initiatives such as the Programa Vivir Sano, implemented in March 2011 to promote healthy eating and physical activity, are a key part of the government strategy to improve the health status of the population in Chile. In May 2013 Law No. 20,670 was issued creating El Sistema Elige Vivir Sano (The Healthy Living System), which aims to promote healthy habits and lifestyles to improve the quality of life and well-being of people. The Law established that all state institutions must incorporate policies to inform and educate the population about public health issues, and promote the prevention of risk factors linked to unhealthy behaviours.
The objectives of Elige Vivir Sano included the coordination of activities across the national, regional and local levels, delivering services to promote a healthy high-quality lifestyle; creating normative frameworks to improve health and quality of life (around tobacco, alcohol, physical activity, pollution, green areas, etc); and to monitor the evolution of ‘healthy communities’ so as to identify and address areas where challenges arise. The programme has an Interministerial Committee that acts as an advisor and in which its Ministers participate from across the government, from the Ministries of Social Development, Finance, Health, Education, Labor and Social Security, Housing and Urbanism, and Ministry of Sport.
Individual Ministries also elaborated their own plans under the Programme, for instance the Ministry of Health identified the ways in which they would contribute to the objectives of El Sistema Elige Vivir Sano. The plan set out by the Ministry of health included the prioritisation of ‘Health in All Polices’, strengthening the public health competencies of national and local health leadership, and promoting engagement between authorities and Chilean citizens. 15 regional plans were developed by the SEREMIS, which identified ways to promote citizen participation through Citizen Dialogues, Regional Public Health Forums, and a competence development programme for public sector managers and civil society leaders.
While some regulations aimed at reducing obesity have been rigorously enforced by the government, others are more challenging or may not yet be matched by sufficient oversight and enforcement. Violation of the ban on advertising unhealthy foods to children, for example, have led to a number of fines by the National Consumer Service (see Chapter 3). Enforcement of Law 20.606 is undertaken regionally by the SEREMI, but may not be sufficient. For instance some examples where foods are not correctly labelled have been identified by consumer groups (see Chapter 2) (Corporación Nacional de Consumidores y Usuarios - CONADECUS, 2017[31]). It may be valuable to introduce a more systematic approach to checking of food labelling procedures and the enforcement of Law 20.606, including chemical testing of nutritional content against the labelling, for instance a periodic audit at the national level. Regional-level checks on food products that are on sale nation-wide may also not be the most efficient approach.
1.3.1. Engagement across government is effective
In addition to clear public health leadership from the Ministry of Health, in particular with regards to leadership of efforts to reduce obesity, collaboration with other government departments is also commendable. While there is always room for broader and deeper collaboration across government on public health issues, the cooperation between the Ministry of Health and, in particular the Ministry of Education but also the Ministries of Agriculture, Finance, Social Development, and Sport are impressive.
Commendably, the Ministries of Social Development, Health, Education, Labour and Social Welfare, Housing, Sport and Finance have a common national strategy for promoting healthy living, under ‘Elige Vivir Sano en Comunidad’ (Choose Healthy Living in the Community) (Gobierno di Chile, 2014[32]). Launched in 2014, and encompassing a series of strategic objectives, programmes and its own budget, Elige Vivir Sano en Communidad aims to promote healthy living and healthy habits, for instance healthy eating and sport. Ministries committed to undertaking different activities to promote this overall goal, for instance the Ministry of Health would support the development of Community Health Promotion Plans (Planes Comunales de Promocion de la Salud), while the Ministry of Sport planned to promote physical activity in public spaces under the “Deporte en Tu Calle” (Sport in Your Street) programme, for instance closing streets to traffic.
Collaboration around diet in schools is a particularly successful example of cross-government working to promote better public health. JUNAEB, the department of the Ministry of Education responsible for welfare in schools and universities established the Contrapeso (‘Against Overweight’) programme along with the Ministries of Health, Sport and Agriculture. Contrapeso includes 50 measures including restriction on the sales of unhealthy foods in schools, improving the quality of food provided to students, and teaching health cooking to families. These measures are further detailed in Chapter 2.
Other select examples of cross-governmental collaboration of public health in Chile, many of which fall under the Elige Vivir Sano en Communidad strategy, include:
The Ministry of Health and the Ministry of Social Development collaborate on efforts to promote child development, including under the programmes ‘Sistema de Protección Integral a la Infancia Chile Crece Contigo’ for example, promoting breast feeding and early learning, as well as other programmes including one to develop school gardens to teach health living habits.
The Ministry of Social Development, Ministry of Sport, Ministry of the Environment and the Ministry of Education are also part of regional and local working groups to which develop efforts to tackle obesity. For instance, the Ministry of Environment contributes advice on development of healthy physical environments.
The Ministries of Health, Education and Sport have been working together to develop recommendations on physical activity for the Chilean population, and encourage health lifestyles. The Ministry of Health is part of the Interministerial Committee on Physical Activity and Sport which is a presidential advisory committee whose objective is to advise on the implementation of the National Policy on Physical Activity and Sport, aimed at expanding the participation of the population in sport, promoting healthy values and the benefits of sport and strengthening sports development. School curricula also include health topics, including about healthy living and wellbeing.
The flow of public health leadership and planning from the central to the regional and local levels appears well thought-out: SEREMIS help to deliver the national Elige Vivir Sano en Comunidad approach, and also develop cross-sectoral programmes according to the ‘Health in All Policies’ (Salud en Todas las Políticas) approach, led by regional health for a (Foros Regionales de Salud Pública). Collaboration is also strong around the ‘Chile Crece Contingo’ (ChCC, Chile Grows with You) multisectoral programme for early childhood development. To deliver ChCC the Ministry of Social Development coordinates with the Ministries of Health and Education to support early years development for vulnerable children.
1.3.2. Regional and local public health leadership
Chile has a decentralised administration, and the responsibility for organising education, social services, primary health care, parks and recreation lies with municipalities rather than the central government.
At the regional level the Regional Health Authorities in Chile (SEREMIS) – of which there are 15 – have an important role in designing and delivering public health actions. The SEREMI are responsible for both key public health safety controls, and enforcement of national public health priorities. For example the SEREMI monitor food products and nutritional labelling, and have the power to issue warnings, administer fines and recalls of food products if they identify anomalies.
The SEREMIS convene and coordinate a series of social participation initiatives, among which are the Consejos Asesores Regionales, (CAR, Regional Advisory Councils), which help to deliver the national ‘Elige Vivir Sano en Comunidad’ (Healthy Living in the Community) policy (see also Chapter 2). From 2014 the SEREMIS were also expected to develop local plans for the health promotion (Planes Comunales de Promoción de Salud) (Departamento de Promoción de Salud, 2013[33]).
SEREMIS also have an opportunity to develop cross-sectoral programmes according to the ‘Health in All Policies’ (Salud en Todas las Políticas) approach. The Health in all Policies approach in Chile has been systematically led by the Foros Regionales de Salud Pública (Regional Public Health Forums) since 2014. The Foros Regionales bring together regional authorities along with representatives of the community to develop strategic plans and actions. For example, Foros have been working to prevent Hepatitis B, improve PAP and mammography rates, reduce obesity or improve air quality (Minsal - Foros Regionales de Salud Publica, 2015[34])
Some local actors are also taking a leading role in public health policies, for example in Santiago where a multidimensional population health initiative is in place (see Box 1.6) and where the Mayor has made tackling childhood obesity a key priority (see Chapter 2).
Box 1.6. Promoting public health at the city level with Santiago Sano
The Santiago Sano programme, based in the Chilean capital Santiago, is a good example of the leadership that individual cities can take in introducing measures to improve the public health of the city. In Santiago the programme, ‘Santiago Sano, brings together stakeholders from every municipal government into 40 dedicated committees. The programme covers five key intervention areas:
Public spaces: Santiago Sano has created a network of healthy kiosks throughout the city, selling fruit, vegetables, nuts and juice. It has also set up a playground to provide young children with a safe place to be active.
Alcohol: To reduce alcohol use, Santiago has implemented a 20% surcharge on the marketing of alcohol, and a 50% surcharge on permits to sell alcohol at events in public places. In addition, community models are being developed to reduce the sale of alcohol to minors and those already inebriated.
Schools: The Nine Steps agenda was developed to improve diets and physical activity in schools, and is being implemented by the Department of Education. The interventions include healthier food options, school gardens, sport facilities and transport to and from school.
Sexual health education: The Santiago Sano programme has created dedicated ‘Friendly Spaces for Adolescents’, where they can go for sexual health counselling, contraceptives and psychological support, delivered by midwifes and psychologists.
The elderly: Santiago Sano organises geriatric evaluations for elderly people with reduced mobility, and runs three-month workshops focusing on maintaining an independent and healthy lifestyle.
Santiago and the Santiago Mayor have also made reducing childhood obesity a policy priority, as detailed in Chapter 2. In 2016 Santiago was one of Bloomberg Philanthropies ‘Mayor’s Challenge’s five Latin American prize winners.
1.3.3. Leadership from Chilean civil society
Coalición Mover (Movement Coalition) is founded Chile’s medical societies promotes physical activity amongst the public, and encourages doctors to prescribe exercise to patients. Civil society groups have also been engaged in monitoring food labelling, as well as local cycle schemes. The government has also supported the implementation of voluntary actions to promote healthy living in workplaces; around 200-250 workplaces have implemented interventions such as physical activity courses and bicycle parking spaces.
The civil society group Conadecus has also played a surveillance role since the introduction of Chile’s new food labelling laws in 2016. As Chile’s national consumer organisation, Conadecus, announced the launch of the Observatory for Food and Advertising. This observatory will regularly review food labels, ingredients and nutritional composition of food products, and advertising practices, to assess whether or not they comply with national regulations. Their aim is to improve transparency for the customers, and increase compliance by providing recommendations to the Ministry of Health (see Chapter 2 for further details).
In addition, the group Educación Popular en Salud (EPES, Public education in health) is a civil society organisation engaged with improving the health and wellbeing of vulnerable people and communities, principally through education, activism and social mobilisation (Educación Popular en Salud (EPES), 2017[38]). Founded in Santiago in the 1982 the group is now active across Chile. EPES is engaged with a wide range of public health issues, including tobacco use, HIV/AIDs and nutrition and food, and undertakes a mix of educational activities, lobbying work, training and workshops, and efforts to promote access to services. For example, EPES has promoted breast self-examination, consulted with the Ministry around tobacco legislation, and promoted citizen monitoring of adherence to food labelling legislations.
Medicos Sin Marca is another noteworthy civil society group, which brings together Chilean doctors to promote responsible evidence-based clinical practice, insulate doctors from conflicts of interest, and resist propaganda and incentives from the medical industry (for instance the pharmaceutical industry) (Médicos Sin Marca, 2017[39]). The group has suggested, for example, that efforts be made to separate the role of industry from funding of Continuing Medical Education (CME) in Chile, and that hat scientific societies, medical publications and educational activities should not receive funding from the pharmaceutical, medical devices and food industries. The group has also been supportive of the recent policies introduced to combat obesity in Chile, for instance the introduction of some limits on food marketing, and labelling and marketing restrictions which have pushed restaurant chains to reduce the sugar content in meals marketed at children.
However, in general engagement of civil society (and the private sector) does not appear to be a main pillar of Chile’s efforts to improve public health. In general the voice of civil society organisations also remains relatively weak; civil society in Chile tends to be arranged in small organisations, which limits their ability to influence and support public health objectives. However, there have been some recent steps in the right direct with regards to engaging civil society in a leadership role for public health. First, in 2015 the Institute of Public Health (Instituto de Salud Pública) opened registration for a Civil Society Council made up of not-for-profit civil society organisations. The working group is composed of 11 counsellors who will engage with the Institute of Public Health on topics including medicines and medical devices and consumer facing products (Instituto de Salud Pública de Chile, 2015[40]). Second, in 2016 the Ministry of Health established the ‘Consultative Council of the Ministry of Health’ (Consejo Consultivo de la Sociedad Civil). This initiative, which will include more than 100 representatives of health-related citizen organisations. The Consultative Council is intended to give a greater citizen voice to setting public health priorities in Chile, and incorporate citizen participation as a guiding axis of the work of the Ministry (Ministerio de Salud, 2016[41]). The Council will work in an advisory capacity for the Ministry, and is also expected to reach out to the Chilean population to gather views and prompt dialogue.
1.4. Partnerships and collaborations
1.4.1. Engagement with patient groups
The role of patients in Chile and in guiding the Chilean health system appears to be growing, and is recognised as being centrally important; in 2012 the Ley de Derechos y Deberes (Law on the Rights and Duties of Patients) was introduced, safeguarding the rights of the patient in both public and private sectors, legally establishing that the main orientation of the health system must be towards health system users, and informing the "Charter of Rights and Duties of Patients", which specifies each of the aspects indicated in the new law (Ministerio de Salud, 2012[42]). Chile has a small number of patient groups, which have grown both in size and influence over the past decade. Around 60% of these groups are also brought together under the Alianza Chilena de Agrupaciones de Pacientes (Chilean Alliance of Patient Groups). The Alliance aims to bring together smaller patient groups to work together with a single stronger voice, with a primary focus on expanding and improving health care coverage (Alianza Chilena de Agrupaciones de Pacientes, 2017[43]).
The introduction of GES in 2005 is reported as having increased interest by patients in engaging with the health system, and in particular advocating for the inclusion of particular conditions under AUGE. However, it appears that the mechanisms by which patients and/or patient groups are consulted over revisions to AUGE are weak, or at least that the process is not particularly transparent. Both the introduction and the operation of the Law Ricardo Soto, which provides coverage for high cost drugs, have a more central role for patient participation. Named after a prominent Chilean journalist and lung cancer patient, the law was established in part in response to popular protest around access to certain drugs including cancer drugs.
Importantly, the law also makes consultation with patients a systematic part of any changes and new inclusions of drugs. The law defines clear mechanisms by which any person or organisation can present technologies for evaluation under the law. Two Commissions, a Commission for Surveilance and Control of the Ricarte Soto Law (Comision Ciudadana de Vigilancia y Control de la Ley Ricarte Soto) and a Commission for Prioritised Recommendation (Comision Recomendacion Priorizada Ley Ricarte Soto) were also established, both of which have patient representatives who are elected to the commissions by their own patient organisation. These different channels should establish diverse formal representation and feedback with patients during and on the decision making process.
There is still likely space for further engagement with patients and patient representatives in the Chilean health system, including around public health issues. Active inclusion of patients and service users’ views in the both setting strategic policy goals for the health system and day-to-day decisions, for example hospital management or deciding on individual’s care strategies, is important from a patient rights perspective and can also improve quality of care (OECD, 2017[44]).
1.4.2. Partnerships with the private sector could be strengthened
While the Chilean government, both Ministries at the central government level and local and regional governments, appear strongly engaged in public health issues, the private sector is far less present. There is more that the government could do to engage with non-governmental actors, in particular with the private sector. In addition, the ISAPREs which hold an important place in the architecture of the Chilean health system are very passive in the field of prevention.
In general, the engagement of the private sector in public health issues is somewhat limited. There are some notable examples of non-governmental involvement with public health. The involvement of MoAgri in providing a platform for the reformulation of food is notable; the National Federation of Independent Street Markets (Confederación Gremial Nacional de Organizaciones de Ferias Libres, persas y afines) has been involved promoting healthy diets both independently and in partnership with Ministries. This group represents 60% of the nearly 86,000 traders of street markets throughout Chile. This Federation's mission is to consolidate strategies and create conditions for street markets to be strengthened and developed as the food main supply channel for households in each of the regions of Chile. Their commitment is to continue supplying the community, especially those with fewer resources of healthy products, with high nutritional value, with high quality and well-priced food. The Federation also Works closely with the Ministry of Health, the Ministry of Social Development and the Ministry of Education on educational campaigns and dissemination of healthy food information.
However, engagement of the private sector) does not appear to be a main pillar of Chile’s efforts to improve public health. A number of OECD countries have pursued a collaborative approach with civil society, and with industry in a number of public health areas. For instance in Canada and Denmark healthy eating campaigns have been implemented as a joint venture with the industry, and Ireland’s obesity policy includes a voluntary code of practice on food advertising and marketing. In other countries public-private collaboration have led to agreements between government and business stakeholders work to improving health, including for instance through reducing salt intake. In Denmark the government collaborated with several retail chains to promote a food labelling scheme which marked out healthful products, with an evaluation showing that the informational campaign impacted shopping behaviour (Mørk et al., 2017[45]).
1.4.3. Chile’s private insurance sector is disengaged from public health issues
The ISAPREs are key actors in the Chilean health system, covering 17-18% of the population. However, the engagement of the ISAPREs in public health and prevention is weak. According to the Association of ISAPREs the high rate of turnover in the insured population reduces the incentive for ISAPREs invest in prevention and public health initiatives. ISAPREs should be playing a greater role in promoting healthy living and prevention strategies. As stressed in Chapter 2 and 3, ISAPREs should recognise the attractiveness of a prevention and promotion package to attract enrolees. This said, more important savings in the medium-to-long term could be felt if all ISAPREs worked together to improve the health of their enrolees.
Insurance providers in other countries have introduced schemes to incentivise participation of enrolees in schemes to improve their health. In Japan and the State of Alabama (United States) health insurance discounts have been offered to those who participate in wellness programmes (OECD, 2010[46]). In the United States the “Affordable Care Act” required new health insurance plans cover alcohol screening and brief interventions without a co-payment (Sassi, 2015[6]). Well-designed secondary and tertiary prevention programmes have also been found to be effective in preventing the development of complications, and can produce savings for insurance companies (Green, Brancati, Albright, & Primary Prevention of Diabetes Working Group, 2012). For example, mobile technology can be used to improve the prevention and management of diabetes by providing information, medication reminders, and by increasing patient-provider communication (World Health Organization, 2016).
Above all, though there should be an expectation that ISAPREs provide care that is at least equal to provision by FONASA, for example covering counselling and diet programmes in primary care. While ISAPREs should see the potential benefits of investing in public health programmes for their enrolees, it may be that more prescriptive requirements by the Ministry are needed, for example through setting minimum prevention requirements across the industry through regulation.
1.5. Financial resources
1.5.1. Spending on health is low compared to the OECD average, but has been increasing
In 2016 health expenditure in Chile was USD 1 977 per capita, and 8.5% of GDP (OECD, 2017[47]), which is below the OECD average of USD 4 003 per capita. A significant proportion of this is voluntary/out-of-pocket spending – in Chile out-of-pocket payments represent 33% of health spending, the 5th highest share among OECD countries. Health expenditure is increasing in Chile – faster than other OECD countries – and is expected to remain fairly stable. Indeed, health expenditure in Chile increased faster than any other OECD country between 2009 and 2016, growing by 5.9% compared to the OECD average of 1.4% (OECD, 2017[47]).
Figure 1.9. Health expenditure per capita, 2017 (or nearest year)
Note: Data for 2017 was estimated by the Secretariat for those countries that were not able to provide this information. PPP stands for Purchasing Power Parities and adjusts health expenditure for differences in price levels between countries.
Source: OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.
1.5.2. When it comes to expenditure on public health, it is hard to identify, and difficult to ring fence
In terms of information gathering and knowledge development, one area of weakness that stands out in Chile is the availability of financial data pertaining to health. Generally, information on health spending in Chile remains at an aggregate level such that any detailed expenditure data specifically on prevention and public health is severely lacking; currently no overall estimates of preventive spending or any of its subcomponents are available. To be able to more effectively identify and monitor public health and prevention spending, significant development in a standardised set of health accounts is required. Chile should continue the efforts that have already begun; working with the OECD and WHO PAHO to improve their reporting on health spending by fully implementing the System of Health Accounts (SHA). While a breakdown of health spending from the financing perspective exists, an allocation of total health spending by the various health care activities (which includes prevention and public health and some important subcomponents) and health care providers is not yet reported as part of the international data collections. In the same vein, Chile should also consider producing health spending data by disease when implementing SHA.
In addition, greater monitoring of some of the public health and prevention programmes that Chile has introduced is needed. In many respects a richer and more regularly updated set of epidemiological surveillance data will help with this monitoring. However, specific efforts to monitor and, particularly to evaluate some of the programmes are needed, for instance cancer screening and early diagnosis as stressed in Chapter 3, and the comprehensive package of obesity prevention measures as set out in Chapter 2.
1.5.3. Some payment mechanisms exist to incentivise public health functions amongst key providers
In Chile, as in many countries, the decentralisation of primary care system governance under the control of municipal governments brings opportunities – notably primary care can better engage and adapt to local needs – but also risks setting this crucial sector outside the broader health system priorities. Primary care practices are key actors in prevention activities in Chile, for instance undertaking health checks and screenings. Other OECD countries have focused on developing primary care as key providers of public health interventions, for example diet and nutrition counselling or smoking cessation programmes (at present Chile’s Vida Sana counselling and physical activity programme is run from primary care, but is an independent programme carried out by dedicated counsellors).
In Chile a system of payment-dependent targets for key primary health indicators are a lever by which the Ministry can set priorities at the primary care level, and could also be used to encourage primary care providers to engage with key public health objectives. A ‘pay-for-performance’ scheme attached to primary care ‘Health Goals’ was first introduced in 2002, wherein a set of 8 goals comprised of 10 indicators are set at when met they deliver a salary bonus for health care workers (Ahumada, Herrera and Tadiri, 2017[48]). Each year an index of priorities is set by the Ministry, and the targets attached to them are then negotiated between the health service and the municipality, for instance the percentage of the covered population who should receive a certain service, or a required improvement in outcome, for instance improving coverage of Pap smears (see Chapter 3). The bonus attached to these targets is significant for the primary care workforce – and represents around 8% of workers’ salaries. In addition, some vertical goals set delivered by health services are tied to funding.
From 2005 a second component of pay-for-performance in primary care was introduced in Chile, through the ‘Primary Health Care (PHC) Activity Indicators’ which introduced a performance criteria to a share of the capitated payments that municipalities receive. If annually set goals across 16 indicators are not met, monthly capitation rates are lowered (Ahumada, Herrera and Tadiri, 2017[48]).As well as being a source of valuable primary care-level data in Chile, these pay-for-performance schemes are levers through which the central government can encourage municipal governments to align themselves with national health care goals, including around public health.
1.6. Knowledge development
1.6.1. Strengthening key data sources
Epidemiological data in Chile is primarily based on the National Health Survey, which was carried out in 2017, and prior to this in 2009 and 2003. The National Health Survey offers a rich source of data on the health status of the Chilean population. For example the National Health Survey in Chile actually includes both measured and self-reported height and weight, which is very useful, and not many surveys include both dimensions. Other sources of data in Chile include the WHO Global Information System on Alcohol and Health (GISAH) includes data for Chile on alcohol consumption (for 2014) and patterns of consumption (for 2010), and JUNAEB’s El Mapa Nutricional which tracks obesity rates in children and adolescents. The ‘National Survey of Quality of Life and Health 2015-16’ (Encuesta de Calidad de Vida y Salud) includes information on smoking rates, as well as on self-perceived health and wellbeing and sexual health.
The Encuesta de Caracterización Socioeconómica Nacional, Casen (National Socioeconomic Characterisation Survey) which is carried out by the Ministry of Social Development biannually or triannually (and was last undertaken in 2015) collects information about poverty and social development, including some health dimensions. For example the survey includes population who have had an accident or illness, who have received health care, or who had an illness that was not covered by their health care provider, and percentage of woman who have had a PAP smear, broken down by region and often by age and sex also.
However, given that the National Health Survey is a very important source of key population health data, it needs to be undertaken on a more regular basis. Undertaking the survey every eight years – which is the time elapsed between the most recent two Health Surveys – is not sufficient to effectively monitor changes in non-medical determinants of health, or to assess the impact of public health policies. Many other countries OECD countries, for instance Italy, France, Canada and England, have surveys much more regularly, even annually. Mexico also has a health survey (ENSANUT), which takes place every 4 years (last one was in 2016), and includes measuring of height and weight. The survey should not be seen as an ad-hoc undertaking, but rather should be a regular part of public health policy. It may be that an established timetable for undertaking the survey needs to be set – for example every 2 to 4 years – and/or that that responsibility for the survey is shifted out of the Ministry to an a-political institution, for instance the Public Health Institute, which might include the survey as part of their core business. The survey should be designed to provide data in line with Chile’s guidelines and thresholds for public health issues. For example, the recommended frequency for consumption of certain foods (daily, weekly, etc) does not always match the survey questions, and the survey does not cover all food types, such as pulses, potatoes, meat, and eggs, which are included in the guidelines.
The Ministry of Health also has a number of administrative data sources and registries, linked to individual national ID numbers, including hospital admissions, an immunization registry, an HIV information system, and a mandatory notification system for select communicable diseases. Some exchange of information agreements have also been the Ministry of Health and other institutions, such as the Ministry of Social Development, the police, and others.
In many respects information on the uptake of public health activities is good. For example uptake of the Vida Sana counselling and physical activity programme in primary care appears well-monitored (see Chapter 2), uptake of the Examen de Medicina Preventiva is recorded (see 1.3.2) and rates of cancer screening are systematically recorded (see Chapter 3). However, space still remains to collect and exploit data more effectively. Notably, a greater capacity to use data to identify individuals with high risk more efficiently and effectively is recommended as part of strengthening cancer screening, but a similar approach could be applied to other disease risks, for example as part of a more tailored approach to applying the Examen de Medicina Preventiva. A more data-driven approach system-wide also demands efforts to integrate data from the private sector; at present data on the activities and patients under Isapres is not systematically included in national data sources. Some data from Isapres is collected by the Superintendency of Health, but availailability and connectedness with other data sources is limited.
1.6.2. Promoting health literacy around public health
When it comes to public health Chile appears to be fully engaged with public education, and improving public health literacy, at least in some key domains. While engagement with patient groups could still stand to be strengthened (see 1.5.1) public education is clearly a priority in Chile. Public health literacy begins at the school level, where JUNAEB runs a comprehensive campaign around healthy eating and obesity. The introduction of clearly understandable labels indicating the nutritional value of packaged food is also a clear step towards improving public understanding of health eating (see Chapter 2).
Earthquake and tsunami drills, education and alerts are also a part of Chilean life, and education around earthquakes begins at school age. Chile’s ‘Plan Francisca Cooper’, also known as ‘Operación Deyse’ sets out that each school must have an earthquake response plan, students must understand how to respond to an earthquake, and drills must be undertaken regularly. In schools in tsunami risk zones the response plan must also include evacuation to an area 30 metres above sea level. Indeed, panels indicating tsunami risk are in place in coastal areas.
Recent campaigns have included campaigns to prevent HIV/AIDS. For example the HIV/AIDS strategy focuses on comprehensive HIV prevention, including promoting condom use, HIV testing, ARV treatment and adherence, and prevention of STIs (Ministerio de Salud, 2017[49]). The campaign includes segments for television and radio, as well as roadside posters, and internet and social network targeting. The campaign, run by the Ministry of Health, was designed in collaboration with civil society groups including the National Council of HIV/AIDS and Human Rights (Mesa Nacional de VIH/SIDA y Derechos Humanos), the National Council of Indigenous Peoples on HIV/AIDS and Human Rights (Mesa Nacional de Pueblos Indígenas en VIH/SIDA y Derechos Humanos) and the National Council of Trans Persons on HIV, Human Rights and Health (Mesa Nacional de Personas Trans, en VIH, Derechos Humanos y Salud).
While campaigns to promote public awareness of key public health issues appear to be generally well-used in Chile, weaknesses in health literacy more generally might need further attention. For example, Chapter 3 sets out that low public awareness and understanding of cancer screening protocols may be discouraging some women (with regards to breast and cervical cancer) from participating. Chile may look for more ways to increase patient participation in both health promoting and disease-detection activities, and encourage patients to better understand their own health, for instance through accessing their own patient data. OECD has identified informed-patient choice, promoting patient education and investing in decision aids for patients as key dimensions of building health literacy (OECD, 2017[44]). In some countries patient-friendly data portals have been a key part of this strategy, for example in England where the MyNHS website gives key performance data on health care providers, or in Portugal where patients can easily access their own care data in a user-friendly format
1.7. Workforce
1.7.1. Human resource shortages are affecting public health care, but the Ministry is addressing the problem head-on
Chile has a shortage of medical staff, which is understood to put strain on the health system. Compared to other OECD countries Chile has low numbers of both doctors and nurses: in 2016 Chile had 2.3 licensed physicians per 1 000 population, compared to the OECD average of 4.9 (number of practicing physicians was not available); in 2015 Chile had 2.4 licensed nurses per 1 000 population, compared to the OECD average of 14.5 (OECD, 2018[2]). Particular pressure points affecting the delivery of public health care are reported. In the primary care sector turnover is high – about half of Chile’s doctors are Generalists – with reports of high levels of job strain, high patient numbers, and high levels of fragmentation. Uneven geographical distribution of the health workforce is another reported challenge, especially for specialists.
The Ministry of Health does appear to be engaging with the challenge health workforce shortages. In 2015, the Government announced a Plan for Recruiting, Training and Retaining Specialist Doctors. This plan should add 1 100 new primary care doctors and 4 000 specialists and dentists over 4 years (Gobierno de Chile, 2015[50]), and contribute to an increase the overall workforce numbers in the years to come. The challenge of geographical distribution of medical staff is being addressed in part through the organisation of specialist regional hubs – for example cancer hubs in the North and the South – as well as through the use of telemedicine for specialist consultations.
1.7.2. To ensure that the public health workforce is able to deliver public health services, Chile could advance its public health and prevention training
At present Chile does not have a registry of public health specialists, and there is no specific guidance when it comes to public health specialist training. Each university which offers public health specialist training defines their own curricula. Likewise, each medical school defines its own curricula, leading to wide variety in the extent and manner in which public health is included. The only common standard which all medical schools follow is the contents profile for which every medical doctor is tested in the National Single Exam of Medical Knowledge at the end of their training.
When it comes to strengthening Chile’s health workforce in the area of public health and prevention, Chile may wish to focus attention on building capacity in primary care. Building capacity to manage health risks in primary care has been a successful approach taken in other OECD countries (OECD, 2017[44]). Primary care can deliver public health services such as targeted education programmes, counselling, cost-effective screening programmes and effective management of chronic diseases.
In Chile the primary care sector is already functioning as a key pillar to efforts to tackle obesity, through the Vida Sana programme. Primary care practitioners are also expected to undertake the EMP screenings and tests, which are incentivised through the pay-for-performance indicators in primary care. Nevertheless, there may still be scope to expand the contribution of the primary care sector.
To enable primary care to act as the provider of public health, nurses and other ancillary functions can be trained to deliver public health services. Throughout the OECD, there exist a number of examples of countries where nurses, community health visitors and other support personnel are trained and empowered to provide counselling, screening and preventive care (see Box 1.7) and Chile may find that following this example is an effective way to expand the public health workforce (Maier, Aiken and Busse, 2017[51]).
Chile already uses nurses for some public health interventions. For example, 92% of PAP smears are done by midwives or nurses in primary health clinics (Suarez and Prieto, 2005[52]). However, the Vida Sana programme is delivered by physicians, dieticians, psychologists and physical therapists. There might be space to involve nurses and other support staff in this programme, especially considering its current low coverage of the eligible population (DIPRES, 2016[53]).
Box 1.7. Building public health capacity in primary care through nurses and other ancillary workforce
Throughout the OECD, there exist a number of examples of countries where nurses, community health visitors and other support personnel are trained and empowered to provide counselling, screening and preventive care. In Canada, Hungary and Brazil nurses are delivering key public health services, and taking on tasks that were previously performed solely by physicians.
Hungary
Before 2010, cervical cancer screening in Hungary was performed solely by gynaecologists. Due to limited access to these specialists, screening participation rates remained low at only 10%, and were particularly low in rural areas. To address this issue, the scope of practice for “health visitors” was expanded in 2010. Health visitors – also called public health nurses – are qualified to provide health promotion advice, health check-ups, immunisation, screenings and preventive care to women, newborns, school children and adolescents. Since 2010, health visitors are also authorised to perform cervical smears after having successfully completed additional training and being licensed to perform this activity. The number of health visitors trained has rapidly increased in recent years, from 250 in 2014 to 1 400 in early 2016 (Maier, Aiken and Busse, 2017[51]).
Canada
In Canada, Nurse Practitioners (NP) are become increasingly common in primary care. In British Columbia, a study showed that NPs provided 20-30 minute consultations per patient instead of 10 minutes by GPs (Roots and MacDonald, 2014[54]). NPs used the extra time for public health activities, including health promotion advice, disease prevention, assessments of complex situations and case management. In addition, NPs often introduced a new, community- and population-based focus to their practices. Activities provided by NPs included outreach activities outside the office to marginalised populations, which was not previously done by GPs GPs (Maier, Aiken and Busse, 2017[51]).
Brazil
In Brazil, primary health care is delivered through a community approach. Family Health teams, consisting of a physician, nurse, nurse assistant and up to 6 full-time community health agents, cover a defined population of up to 1 000 households. The community health agents, who are lay people from the community, provide an essential part of public health services by visiting families, identifying issues or risk factors, and supporting their access to preventive care or treatment (Macinko and Harris, 2015[55]).
1.8. Conclusion
Chile has a well-functioning, well-organised and effectively governed health system and public health architecture, which both appear to be in good shape to tackle some of the significant public health challenges that Chile faces. Perhaps the biggest among these challenges is the significant burden of obesity amongst the Chilean population, both adults and children. This burden of obesity, and the concurrent health problems, would be a strain on any health system, but Chile is showing itself to be capable of thorough and determined policy making across different sectors of government, as discussed in Chapter 2. Other public health challenges are intertwined with the organisation of the health system; some advances in cancer screening and treatment appear held back by insufficient health infrastructure and human resources, and gaps in health care coverage (Chapter 3). Meanwhile, health system funding remains tight, and there is some question of a need for a significant health system reform, in part to address a serious budget deficit.
Having shown a clear capacity for decisive policy making, effective health system leadership and reform, a key challenge for Chile now will be to find the right balance between ambitious and innovative policy packages – for instance the range of policies to tackle obesity and overweight, or to effectively engage with personalised medicine – and getting some of the basic building blocks of the public health system right. In some key areas – notably health data and information, some areas of health system infrastructure and resources, and some technical advisory domains – there are weaknesses that risk rendering existing policies approaches less effective, and becoming increasingly important obstacles to implementing good policies in the years to come.
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