Transcript Mother & Child Health Protection Policy, Chile
Slide 1
MATERNAL-CHILD HEALTH POLICY
DR. RENE CASTRO S.
Regional Forum on Social Protection in Health for Women,
Newborn and Child Populations in LAC – Lessons learned to
prompt the way forward.
Tegucigalpa, 8 -10 November 2006
Slide 2
“Maternal and child mortality is one of
the demographic facts that can be
influenced in a more or less serious way
since it depends a great deal on the care
that the mother and child receive before,
during and after birth.”
Dr. Salvador Allende, Minister of Health (1940)
Slide 3
LA REALIDAD
MEDICO – SOCIAL
CHILENA
“Chilean Medical – Social Reality”
Slide 4
Maternal, perinatal and child
health
indicators
reflect
a
country’s economic, cultural,
social and health development.
Slide 5
Risk of death in Latin America and the Caribbean
( compared to USA and Canada)
Relative Risk
Child Mortality
Maternal Mortality
3-4
9 - 10
Slide 6
Until 1920, the health situation in Chile qualified
as a “savage state”: the highest child
mortality in the world.
1952: Life expectancy at birth - 54.9 years –
among the lowest at the global level, reflecting
the poor living conditions in the country.
Slide 7
INFANT MORTALITY
PER 1,000 LIVE BIRTHS
Slide 8
1 1
Life expectancy at birth
Sex
Sex Differential
Men
Women
PERIODS
LIFE EXPECTANCY AT
BIRTH ANDHALF LIFE
1920-2002
1919-22
1929-32
1939-42
1952-53
1960-61
1969-70
1980-85
1991-92
2001-02
30.90
39.47
40.65
52.95
54.35
58.50
67.37
71.37
74.42
32.21
41.75
43.06
56.83
59.90
64.68
74.16
77.27
80.41
1.31
2.28
2.41
3.88
5.55
6.18
6.79
5.90
5.99
2
Average Age
Men
Women
28
44
48
62
63
66
72
75
77
29
46
50
67
70
72
78
81
83
1. The number of years a newborn would live if age-specific mortality rates at time
of birth (shown in Table) continued throughout the child’s life.
2. Age at which 50% of the survivors from a cohort of 100,000 live births are still
alive; according to mortality observed at the time referred to in the Mortality Table.
Infant Mortality3
PERÍODS
CHILD MORTALITY AND
YEARS OF LIFE LOST
1920-2002
1919-22
1929-32
1939-42
1952-53
1960-61
1969-70
1980-85
1991-92
2001-02
Men
264.0
217.5
205.4
128.0
125.6
89.2
25.8
15.5
9.4
Women
248.7
198.7
188.5
112.4
108.3
75.4
21.6
13.1
7.5
Male
Overmortality
1.1
1.1
1.1
1.1
1.2
1.2
1.2
1.2
1.2
Years of life lost from birth to age 854
Men
54
46
45
32
31
27
18
15
12
Women
Difference
53
44
42
29
26
21
12
10
8
9
1
13
2
4
9
3
2
3. Probability of dying under one year of age at the time referred to in the Mortality Table.
4. Number of additional years that people who died should have lived. The difference
between one period and another indicates the impact of the change in mortality on human
life.
Slide 9
MATERNAL-CHILD CARE
• 1901 National Children’s Board
• 1924 Workers’ Insurance Law
• 1942 Health Units (district-level)
• 1952 National Health Service
• 1980 National Health Service System:
Ministry – Social Security – Regional
Ministerial Secretary (Seremi)
(decentralization)
• 2000 Sector reform (ongoing)
Slide 10
NATIONAL HEALTH SERVICE (1952–1979)
August 1952 Law 10.383: creates the SSS and
the National Health Service (SNS): “political will”
for the search for social balance and institutional justice
– new social pact - will allow the working and
proletariat classes to be integrated into the system.
Wide national agreement; support of the University (School
of Public Health) and the Medical Association.
Social Medicine: incorporates the fundamental
principle of the WHO, created in 1948: health as “a right
and obligation of every human being and of countries as
a group.”
Slide 11
NATIONAL HEALTH SERVICE (1952–1979)
Chile was the second country at the
global level (4 years after England); it
integrated 6 institutions that addressed
different areas of social security and health
management.
Objectives:
- reduction
mortality,
of
maternal
and
child
- control of infectious diseases,
- eradication of malnutrition and,
- coordination with other social sectors that
have links to health determinants.
Slide 12
MATERNAL MORTALITY BY CAUSE
CHILE 1951-2000
35
30
M.M. Rate
20
M.M. Rate x E-P- P
M.M. Rate x Abortion
15
10
5
0
19
51
19
55
19
60
19
65
19
70
19
75
19
80
19
85
19
90
19
95
20
00
RATE PER 10000 LB
25
YEAR
Slide 13
INFANT MORTALITY
CHILE 1980 – 2003 *
35
Infant Mort.
Neonatal Mort.
30
Late Inf. Mort.
25
20
15
10
5
(*) Rates per 1,000 LB
2
0
98
96
94
92
90
88
86
84
82
80
0
Slide 14
WOMEN’S HEALTH PROGRAM
Years
Prenatal
Family Plan.
Skilled Care
Maternal Mortality
Check-Up
Coverage
at Birth
Rate x 10,000 L. B.
%
%
%
1965
50.1
6.0
75.5
27.9
1970
52.0
13.7
81.1
16.8
1975
55.0
23.7
87.4
13.1
1980
57.4
26.7
91.4
7.3
1985
69.2
23.6
97.4
5.0
1990
85.0
17.3
99.1
4.0
1995
92.5
22.2
99.5
3.1
1998
92.6
22.5
99.7
2.0
Slide 15
S.N.S.S. CARE NETWORK
•PRIMARY CARE
General Doctor’s Offices
•
•
•
Urban
Rural
Rural Posts
250
150
> 1,100
• HOSPITAL-BASED CARE : 162/177
Slide 16
FAMILY PLANNING IN CHILE
1967: POLICY BASED ON HEALTH OBJECTIVES
a. Reduce Maternal Mortality due to Induced Abortion
(Avoid Unwanted Pregnancy) ;
b. Reduce Child Mortality associated with high
fertility;
c. Promote Family Well-being
(Responsible Parenting)
Slide 17
Total and Abortion-related
Maternal Mortality
vs. % MAC Users.
1951 -1999
35
30
30
T
a
s
a
25
%
25
20
20
15
15
10
10
5
5
0
0
1951 1955 1960 1965 1970 1975 1980 1985 1990 1995 1998 1999
Maternal Mort.
Abortion-related Mort.
% WFA using MAC
Women’s Health Program
Corrected rate per 10,000 Live Births
Source : Anuarios Demografía INE (National Institute of Statistics)
Dpto. Coordinación e Informática
Slide 18
Abortion-related Mortality 1960 - 2000
Year
Number
Rate
% Maternal
Deaths
1960
302
10.7
35.7
1970
185
7.1
42.1
1980
71
2.8
38.4
1990
23
0.7
18.7
1998
14
0.5
25.4
2000
13
0.49
26.5
2001
4
0.15
13.3
Slide 19
Foundation for a Family Planning Policy
“The Government of Chile recognizes the benefit
that the population achieves through Family
Planning activities, which allow individuals to have
the number of children with the desired spacing and
timing. For this reason, it maintains its support for
Family Planning activities in order to promote the
achievement of adequate comprehensive
reproductive health.”
October 1990
Slide 20
PROFESSIONAL DELIVERY CARE
YEAR
%
1965
74.3
1975
87.4
1985
97.4
1998
99.6
“ From empiricism to professionalism
in delivery care”
Prof. F. Mardones-Restat
Slide 21
Maternal Mortality and
Professional Delivery Care
1950 - 2001
PERCENTAGE
RATES
36
100
33
90
30
80
27
70
MATERNAL MORT. (RATE X 10,000 LB)
24
ABORT.-REL. MORT. (RATE X 10,000 LB)
21
60
PROFESS. DELIV. CARE (PERCENTAGE)
18
50
15
40
12
30
9
20
6
10
3
0
0
1950
55
1960
65
1970
75
80
85
90
94
98
2001
Slide 22
MATERNAL-CHILD HEALTH 1960 – 2000
Rates per 1,000 LB
1960
2000
Birth Rate
35.5
17.2
Total Maternal Mort.
2.99
0.2
M.M. due to Abortion
1.07
0.05
Infant Mortality
125.1
Neonatal Mort. < 28 d. 36.2
8.9
5.6
Slide 23
REDUCTION OF MATERNAL
MORTALITY IN CHILE :
LESSONS LEARNED
1950-2000
Ministry of Health, CHILE
Universidad de la Frontera
Pan American Health Organization
PAHO/USAID
Slide 24
Steps for Reducing Maternal Mortality
• Consider
M.M. to be a human rights and social justice
problem.
• Recognize that every pregnancy has some level of risk.
• Assure that skilled personnel attend births.
• Promote maternal health as a vital economic and social
investment :
Postpone motherhood.
Prevent unwanted pregnancy.
Prevent unsafe abortion.
• Facilitate access to maternal health services.
• Improve the quality of maternal health services.
• Supervise and evaluate changes.
Slide 25
...the decade in Chile...
YEAR
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Maternal
mortality
Late fetal
mortality
Early
neonatal
mortality
Infant
mortality
(x 100,000 lb)
(x1,000 lb)
(x1,000 lb)
(x 1,000 lb)
40.0
35.4
31.0
34.4
25.3
30.7
23.0
22.3
20.3
22.7
18.7
5.8
5.9
5.7
5.3
4.6
4.6
4.5
4.5
4.3
4.1
4.3
6.8
6.4
6.1
5.3
5.2
4.6
4.8
4.5
4.5
4.5
4.3
16.0
14.6
14.3
13.1
12.0
11.1
11.1
10.0
10.3
10.1
8.9
Slide 26
PEDIATRICS, 10 April 2006
Slide 27
MATERNAL – CHILD HEALTH SITUATION
Stable health policies during the last 50
years
Institutionalized National Health System
Human resources that are committed to
their work
Culture of health among the population
Slide 28
“Chile is better - Health Reform”
Slide 29
The Health Planning Process1
Values-based
Framework
(Vision)
General
Objectives
Specific
Objectives
Interventions
(AUGE)
Implementation
of Public Health
activities for the
entire
population
Provision of
preventive and
early diagnostic
services to all
individuals
Materialization of a
system of universal,
equitable and sufficient
protection when facing
unpreventable illnesses
Guarantee of
quality services
for everyone
Health Determinants
Social Policies (Educational, Work-related, Economic)
Organized System for the Promotion, Prevention and Recovery of Health
Individual
Physical environment
Behavior
Social environment
Actions linked to health
Socio-economic level
Risk factors
Biological
Social participation
Characteristics
State of health: of the population
and by socio-economic level
1
Adapted from “Healthy People 2010,” US Department of Health and Human Services,
January 2000
Slide 30
SEXUAL AND REPRODUCTIVE HEALTH
“DESIGN AND IMPLEMENTATION OF HEALTH PRIORITIES
Chilean Programmatic Reform”
Slide 31
REPRODUCTIVE HEALTH
PRECONCEPTION
CARE
+
PRENATAL
CARE
+
DELIVERY AND
POSTPARTUM
CARE
=
HEALTHY MOTHERS
AND NEWBORNS
+
NEONATAL
CARE
Slide 32
Health Objectives: Cornerstone of the Reform
•Improve the health objectives attained
–Child health, women’s health, infectious
diseases
•Confront the challenges that result from aging
and other changes in society
–Determinants of the health situation, primary
causes of death and disability
•Reduce health inequalities
–Living conditions and determinants, health
situation, access to health
•Provide services according to the population’s
expectations
–Financial justice, care according to
expectations, quality of care
“Health Objectives for the
Decade 2000-2010”
Slide 33
Model for Comprehensive Health Care
Primary Care constitutes the
strategic axis for Health Reform
Community component
Inter-sectoral
Health
promotion
Service network
Disease
prevention
Management
team
PHC
Targeting
by risk
Welfare component
Humanized
Entire life
cycle
F
a
m
i
l
y
Slide 34
Unwanted Pregnancies
Health Objectives and Goals for Unwanted Pregnancies
Impact Goals:
•Decrease the gap between desired and observed fertility: the gap between desired and
observed fertility should be under 20%
•By age group, maternal educational level, socio-economic level, experience with use
of contraceptive methods (methods used, duration of use)
•Reduce pregnancies in adolescents: see Chapter 2 on Risk Factors, Sexual Behavior
•Reduce abortion-related maternal mortality by 50% (over the level in 2000)
•Counseling on Sexual and Reproductive Health for the population at greatest risk
of abortion (detected using predictive instrument)
•Coverage for Fertility Regulation: by five-year age groups
•Audit of complicated abortions by cause at the level of hospitals and/or primary
care establishments
Slide 35
mortalidad
materna y por aborto,mortality,
Chile 1990-2004
Maternal
and abortion-related
Chile 1990-2004
4,0
Mortalidad
Materna Mortality
Maternal
3,5
3,4
Mortalidad por aborto
3,1
Abortion-related mortality
3,1
3,0
2,5
2,3
2,5
2,2
2,3
2,0
1,9
2,0
1,1
0,7
0,7
0,5
0,4
0,5
0,5
0,5
0,2
0,2
0,3
0,2
0,2
2004
1,0
2003
1,0
0,9
1,7
1,7
1,3
1,3
1,5
1,7
2002
3,5
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
0,0
1990
x 10,000
Rates Tasas
porLB
10.000 NV
4,0
2001
4,5
Objective
Degree of progress
Reduce maternal mortality by 50%
From 1.9 in 2000 to 1.2 en 2010 (per 10,000 L.B.)
Advance of 29%.
2004 Rate: 1.7
Reduce abortion-related maternal mortality by 50%.
From 0.5% in 2000 to 0.25% in 2010 (per 10,000 L.B.)
Reached.
2003 Rate: 0.2
Reduce mortality due to obstetric complications.
47%
1999 Rate: 0.53 ; 2003 Rate: 0.28
Reduce adolescent pregnancies by 30%.
Fertility rate from 65.4 to 46 per 1,000 women age 15-19
years old.
Advance of 77%
2003 Rate: 50.3
Reduce the gap between desired and actual fertility:
Gap between desired and actual fertility under 20%.
Reached.
Global fertility rate of 1.9 children per women in
2003.
SO 1: Maintain the achievements attained
Slide 36
Infant mortality and its components, Chile 1995-2004
Mortalidad Infantil y sus componentes, Chile 1995-2004
12
11,1
Infantil
Infant
11,1
LB1000 NV
10,000por
Rates xTasas
10,0
10,3
10
8,9
8
6,4
6,6
6
6,3
6
5,9
5,6
8,3
Salud
Infantil con avance
4
5,3
5,1
4,5
4,6
Postneonatal
Post neonatal
Neonatal
10,1
4,2
2
5
3,3
3,4
2000
2001
8,4
7,8
7,8
5
4,9
2,8
2,9
3
2002
2003
2004
5,4
0
1995
1996
1997
1998
1999
Fuente: DEIS, MINSAL.
Objective
Degree of progress
Reduce infant mortality by 25%, from 10.1 in 1999 to 7.5
en 2010.
Advance of 65%.
2003 Rate: 7.8 (2004: 8.4)
Reduce neonatal morbi-mortality.
Mortality by 12.5%.
2000 Rate: 5.6 2004: 4.4
(per 1,000 L.B.)
Reduce late fetal mortality: Rate under 3 per 10,000 L.B.
Advance of 62%.
1998 Rate: 4.3 2003: 3.5
(per 10,000 L.B.)
Prevent the occurrence of congenital anomalies (neural
tube defects).
40% incidence of N.T.D.
In the maternity wards of hospitals w/ RM base,
bet. 1999 and 2005.
SO 1: Maintain the achievements attained
Slide 37
Millennium Development Goals
GOAL 1
Eradicate extreme poverty and hunger
GOAL 2
Achieve universal primary education
GOAL 3
Promote gender equality and empower women
GOAL 4
Reduce child mortality
GOAL 5
Improve maternal health
GOAL 6
Combat HIV/AIDS, malaria and other diseases
GOAL 7
Ensure environmental sustainability
Slide 38
“This is how the AUGE works: explicit health guarantees”
Slide 39
12 September 2004
“The regime of General Health Guarantees is a health regulation
instrument that is an integral part of the Health Services Regime.”
Slide 40
12 September 2004
“The Explicit Guarantees relate to access, quality, financial
protection and timeliness.”
Slide 41
What if a boy or girl is born with an operable
congenital cardiopathy?
What if a girl or boy is born with a cleft lip
and/or palate?
What if a boy or girl is born with an operable
malformation of the spinal cord?
What if a woman needs preventive
services for a premature birth?
Slide 42
Government Program
“ A good social protection
system accompanies
people throughout their
life cycle, protecting their
first steps, …”
Slide 43
“My goal, at the end of the Administration,
is that we will have achieved the
implementation of a child protection system
aimed at leveling the development
opportunities of Chilean children in the first
eight years of life, independent of social
origin, gender, geography or household
structure.
A task of this magnitude far exceeds the
reach of traditional social policy approaches
and will require a set of programs and
instruments...”
Constitution Ceremony of the Presidential Advisor for
the Reform of Childhood Policies, 30 March 2006.
Slide 44
Comprehensive focus on social determinants
Social Protection System for Childhood
under development
Link activities for support and social services,
considering childhood to be the final subject of the
intervention, including protection networks that favor the
role and participation of the family.
WHO definition
of health
PUBLIC SERVICE
NETWORK
AND
COORDINATED
PROGRAMS
FAMILY
BOY
OR
GIRL
DEVELOPMENT
AND SOCIAL
INTEGRATION
OF THE
BOY/GIRL
Simultaneous approach to the distinct areas of the life of the boy or girl and
his/her family, understanding that each one represents a fundamental aspect:
Identification, learning, health, family environment, living conditions,
income and work.
Slide 45
The logic of the intervention
The following matrices have been developed for
each stage of the boy’s or girl’s life cycle:
•
Baby from gestation until 3 months.
•
From 3 months to 3 years.
•
From 4 to 5 years.
•
From 6 to 10+ years (4th of basic).
The matrices have a logic of continuity: the boy/girl
enters the System at the gestation stage and the
System accompanies him/her from that moment
throughout the different stages of the life cycle.
Slide 46
“The future of children is always today
Proposals by the Presidential Advisor for the Reform of Childhood Policies”
Slide 47
13.10.06
“Chile grows with you”
Slide 48
System for the Protection of Childhood
Chile Grows With You
Pregnancy control will mark the entrance of
women into the public health system.
Automatic one-time family subsidy for the entire
gestational period (R.N. Subsidy).
Pregnancy and delivery manual, organized by
weeks of gestation.
Program for the integrated development of
doctor’s visits (complement to prenatal and
healthy child controls)
.
Humanized delivery care
(AUGE 2007)
MATERNAL-CHILD HEALTH POLICY
DR. RENE CASTRO S.
Regional Forum on Social Protection in Health for Women,
Newborn and Child Populations in LAC – Lessons learned to
prompt the way forward.
Tegucigalpa, 8 -10 November 2006
Slide 2
“Maternal and child mortality is one of
the demographic facts that can be
influenced in a more or less serious way
since it depends a great deal on the care
that the mother and child receive before,
during and after birth.”
Dr. Salvador Allende, Minister of Health (1940)
Slide 3
LA REALIDAD
MEDICO – SOCIAL
CHILENA
“Chilean Medical – Social Reality”
Slide 4
Maternal, perinatal and child
health
indicators
reflect
a
country’s economic, cultural,
social and health development.
Slide 5
Risk of death in Latin America and the Caribbean
( compared to USA and Canada)
Relative Risk
Child Mortality
Maternal Mortality
3-4
9 - 10
Slide 6
Until 1920, the health situation in Chile qualified
as a “savage state”: the highest child
mortality in the world.
1952: Life expectancy at birth - 54.9 years –
among the lowest at the global level, reflecting
the poor living conditions in the country.
Slide 7
INFANT MORTALITY
PER 1,000 LIVE BIRTHS
Slide 8
1 1
Life expectancy at birth
Sex
Sex Differential
Men
Women
PERIODS
LIFE EXPECTANCY AT
BIRTH ANDHALF LIFE
1920-2002
1919-22
1929-32
1939-42
1952-53
1960-61
1969-70
1980-85
1991-92
2001-02
30.90
39.47
40.65
52.95
54.35
58.50
67.37
71.37
74.42
32.21
41.75
43.06
56.83
59.90
64.68
74.16
77.27
80.41
1.31
2.28
2.41
3.88
5.55
6.18
6.79
5.90
5.99
2
Average Age
Men
Women
28
44
48
62
63
66
72
75
77
29
46
50
67
70
72
78
81
83
1. The number of years a newborn would live if age-specific mortality rates at time
of birth (shown in Table) continued throughout the child’s life.
2. Age at which 50% of the survivors from a cohort of 100,000 live births are still
alive; according to mortality observed at the time referred to in the Mortality Table.
Infant Mortality3
PERÍODS
CHILD MORTALITY AND
YEARS OF LIFE LOST
1920-2002
1919-22
1929-32
1939-42
1952-53
1960-61
1969-70
1980-85
1991-92
2001-02
Men
264.0
217.5
205.4
128.0
125.6
89.2
25.8
15.5
9.4
Women
248.7
198.7
188.5
112.4
108.3
75.4
21.6
13.1
7.5
Male
Overmortality
1.1
1.1
1.1
1.1
1.2
1.2
1.2
1.2
1.2
Years of life lost from birth to age 854
Men
54
46
45
32
31
27
18
15
12
Women
Difference
53
44
42
29
26
21
12
10
8
9
1
13
2
4
9
3
2
3. Probability of dying under one year of age at the time referred to in the Mortality Table.
4. Number of additional years that people who died should have lived. The difference
between one period and another indicates the impact of the change in mortality on human
life.
Slide 9
MATERNAL-CHILD CARE
• 1901 National Children’s Board
• 1924 Workers’ Insurance Law
• 1942 Health Units (district-level)
• 1952 National Health Service
• 1980 National Health Service System:
Ministry – Social Security – Regional
Ministerial Secretary (Seremi)
(decentralization)
• 2000 Sector reform (ongoing)
Slide 10
NATIONAL HEALTH SERVICE (1952–1979)
August 1952 Law 10.383: creates the SSS and
the National Health Service (SNS): “political will”
for the search for social balance and institutional justice
– new social pact - will allow the working and
proletariat classes to be integrated into the system.
Wide national agreement; support of the University (School
of Public Health) and the Medical Association.
Social Medicine: incorporates the fundamental
principle of the WHO, created in 1948: health as “a right
and obligation of every human being and of countries as
a group.”
Slide 11
NATIONAL HEALTH SERVICE (1952–1979)
Chile was the second country at the
global level (4 years after England); it
integrated 6 institutions that addressed
different areas of social security and health
management.
Objectives:
- reduction
mortality,
of
maternal
and
child
- control of infectious diseases,
- eradication of malnutrition and,
- coordination with other social sectors that
have links to health determinants.
Slide 12
MATERNAL MORTALITY BY CAUSE
CHILE 1951-2000
35
30
M.M. Rate
20
M.M. Rate x E-P- P
M.M. Rate x Abortion
15
10
5
0
19
51
19
55
19
60
19
65
19
70
19
75
19
80
19
85
19
90
19
95
20
00
RATE PER 10000 LB
25
YEAR
Slide 13
INFANT MORTALITY
CHILE 1980 – 2003 *
35
Infant Mort.
Neonatal Mort.
30
Late Inf. Mort.
25
20
15
10
5
(*) Rates per 1,000 LB
2
0
98
96
94
92
90
88
86
84
82
80
0
Slide 14
WOMEN’S HEALTH PROGRAM
Years
Prenatal
Family Plan.
Skilled Care
Maternal Mortality
Check-Up
Coverage
at Birth
Rate x 10,000 L. B.
%
%
%
1965
50.1
6.0
75.5
27.9
1970
52.0
13.7
81.1
16.8
1975
55.0
23.7
87.4
13.1
1980
57.4
26.7
91.4
7.3
1985
69.2
23.6
97.4
5.0
1990
85.0
17.3
99.1
4.0
1995
92.5
22.2
99.5
3.1
1998
92.6
22.5
99.7
2.0
Slide 15
S.N.S.S. CARE NETWORK
•PRIMARY CARE
General Doctor’s Offices
•
•
•
Urban
Rural
Rural Posts
250
150
> 1,100
• HOSPITAL-BASED CARE : 162/177
Slide 16
FAMILY PLANNING IN CHILE
1967: POLICY BASED ON HEALTH OBJECTIVES
a. Reduce Maternal Mortality due to Induced Abortion
(Avoid Unwanted Pregnancy) ;
b. Reduce Child Mortality associated with high
fertility;
c. Promote Family Well-being
(Responsible Parenting)
Slide 17
Total and Abortion-related
Maternal Mortality
vs. % MAC Users.
1951 -1999
35
30
30
T
a
s
a
25
%
25
20
20
15
15
10
10
5
5
0
0
1951 1955 1960 1965 1970 1975 1980 1985 1990 1995 1998 1999
Maternal Mort.
Abortion-related Mort.
% WFA using MAC
Women’s Health Program
Corrected rate per 10,000 Live Births
Source : Anuarios Demografía INE (National Institute of Statistics)
Dpto. Coordinación e Informática
Slide 18
Abortion-related Mortality 1960 - 2000
Year
Number
Rate
% Maternal
Deaths
1960
302
10.7
35.7
1970
185
7.1
42.1
1980
71
2.8
38.4
1990
23
0.7
18.7
1998
14
0.5
25.4
2000
13
0.49
26.5
2001
4
0.15
13.3
Slide 19
Foundation for a Family Planning Policy
“The Government of Chile recognizes the benefit
that the population achieves through Family
Planning activities, which allow individuals to have
the number of children with the desired spacing and
timing. For this reason, it maintains its support for
Family Planning activities in order to promote the
achievement of adequate comprehensive
reproductive health.”
October 1990
Slide 20
PROFESSIONAL DELIVERY CARE
YEAR
%
1965
74.3
1975
87.4
1985
97.4
1998
99.6
“ From empiricism to professionalism
in delivery care”
Prof. F. Mardones-Restat
Slide 21
Maternal Mortality and
Professional Delivery Care
1950 - 2001
PERCENTAGE
RATES
36
100
33
90
30
80
27
70
MATERNAL MORT. (RATE X 10,000 LB)
24
ABORT.-REL. MORT. (RATE X 10,000 LB)
21
60
PROFESS. DELIV. CARE (PERCENTAGE)
18
50
15
40
12
30
9
20
6
10
3
0
0
1950
55
1960
65
1970
75
80
85
90
94
98
2001
Slide 22
MATERNAL-CHILD HEALTH 1960 – 2000
Rates per 1,000 LB
1960
2000
Birth Rate
35.5
17.2
Total Maternal Mort.
2.99
0.2
M.M. due to Abortion
1.07
0.05
Infant Mortality
125.1
Neonatal Mort. < 28 d. 36.2
8.9
5.6
Slide 23
REDUCTION OF MATERNAL
MORTALITY IN CHILE :
LESSONS LEARNED
1950-2000
Ministry of Health, CHILE
Universidad de la Frontera
Pan American Health Organization
PAHO/USAID
Slide 24
Steps for Reducing Maternal Mortality
• Consider
M.M. to be a human rights and social justice
problem.
• Recognize that every pregnancy has some level of risk.
• Assure that skilled personnel attend births.
• Promote maternal health as a vital economic and social
investment :
Postpone motherhood.
Prevent unwanted pregnancy.
Prevent unsafe abortion.
• Facilitate access to maternal health services.
• Improve the quality of maternal health services.
• Supervise and evaluate changes.
Slide 25
...the decade in Chile...
YEAR
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Maternal
mortality
Late fetal
mortality
Early
neonatal
mortality
Infant
mortality
(x 100,000 lb)
(x1,000 lb)
(x1,000 lb)
(x 1,000 lb)
40.0
35.4
31.0
34.4
25.3
30.7
23.0
22.3
20.3
22.7
18.7
5.8
5.9
5.7
5.3
4.6
4.6
4.5
4.5
4.3
4.1
4.3
6.8
6.4
6.1
5.3
5.2
4.6
4.8
4.5
4.5
4.5
4.3
16.0
14.6
14.3
13.1
12.0
11.1
11.1
10.0
10.3
10.1
8.9
Slide 26
PEDIATRICS, 10 April 2006
Slide 27
MATERNAL – CHILD HEALTH SITUATION
Stable health policies during the last 50
years
Institutionalized National Health System
Human resources that are committed to
their work
Culture of health among the population
Slide 28
“Chile is better - Health Reform”
Slide 29
The Health Planning Process1
Values-based
Framework
(Vision)
General
Objectives
Specific
Objectives
Interventions
(AUGE)
Implementation
of Public Health
activities for the
entire
population
Provision of
preventive and
early diagnostic
services to all
individuals
Materialization of a
system of universal,
equitable and sufficient
protection when facing
unpreventable illnesses
Guarantee of
quality services
for everyone
Health Determinants
Social Policies (Educational, Work-related, Economic)
Organized System for the Promotion, Prevention and Recovery of Health
Individual
Physical environment
Behavior
Social environment
Actions linked to health
Socio-economic level
Risk factors
Biological
Social participation
Characteristics
State of health: of the population
and by socio-economic level
1
Adapted from “Healthy People 2010,” US Department of Health and Human Services,
January 2000
Slide 30
SEXUAL AND REPRODUCTIVE HEALTH
“DESIGN AND IMPLEMENTATION OF HEALTH PRIORITIES
Chilean Programmatic Reform”
Slide 31
REPRODUCTIVE HEALTH
PRECONCEPTION
CARE
+
PRENATAL
CARE
+
DELIVERY AND
POSTPARTUM
CARE
=
HEALTHY MOTHERS
AND NEWBORNS
+
NEONATAL
CARE
Slide 32
Health Objectives: Cornerstone of the Reform
•Improve the health objectives attained
–Child health, women’s health, infectious
diseases
•Confront the challenges that result from aging
and other changes in society
–Determinants of the health situation, primary
causes of death and disability
•Reduce health inequalities
–Living conditions and determinants, health
situation, access to health
•Provide services according to the population’s
expectations
–Financial justice, care according to
expectations, quality of care
“Health Objectives for the
Decade 2000-2010”
Slide 33
Model for Comprehensive Health Care
Primary Care constitutes the
strategic axis for Health Reform
Community component
Inter-sectoral
Health
promotion
Service network
Disease
prevention
Management
team
PHC
Targeting
by risk
Welfare component
Humanized
Entire life
cycle
F
a
m
i
l
y
Slide 34
Unwanted Pregnancies
Health Objectives and Goals for Unwanted Pregnancies
Impact Goals:
•Decrease the gap between desired and observed fertility: the gap between desired and
observed fertility should be under 20%
•By age group, maternal educational level, socio-economic level, experience with use
of contraceptive methods (methods used, duration of use)
•Reduce pregnancies in adolescents: see Chapter 2 on Risk Factors, Sexual Behavior
•Reduce abortion-related maternal mortality by 50% (over the level in 2000)
•Counseling on Sexual and Reproductive Health for the population at greatest risk
of abortion (detected using predictive instrument)
•Coverage for Fertility Regulation: by five-year age groups
•Audit of complicated abortions by cause at the level of hospitals and/or primary
care establishments
Slide 35
mortalidad
materna y por aborto,mortality,
Chile 1990-2004
Maternal
and abortion-related
Chile 1990-2004
4,0
Mortalidad
Materna Mortality
Maternal
3,5
3,4
Mortalidad por aborto
3,1
Abortion-related mortality
3,1
3,0
2,5
2,3
2,5
2,2
2,3
2,0
1,9
2,0
1,1
0,7
0,7
0,5
0,4
0,5
0,5
0,5
0,2
0,2
0,3
0,2
0,2
2004
1,0
2003
1,0
0,9
1,7
1,7
1,3
1,3
1,5
1,7
2002
3,5
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
0,0
1990
x 10,000
Rates Tasas
porLB
10.000 NV
4,0
2001
4,5
Objective
Degree of progress
Reduce maternal mortality by 50%
From 1.9 in 2000 to 1.2 en 2010 (per 10,000 L.B.)
Advance of 29%.
2004 Rate: 1.7
Reduce abortion-related maternal mortality by 50%.
From 0.5% in 2000 to 0.25% in 2010 (per 10,000 L.B.)
Reached.
2003 Rate: 0.2
Reduce mortality due to obstetric complications.
47%
1999 Rate: 0.53 ; 2003 Rate: 0.28
Reduce adolescent pregnancies by 30%.
Fertility rate from 65.4 to 46 per 1,000 women age 15-19
years old.
Advance of 77%
2003 Rate: 50.3
Reduce the gap between desired and actual fertility:
Gap between desired and actual fertility under 20%.
Reached.
Global fertility rate of 1.9 children per women in
2003.
SO 1: Maintain the achievements attained
Slide 36
Infant mortality and its components, Chile 1995-2004
Mortalidad Infantil y sus componentes, Chile 1995-2004
12
11,1
Infantil
Infant
11,1
LB1000 NV
10,000por
Rates xTasas
10,0
10,3
10
8,9
8
6,4
6,6
6
6,3
6
5,9
5,6
8,3
Salud
Infantil con avance
4
5,3
5,1
4,5
4,6
Postneonatal
Post neonatal
Neonatal
10,1
4,2
2
5
3,3
3,4
2000
2001
8,4
7,8
7,8
5
4,9
2,8
2,9
3
2002
2003
2004
5,4
0
1995
1996
1997
1998
1999
Fuente: DEIS, MINSAL.
Objective
Degree of progress
Reduce infant mortality by 25%, from 10.1 in 1999 to 7.5
en 2010.
Advance of 65%.
2003 Rate: 7.8 (2004: 8.4)
Reduce neonatal morbi-mortality.
Mortality by 12.5%.
2000 Rate: 5.6 2004: 4.4
(per 1,000 L.B.)
Reduce late fetal mortality: Rate under 3 per 10,000 L.B.
Advance of 62%.
1998 Rate: 4.3 2003: 3.5
(per 10,000 L.B.)
Prevent the occurrence of congenital anomalies (neural
tube defects).
40% incidence of N.T.D.
In the maternity wards of hospitals w/ RM base,
bet. 1999 and 2005.
SO 1: Maintain the achievements attained
Slide 37
Millennium Development Goals
GOAL 1
Eradicate extreme poverty and hunger
GOAL 2
Achieve universal primary education
GOAL 3
Promote gender equality and empower women
GOAL 4
Reduce child mortality
GOAL 5
Improve maternal health
GOAL 6
Combat HIV/AIDS, malaria and other diseases
GOAL 7
Ensure environmental sustainability
Slide 38
“This is how the AUGE works: explicit health guarantees”
Slide 39
12 September 2004
“The regime of General Health Guarantees is a health regulation
instrument that is an integral part of the Health Services Regime.”
Slide 40
12 September 2004
“The Explicit Guarantees relate to access, quality, financial
protection and timeliness.”
Slide 41
What if a boy or girl is born with an operable
congenital cardiopathy?
What if a girl or boy is born with a cleft lip
and/or palate?
What if a boy or girl is born with an operable
malformation of the spinal cord?
What if a woman needs preventive
services for a premature birth?
Slide 42
Government Program
“ A good social protection
system accompanies
people throughout their
life cycle, protecting their
first steps, …”
Slide 43
“My goal, at the end of the Administration,
is that we will have achieved the
implementation of a child protection system
aimed at leveling the development
opportunities of Chilean children in the first
eight years of life, independent of social
origin, gender, geography or household
structure.
A task of this magnitude far exceeds the
reach of traditional social policy approaches
and will require a set of programs and
instruments...”
Constitution Ceremony of the Presidential Advisor for
the Reform of Childhood Policies, 30 March 2006.
Slide 44
Comprehensive focus on social determinants
Social Protection System for Childhood
under development
Link activities for support and social services,
considering childhood to be the final subject of the
intervention, including protection networks that favor the
role and participation of the family.
WHO definition
of health
PUBLIC SERVICE
NETWORK
AND
COORDINATED
PROGRAMS
FAMILY
BOY
OR
GIRL
DEVELOPMENT
AND SOCIAL
INTEGRATION
OF THE
BOY/GIRL
Simultaneous approach to the distinct areas of the life of the boy or girl and
his/her family, understanding that each one represents a fundamental aspect:
Identification, learning, health, family environment, living conditions,
income and work.
Slide 45
The logic of the intervention
The following matrices have been developed for
each stage of the boy’s or girl’s life cycle:
•
Baby from gestation until 3 months.
•
From 3 months to 3 years.
•
From 4 to 5 years.
•
From 6 to 10+ years (4th of basic).
The matrices have a logic of continuity: the boy/girl
enters the System at the gestation stage and the
System accompanies him/her from that moment
throughout the different stages of the life cycle.
Slide 46
“The future of children is always today
Proposals by the Presidential Advisor for the Reform of Childhood Policies”
Slide 47
13.10.06
“Chile grows with you”
Slide 48
System for the Protection of Childhood
Chile Grows With You
Pregnancy control will mark the entrance of
women into the public health system.
Automatic one-time family subsidy for the entire
gestational period (R.N. Subsidy).
Pregnancy and delivery manual, organized by
weeks of gestation.
Program for the integrated development of
doctor’s visits (complement to prenatal and
healthy child controls)
.
Humanized delivery care
(AUGE 2007)