Mortalidad por cáncer de vesícula y egresos hospitalarios por patología biliar en Chile 2002-2014, en relación a la garantía GES colecistectomía preventiva / Changes in gallbladder cancer mortality and hospital discharges due to preventive cholecystectomy in Chile

Background: Gallbladder cancer is a relevant public health problem in Chile. Aim: To analyze the mortality trend due to gallbladder cancer and hospital discharges due to biliary disease between 2002 and 2014. To analyze the effect on these parameters of the new health system called explicit guaranties in health whose acronym in Spanish is GES. Material and Methods: Mortality and hospital discharge databases available at the website of the Ministry of Health were analyzed. Changes in crude and adjusted rates were evaluated, analyzing data by geographical regions, sex and age. The standardization was carried out using the direct method and using as reference the Chilean population in 2002. The trends were evaluated through the Poisson regression method. Results: There is a 4.5% trend towards a decreasing mortality at a national level, as compared with the figures before GES came into force. Mortality among people aged 35 to 49 decreased by 4% before GES, and by 8% after GES. The trend of hospital discharges varied from −1% before GES, to a 2% increase after GES. Discharges among people aged 35-49 years increased from 0.1% to 2.9%. Conclusions: The discharge rate increase after GES, does not yet show a break in the reduction of mortality at the national level, although it does benefit the group of 35 to 49 years.

Equidad en salud en la región más desigual del mundo: un reto de políticas públicas en América Latina / Health equity in the world´s most unequal region: a challenge for public policy in Latin America

La redemocratización ha transformado la agenda social y el rol del Estado en América Latina con un compromiso creciente con la equidad y la justicia sanitaria que está tensionado por las profundas desigualdades socioeconómicas. Los esfuerzos por universalizar el derecho a la salud han llevado a desarrollar diversas políticas públicas, cuyo alcance depende del entendimiento de los conceptos de salud y equidad. El foco de acción se ha concentrado en reformas al sistema de salud y solo recientemente hay esbozos de políticas intersectoriales que abordan los determinantes sociales estructurales. Además, si la equidad en salud es el norte la estrategia predominante de establecer garantías mínimas no puede ser la respuesta final, sino un paso en el camino hacia la igualdad. Por último, avanzar hacia la cobertura universal del derecho a la salud requiere fortalecer capacidades institucionales de los gobiernos relacionadas con políticas públicas, con una mirada intersectorial y participativa.

Re-democratization has transformed the social agenda and the role of the state in Latin America with a growing commitment to health equity and social justice, yet these aspirations are strained by the region´s profound socioeconomic inequalities. Efforts to provide universal coverage to the right to health have led to the development of a variety of public policies, whose scope depends on how the concepts of health and equity are understood. In general, policy action has centered on health system reforms and only recently on integrated intersectorial action to address wider social determinants of health, particularly structural determinants. Furthermore, if the goal is health equity the predominant minimum standards approach cannot be the final answer, but only a step on the road to equality. Finally, realizing universal coverage of the right to health through public policy requires the strengthening of governmental institutional capacities with an intersectorial and participatory lens.

Integrating social determinants of health in the universal health coverage monitoring framework / La integración de los determinantes sociales de la salud en el marco de la vigilancia de la cobertura universal de salud

Underpinning the global commitment to universal health coverage (UHC) is the fundamental role of health for well-being and sustainable development. UHC is proposed as an umbrella health goal in the post-2015 sustainable development agenda because it implies universal and equitable effective delivery of comprehensive health services by a strong health system, aligned with multiple sectors around the shared goal of better health. In this paper, we argue that social determinants of health (SDH) are central to both the equitable pursuit of healthy lives and the provision of health services for all and, therefore, should be expressly incorporated into the framework for monitoring UHC. This can be done by: (a) disaggregating UHC indicators by different measures of socioeconomic position to reflect the social gradient and the complexity of social stratification; and (b) connecting health indicators, both outcomes and coverage, with SDH and policies within and outside of the health sector. Not locating UHC in the context of action on SDH increases the risk of going down a narrow route that limits the right to health to coverage of services and financial protection.

El respaldo al compromiso mundial con la cobertura universal de salud representa la principal función de la salud en favor del bienestar y el desarrollo sostenible. La cobertura universal de salud se propone como una meta general de salud en el programa de desarrollo sostenible para después del 2015, pues conlleva una prestación eficaz, universal y equitativa de servicios de salud integrales por medio de un sistema de salud fuerte, en consonancia con múltiples sectores en torno a la meta compartida de una mejor salud. En el presente artículo, se sostiene que los determinantes sociales de la salud son centrales en la búsqueda equitativa de vidas saludables y también en la prestación de servicios de salud para todos y, por consiguiente, estos determinantes se deben incorporar explícitamente en el marco de la vigilancia de la cobertura universal de salud. Esto puede llevarse a cabo: a) desglosando los indicadores de la cobertura universal en función de las diferentes mediciones de la situación socioeconómica a fin de que reflejen el gradiente social y la complejidad de la estratificación social; y b) vinculando los indicadores de salud, tanto de resultados como de cobertura, con los determinantes sociales de la salud y con las políticas dentro y fuera del sector sanitario que influyen sobre la salud. Si no se sitúa la cobertura universal en el contexto de la acción sobre los determinantes sociales de la salud, aumenta el riesgo de interpretar el derecho a la salud como un derecho circunscrito a la cobertura de servicios y la protección económica.

Evaluación de competencias de los gestores de la salud y seguridad ocupacional en Chile / Skills evaluation of the occupational safety and health managers in Chile

El estudio consistió de una consulta a expertos de diversas disciplinas y campos de actividad en Salud y Seguridad Ocupacional (SSO) a través de técnica DELPHI. El propósito del estudio es contribuir al fortalecimiento de las competencias de los gestores de SSO y, por extensión, de todo el sistema de SSO en Chile. El estudio identifica las competencias prioritarias que, en opinión de expertos, deben poseer los gestores de SSO. De esta manera, se busca superar el problema producido por la heterogeneidad, en contenidos y calidad, de programas de formación de dichos gestores. De este modo, el estudio introduce y promueve el enfoque de formación por competencias que demuestra ser el más apropiado para el desempeño laboral de estos profesionales. Finalmente, el estudio aporta un exhaustivo análisis del estado del arte internacional en esta materia. La aplicación de tres rondas de consulta Delphi arrojaron como resultado que los expertos consideran prioritarias las áreas de: análisis y gestión de riesgos; efectos en la salud relacionados con el trabajo; gestión de servicios y programas de higiene ocupacional; legislación; gestión empresarial; prevención y control de riesgos ocupacionales.

The study consisted of an enquiry to experts from various disciplines and fields of activity in Occupational Health and Safety (OHS) through DELPHI method. The purpose of the study is to contribute to strengthening the skills of the managers of OHS and, by extension, the entire OHS system in Chile. The study identifies priority skills that, according to the opinion of experts, OHS managers must have. In this way, we seek to overcome the problem caused by the heterogeneity in content and quality of training programs such interfaces. Thus, the study introduces and promotes skills training approach that proves to be the most appropriate for the job performance of these professionals. Finally, the study provides a comprehensive analysis of the state of international art in this area. The application of three rounds of Delphi consultation gave results that experts consider priority areas: risk analysis management; health effects related to work, service management and occupational health programs, legislation, business management, prevention and control of occupational hazards.

Seguimiento de cobertura sanitaria universal con equidad en Chile entre 2000 y 2011 usando las Encuestas CASEN / Universal health coverage assessment based on national socioeconomic characterization surveys

Background: The Chilean health reform aimed to expand universal health coverage (UHC) with equity. Aim: To analyze progress in health system affiliation, attended health needs (health visit for a recent problem) and direct payment for services, between 2000 and 2011. Material and Methods: We evaluated these outcomes for adults aged 20 years or older, analyzing databases of five National Socioeconomic Characterization Surveys. Using logistic regression models for no affiliation and unattended needs, we estimated odds ratios (OR) and prevalences, adjusted for socio-demographic characteristics. Results: The unaffiliated population decreased from 11.0% (95% confidence interval (CI) 10.6-11.4) in 2000 to 3.0% (95% CI 2.8-3.2) in 2011. According to the model, self-employed workers had a higher adjusted prevalence of no affiliation: 27.4% (95% CI 24.1-30.6) in 2000 and 7.8% (95% CI: 5.9-9.7) in 2011. The level of unmet needs decreased from 33.5% (95% CI 31.8-35.1) to 9.1% (95% CI 8.1-10.1) in this period. Not being affiliated to the health system was associated with higher unmet needs in the adjusted model. Indigent affiliates, entitled to free care in the public system, reported payments for general and specialist visits in a much lower proportion than other groups. However, direct payments for visits increased for this group during the decade. Conclusions: Concurrent with the introduction of new health and social policies, we observed significant progress in health system enrolment and attended health needs. However, the percentage of impoverished people who made direct payments for services increased.

Aplicación de una aproximación metodológica simple para el análisis de las desigualdades: El caso de la mortalidad infantil en Chile / Application of a simple methodological approach to analyze health inequalities: The case of infant mortality in Chile

Background: The infant mortality gradient by maternal education is a good indicator of the health impact of the social inequalities that prevail in Chile. Aim: To propose a systematic method of analysis, using simple epidemiological measures, for the comparison of differential health risks between social groups that change over time. Material and Methods: Data and statistics on births and infant deaths, obtained from the Ministry of Health, were used. Five strata of maternal schooling were defined and various measures were calculated to compare infant mortality, according to maternal education in the periods 1998-2001 and 2001-2003. Results: Of particular interest is the distinction between a measure of effect, Relative Risk (RR), which indicates the size of the gap between socioeconomic extremes and the etiological strength of low maternal schooling on infant mortality, and a measure of global impact, the Population Attributable Risk (PAR percent), which takes into account the whole socioeconomic distribution and permits comparisons over time independently of the variability in the proportions of the different social strata. The comparison of these measures in the two periods studied, reveals an increase in the infant mortality gap between maternal educational extremes measured by the RR, but a stabilization in the population impact of low maternal schooling. Conclusions: These results can be explained by a decline in the proportion of mothers in the lowest educational level and an increase in the proportion in the highest group.