From the President: The theme is team - Primary Health Care in Chile
Chile is a country of contrasts. Down the length of the nation, the heights of the Andes are only a short distance from the depths of the Pacific. Chileans (“Chilenos”) are friendly and direct, yet self-doubting and cautious.
In October, I was invited to Chile to speak at the annual meeting of the Sociedad Chilena de Medicina Familiar (SOCHIMEF), which attracted approximately 250 registrants. Especially enjoyable was the chance to visit with about 100 representatives of 12 Latin American countries, at a meeting of the young family doctor movement known as Waynakay, Quechua for “youth.”
I had been to Chile before, but during this week long trip I was able to see more of the country and to spend more time examining primary health care. My visit to Chile reminded me of the importance of the primary health care team. Few national health systems have put as much thought and effort into primary care teams as has Chile.
Picture of a funicular in Vina del Mar, where the SOCHIMEF annual meeting was held.
The context
First, I should offer a few reflections about Chilean history and its health system. Always present, but not often discussed, is the painful history that has shaped modern Chile. The politics of late 20th century Chile reflected the excesses of both the left and right, from the expropriations, hyperinflation, and people’s militia of Allende to the Caravan of Death (death squads) and Desaparecidos (“disappeared”) of Pinochet. Understandably, these deep wounds have still not healed in Chile, which is why few Chilenos wanted to revisit that history when I asked them. Yet, to understand a country’s health system, it is first necessary to understand its history and context.
Built on mining and agriculture, Chile is viewed today as one of the most stable and prosperous countries in Latin America, with the highest per capita income in the region. In 2010, it was the first country in Latin America admitted to the OECD (Organization for Economic Co-operation and Development). At the same time, Chile has significant income inequality, with about one in four living in poverty.
Photo of a typical home in middle class portion of Santiago. The concept
The first family doctors were trained in Chile in 1982. After 17 years in control, the Pinochet government left power in 1990. The overlap of the two events is not coincidental. Arising out of a public health tradition, the primary health care system (“APS” or Atención Primaria de Salud) was designed to serve as a safety net for the poor and to promote equity. The APS system is funded and governed primarily by the municipalities. APS services are generally free to the user. As the gap grew between rich and poor during the Pinochet years, APS was one way to reduce the disparities. Primary health care teams (“equipo de APS”) were constructed carefully to avoid the arbitrary rule of a few dictators and to advance the ideals of democracy and egalitarianism – everyone on the team was important.
Given the substantial number of poor Chilenos, the APS strategy has worked. The WHO report published in 2000 that compared the world’s health systems ranked Chile 21st for health outcomes and 33rd for overall performance. Chile’s achievements in maternal and child health have been especially notable.
Group photo of some of the doctors of the University of Chile Dept of Family and Community Medicine. Dra Isabel Segovia, one of the very first family doctors in Chile and now chair at the University of Chile is seated to the right (wearing gray).
About three out of four Chilenos depend on the public health system, which is centered on APS. There are two APS doctors per 1000 people, which works out to about 25,000 doctors in APS, only 500 of whom are trained family doctors – most are general doctors. Across Chile, there are slightly more than 1900 APS units and 183 hospitals with 26,000 beds. The six public and 12 private medical schools graduate about 800 physicians annually, only about 5-10% a year choose a residency in Family Medicine. An APS doctor earns about USD 2000 per month for 20 hours per week working in the APS unit. While some family doctors are full-time public employees in APS, most work another 20 hours per week or so in the private sector, where they typically earn another USD 3700 per month.
The culture
The national health strategy includes nine objectives, 50 metrics, and 513 indicators, which can be found at http://deis.cl/minsal. I believe that a large part of the success of the Chilean health system can be attributed to its APS strategy. Targets for routine services that everyone should receive (immunizations, prenatal visits, etc.) are achieved with considerable dependability. APS teams are multi-disciplinary and consist typically of a doctor, dentist, nurse, midwife, and community health worker, along with ready access to mental health workers and other professionals. Teams participate together in a certification program that is taught on Friday afternoon and Saturday every two weeks for nine months. One Saturday, I was able to watch the various teams learning together as they worked through case presentations and discussed the philosophy and tactics of primary health care.
I spent an afternoon watching a compassionate family doctor, Dra Paola Rodriguez, as she consulted with patients. During one consultation, she diagnosed a nine year old girl’s cough as seasonal allergies and prescribed chlorpheniramine. She then turned to the girl’s 65-year old grandmother who had brought her to the doctor. The grandmother’s diabetes, polyarthralgia, and worry over the mental health problems of her adult daughter occupied most of the 45 minute consultation. At several times during the office visit, other members of the APS team stepped into the room to drop off papers for signature or to pass along a brief message to Dra Paola. It was clear that the other members of the PHC team helped make sure that the two patients were up to date on immunizations and other routine services.
The caution
Much of what I saw in APS in Chile was admirable. The facilities were clean and had the necessary equipment. The APS teams were staffed by capable health care professionals who were caring, committed, and competent. The teams appeared to function as they were designed – a variety of skills were available, everyone on the team was valued, and routine services were accomplished dependably. The result is that the basic health indicators for Chile are excellent given the amount of funds they have to invest on health care.
Yet, Chile could do better. The work of Stanfield and others has shown that the two key aims, and assets, of primary care are the continuity relationship and comprehensiveness of services. In Chile, APS patients have access to information and management continuity (i.e., the APS units they attend record their information in the electronic record and the units follow standard protocols). However, APS patients do not have much personal continuity, as they are handed off from one health worker to another. In conversations with several dozen family doctors, I could not find one who had stayed with the same APS team for more than 3-4 years. This is concerning since the full power of a continuity relationship appears on average to require 3-4 visits over 2-3 years.
I believe that the future of health care will require not only doing the routine dependably, as the Chilenos have done superbly, but also addressing the growing complexity and multiplicity of health problems that individual patients will increasingly present. Continuity relationships will be even more important as health professionals seek to leverage that trust to promote healthy behaviors, assure adherence to complex treatment regimens, and coordinate care across many clinicians.
As family doctors, most of us could not conceive of having a satisfying and successful practice without a team of colleagues to extend our reach and relationships with patients. Yet, teams are accountable only to team members. For example, it is impossible for a team to apologize meaningfully to an injured patient. That must be done by a person, or by several people, not by “the team.” Teams also consume enormous amounts of energy and time, as considerable effort is invested in keeping everyone on the team happy and effective.
Health care is a series of dyadic relationships. Ideally, all of the members of the health care team will individually have valued and trusted relationships with each patient they serve. Ultimately, there is a need for someone to make sense all the pieces of health information and connect those to the patient’s values and preferences, while understanding the patient’s family and context. Around the world, we have found that the family doctor is best suited to play that role.
Why then do the APS units in Chile have a difficult time keeping family doctors on their teams? My answers are not what you might think. The usual response is that the specialty of Family Medicine is not well known or valued among health professionals or the public. While that might be true, it is not a relevant argument for the physician who has chosen Family Medicine and yet moves from one APS unit to another. Another response is that family doctors are not paid as well as other physicians. While that is also likely true, it does not explain why the family doctor moves from one low paying APS unit job to another.
I believe the problem is that the members of the APS team have defined their roles as a series of tasks, or things they do to patients, rather than as extending or enhancing the relationship that the family doctor has with every patient, regardless of problem. Even among the family doctors in Chile, there have been examples of this, such as recent efforts in some training to create a family doctor who specializes only in adults or only in children. The practical import of this is that the various members of the team view themselves as the exclusive purveyor of a limited set of services (“this is [only] what I do as a family doctor for children, a nurse, dentist, etc.”), and not as collaborators in helping the family doctor to establish and maintain a trusted healing relationship, and provide comprehensive services. This replicates within the APS team the same fragmentation of services one finds in specialist-dominated systems such as in my own country, the United States.
We can also see these trends in other countries that have lost some of their primary care luster as they shifted their focus to achieving biometric targets by delegating tasks to an ever more complex array of specialized professionals within the primary care team, such as occurred in the United Kingdom with its Quality Outcomes Framework. Over time, such shifts mean that more energy is devoted to improving team effectiveness and pursuing system-defined outcomes, to the detriment of a holistic approach to care and to the patient’s agenda. This fragmentation will eventually lead to more iatrogenic harms, worse outcomes that matter to patients, and lower patient satisfaction.
The challenge
Most health systems depend on doctors to make most of the resource allocation decisions (when and what to prescribe? when to send to hospital? when to refer for specialist consultation?). Yet, if other team members are allowed to choose their tasks only with an eye to what they enjoy doing most, then the family doctor is typically left with much of the drudgery of practice (writing letters for disability or absences, signing off on the care decisions of others), at the expense of the joy and meaning of the relationship with the patient, with its attendant negative impact on resource decisions.
Chile has created an APS system with enviable results. To improve further, the emphasis will need to shift more to the patient’s agenda, rather than focusing primarily on system-defined outcomes, and to make explicit the primacy of the relationship between patient and family doctor, rather than indulging each team member’s desire to do only self-defined work.
Chile is a beautiful country with a good primary health care system. It could have a great system if it improved the role, status, support, and payment of family doctors.
Professor Richard Roberts