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| (...) there are two perspectives: one from the viewpoint of what is financed, and the other, a more comprehensive and social view of illness and individuals within a social context. Then, there are frictions between the system view and the GES (E6).
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Free choice
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If it is a disease with many costs, they use the public system. Because the private sector is very expensive. When it is a simpler problem, a headache, for example, they prefer to use the free choice, otherwise they have to go to a general practitioner, do an inter-consultation at the hospital, which can take a long time ... The payment of the consultation is financially affordable under free choice, but hospitalization cost is very high (E1).
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| (...) for various reasons, some ideological, it is better not to have any communication between public and private sectors, or that public sector does not feel threatened, since it could encourage a greater use of the private and less public investment... it is a complex system. .. Another issue is that public and private network’s doctor is often the same. So if you can provide all medicines in the private network, why stay in the public network? For this reason, there are no such cross-incentives... (E1). (...) |
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The private outpatient and hospital services continue to grow. Many private clinics live on Fonasa’s free choice. That is, it is a transfer of resources from public insurance to private clinics. Furthermore, public hospitals lacking critical bed capacity purchase them from private ones. The very characteristic of the Chilean system, a mixed system, provides for a complementary private system use (E10).
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Proposed health system reform
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The Isapres use public security, but set conditions, that is, they select clientele. This has not changed. The Bachelet’s Government (2014-2018) invested heavily in health centers and in hospitals. A reform that blocks the outflow of public resources is fundamental. The country is in a difficult time for reforms (E10).
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Comprehensive Family and Community Health Care Model
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| (...) one is the theme of family and the other is community. From 2005 onwards, the Ministry strongly shaped this vision. We have seen that this comprehensive health model with emphasis on family and community in networks was set as the PHC model (E5).
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Definition of PHC’s role
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| (...) In our country, primary care country is municipalized, but administratively relies on the Ministry. They do not apply anything, nor invent any standard. They apply the standards set by the Ministry of Health (E2).
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Voluntary Community Health Workers
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| (...) paying for someone who does this work would generate issues in the relationship with the community itself. We are reluctant to this issue (E10).
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Competition of models in PHC
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What happens is that the family health model is counter-cultural. There is a design competition. Despite efforts, people prefer a model that is not networked and of access to specialists. When they can, they buy a care bonus in the free choice system (E10).
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Many people die in primary care because they have spent all the money to pay for a cancer or any other thing and come to primary care because they can no longer afford to pay for their illness. Chile’s problem is that many people do not know the benefits of primary care (...) It is the very Fonasa that promotes segmentation (E16).
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Hospitals’ leading role in the RISS
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The network is set around hospitals; the territory itself was not structured based on characteristics of health centers, but by the reference of hospitals. Hospitals are there to establish networks and received the flow, rather than other characteristics of the territory. This also assigns a curative perspective to the model. This is a team’s reflection. (E10)
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The hospital is in charge of resolving all incoming PHC requests. Some Health Services are concerned that hospitals work closer to clinics (health centers), hence send specialists, along with physicians to review cases, but are one-off experiences (E1).
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When we set a GES guarantee or an explicit health guarantee on the system, we are already passing on the responsibility to the hospital (E11).
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Care Networks Integration Councils - CIRA
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Thus, you have to have a good leadership, a good manager to have the ability to make these changes, and they are often anti-cultural and have to break with what I am already accustomed to do (E6).
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Regarding waiting lists and lack of experts, we do not have the power to solve, but we can say why these themes emerge. As the Services, in some cases, we can be more organized and define strategies through a better diagnosis. This is why it is important to incorporate the community: when it begins to realize that the lack of an expert does not depend only on the will, then those who have greater voicing power begin to press to secure resources (E9).
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PHC centrality in networks
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This country has a segmented public and private system. These systems do not communicate with each other, only through the patient. In the health system, primary care remains as the poor relative. (...) The big issue is how much more hospitals we are going to build in Chile, when it is already known worldwide that they are no longer what we need (E16).
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Health work in networks is still understood as quite a vertical thing. Hospital is here and PHC there. Discourse says that PHC is the most important, but what really happens is that most of the resources and themes are in hospitals. This also includes social valuation (E9).
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Health Care Protocols
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Thus, when they created this program, they made a very well established protocol, and patients who had chronic problems then and were practically living in the hospital began their rehabilitation in primary care (E8).
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Therefore, everything is subject to a protocol. We review the waiting list, define pathologies that have more demands that are not AUGE, who does not have a protocol and define the protocol for each pathology (E8).
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Shared care
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They do not know each other. When they go from the hospital to the primary care to know their reality and the primary care to the hospital, to know the reality of the hospital that leads then to think that the expert, for example, does not want to see the patients, they recognize the problems of each level. Thus, this makes the process much easier (E8).
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Leadership for Coordination Goals
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A director of a health service who says ‘I have nothing to do with PHC’ is not acceptable today. Five years ago, one would hear that, nowadays it is not acceptable. Thus, your entire team. This is a first line of strategy that is key (E2).
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Referral and counter-referral
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| (...) counter-referral is not done when the patient is discharged, even with protocolled flows. Specialized care doctor does not counter-refer. We have less than 30% of the patients with a counter-referral. The system does not support counter-referrals. Inpatient follow-up is irregular (E10).
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