By Alexis Ahumada, Cristian A. Herrera, Elisabeth Tadiri, and Hannah Ratcliffe
The healthcare system in Chile has undergone many transformations and reforms over the past few decades, and currently operates as a dual healthcare system, in which people have a voluntary, but mandatory for salaried workers, choice of coverage by the public National Health Insurance Fund (approximately 80% of the population) or by private insurance companies (approximately 17% of the population). Because of this dual system, there has historically been a lack of coordination between public and private sectors, resulting in access and quality disparities between the populations served. In efforts to address these structural issues, substantial work has been done to organize and develop primary health care networks in the public sector. An integral part of primary health care organization within the public sector, and a critical component to effective service delivery, is the system of sector-wide monitoring of primary health care indicators linked to payments for performance. Chile’s monitoring system is an excellent example of using a parsimonious indicator set to holistically measure primary health care functionality and connect these measurements to payments and performance management for improvement.“Health Goals." The Health Goals are a set of 8 goals comprised of 10 indicators, which serve as an economic incentive for frontline healthcare workers by providing a bonus in salary for achieving the set targets. Workers have the opportunity to receive bonus wages every 3 months, ultimately adding up to 2 months of potential extra payment over the course of a year. The same indicators and "minimum goal" are used throughout the country, but the targets are adapted to the context of each municipality. Development of these Health Goals was a politically complex process, which included working with the Ministry of Health (MoH), Ministry of Finance, the Association of Chilean Municipalities, and the National Union of Workers of Primary Care to come up with the agreed upon indicators and incentives. The goals were developed to target the main burdens of disease in the country and areas with low-compliance to set standards.
In 2005, the second component of the shared monitoring system was developed. In an effort to make payments to municipalities more transparent and increase their accountability for the health of their populations, the Ministry of Health established the Primary Health Care (PHC) Activity Indicators as a means of providing a share of the capitated payments for performance. The PHC Activity Indicators determine the monthly capitation payments from the MoH to municipalities, and are comprised of three categories of activity: general activity, such as coverage of preventive medical exams and other process indicators (13 indicators); continuity of care activity, such as night and weekend care availability (2 indicators); and health care services guarantee activity, which measures the timely compliance with care standards for 12 tracer diseases (1 indicator). Evaluations are conducted quarterly, and if the annually set goals for each of the 16 indicators are not met, monthly capitation rates are lowered accordingly.
Figure 1: Chile's shared monitoring system for primary health care
The process of data collection for both these sets of indicators is standardized throughout the country. First, all clinicians (medical doctors, dentists, nurses, nutritionists, physiotherapists, psychologists and others in the PHC team) must keep clinical records, which are now electronic in almost 80% of PHC facilities. Data are collected daily from these clinical records in a central Medical and Statistical Orientation Office (“SOME office”) at every facility. The SOME office transfers the daily data to the "REM" (the Monthly Statistical Register, the national tool used by all facilities). Each facility must complete the REM monthly and deliver the information to the municipality, where it is validated. Each municipality collects the REM from their facilities and sends it to the territorial Health Service, which again validates the data, and delivers it to the Ministry of Health. The MoH conducts the evaluation of PHC Activity Indicators and Health Goals and reports the results back to every Health Service, who communicate the results to their municipalities for use in setting local and facility improvement targets. Through the Department of Health Statistics and Information, the Ministry of Health also publicly reports the results of all indicators online.
The Ministry of Health conducts this evaluation of PHC Activity indicators four times per year, and the capitation rates for municipalities are set accordingly for the following month. For the Health Goals, the Ministry of Health evaluates once per year, and the payments for the workers are made four times over the following year. Municipality representatives, the Ministry of Health, and the National Union of Workers of Primary Care meet annually to discuss Health Goal achievements and results by region, and to revise indicators or targets for next year if necessary, although the indicators have not changed drastically over the past 14 years. PHC Activity Indicators are also discussed and revised annually to ensure that they capture an accurate picture of primary health care needs, as determined by an assessment of the burden of disease in Chile. For example, in 2015, a new indicator (comprehensive health control coverage in adolescents from 10 to 14 years) was added to the set of general activity indicators.
There are three primary challenges to Chile’s monitoring system. First, the goals and indicators have not changed much over time and cover only some health conditions. This might be leading to what has been called ‘distortions’ where teams tend to overlook other important tasks that are not rewarded with incentives. Second, since there is a financial reward associated with the indicators, there is a need to solve some practical issues in reporting the results through stronger oversee and audit activities. Third, Chile has registries with limited capacity to identify and follow individual patients in order to explore utilization, health status, consumption, etc. with more detail, which should be also combined in the near future with indicators coming directly from patients, for instance, patient reported outcome or experience measures. It will be critical that Chile address these challenges in the future through the development and improvement of its PHC performance measurement framework.
Chile’s system is an example of how municipalities, national policy-makers, and professional associations can work together to establish a simple method for assessing the overall performance of a primary health care system to drive accountability and incentivize quality. Although all vertical programs in Chile—such as opthamalology, pediatrics, etc.—collect and utilize their own sets of indicators, together the PHC Activity and Health Goals provide a snapshot of system performance, enabling the Ministry of Health to hold local levels of healthcare delivery accountable for their performance and to identify problematic areas in need of additional focus.
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Alexis Ahumada is Professional at PHC Management Control Department, Ministry of Health of Chile.
Cristian A. Herrera is Head of the Division of Health Planning, Ministry of Health of Chile.
Elisabeth Tadiri is a PHC Intern at Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T. H Chan School of Public Health.
Hannah Ratcliffe is a Research Specialist at Ariadne Labs.