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Offer of a Program of General Doctors for the Primary Care of Health of Chile

Camilo Bass*
School of Public Health, University of Chile, Chile
Corresponding Author : Bass C
Associate Professor, School of Public Health
University of Chile
Av Libertador Bernardo O‘Higgins 1058
Santiago, Chile
Tel: +562 29786133
E-mail: [email protected]
Received June 23, 2015; Accepted September 14, 2015; Published September 16, 2015
Citation: Bass C (2015) Offer of a Program of General Doctors for the Primary Care of Health of Chile. Review Pub Administration Manag 3:167. doi:10.4172/2315-7844.1000167
Copyright: © 2015 Bass C. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

In spite of the intentions declared in last reform of health of Chile, implemented for more than ten years, of placing to the Primary care of Health as the backbone of the System of Health and of that they have increased progressively the resources destined for this level of attention, in the practice, there exist not approached problems that threaten the success of this process, as well as the result of the National Strategy of Health 2011-2020. A relevant example is the absence of an integral politics of development of the medical resource of the Primary care of Health, which produces that at present there persists a significant deficit of medical hours in this level of attention, consisting of a range brought near between 3.000 to 7.500 Medical Equivalent Days. Inside the offers to diminish this doctors’ important gap of Primary care of Health, there appears the Program of General Doctors for the Primary care of Health. This strategy considers to integrate the doctors newly gone away to the Public System of Health, in order that they initiate his professional exercise, which allows in a nearby future to implement a standard of 1 doctor medical equivalent day every 2.000 persons (maximum) in the Primary care of Health, with the aim to improve the quality of the attention that is offered to the community, strengthening the permanency of the doctors in the first level of attention, in addition to the resoluteness which must provide the Primary care of Health of our country.

Introduction
Current health reform rose to an unprecedented boost to Primary care of Health and to achieve the necessary to solve as many problems in medical practice with the implementation of programs of promotion, prevention, care and rehabilitation of community health coverage [1].
However, despite the declared intentions in the reform, it implemented for more than ten years ago, to place primary care as the hub of the health system and they have progressively increased resources for this level of care, in practice there are not addressed problems that threaten the success of this process.
A relevant example is the absence of a comprehensive policy for medical resource development of primary health care, which results which currently persists a significant deficit of medical hours in this level of care, consisting of an approximate range between 3000-7500 Medical Equivalent Days.
Among other factors, the increase is the key factor in solving capacity to meet the expectations of this reform primary level. This results in the ability to diagnose and treat the prevalent disease, with diagnostic and therapeutic methods, as appropriate to derive timely and influence the incidence of diseases through effective prevention methods [2].
Even before the reform was standing out the importance that has the medical work of the primary level of attention. This reality has become more evident in the measure in which they have increased the access and the coverage of the population. In the year 2007, the attentions of the doctors of primary care corresponded to 71.1% of the total of medical consultations not urgencies (16.430.089 of 23.107.703), on the other hand, in the Services of Primary care of Urgencies 6.278.006 persons attended, which constitutes 39, 5% of the total of 15.891.637 attentions of urgencies of the public system [3].
System of health and primary care of health in Chile
The percentage of Gross Domestic Product (GDP) for health spending in Chile was 7.4% in 2013 (compared with an Organization for Economic Cooperation and Development (OECD) average of 8.9%). The share of public spending in Chile as a percentage of total health expenditure has remained very low - the lowest in the OECD - in 46% (well below the OECD average of 73%). The proportion of pocket expense was 33% of total health spending in 2013, one of the highest in the OECD (the OECD average pocket spending is 19.5%) [4].
The situation described above has remained in recent decades, with the introduction of the market in the health system, reflected in: the plan of hospital infrastructure concessions, increased transfers and subsidies from public funds to private clinics, self-management policy Health Services that constitute a threat to the articulation of the health care network and tariff policies and co-payments in health benefits that seek to replicate the model of private health. These logical only weaken the public network, and strengthening the character of tradable good of our health.
Health and other areas of fundamental rights of citizens have been shaped by a tax model illegitimately for over 30 years and are now in crisis. The set of social rights cannot remain tradable on the market, consecrated by a subsidiary state that promotes the delivery of resources to private situation, and undermining public alternatives. This generates systematic segregation and inequality, manifested in health for poor and sick, and quite another for the rich and healthy.
Due to the situation previously described, the doctors’ quantity that is employed at the Public System of Health is only 44% of the total doctors of the country, who would have to attend to 80% of the population. This generates a great inequity in the access to the medical attentions between the system public and deprived of health.
Our country has a long tradition of development in health issue. In 1924 the Law on Compulsory Insurance Workers (Law No. 4,054), whereby employers and workers should impose monthly health insurance and disability solidarity fund or issued. This law meant the commitment of the State to provide health care to all workers, which gave birth to social medicine in Chile. Health promotion, disease prevention, cure and rehabilitation: 10,383 In 1952 the Law establishing the National Health Service, a public body responsible for carrying out all health actions [5].
This early development in the issue of social security in health, led the Chilean doctors to make proposals on what would later be defined as Primary care of Health. An example of this can be found in the “Health Plan, health care and social medicine - Chile 1964” prepared by the Group Health Central Planning Office of the presidential candidacy of Dr. Salvador Allende. In this document there is established the concept of Integral Attention as “a medical efficient and opportune attention for the whole population and for every person considered integrally. More that to the patient or to the disease as isolated facts; it goes to the human being in its entirety physical and mental, in continuous adjustment to his sociocultural environment. Decentralized attention, next to the home or to the site of work, at the expense of an equipment integrated well civil servant, in narrow harmony and continuity with the Hospital Bases and with all the local organisms. Attention that integrates, in every presentation, the somatic and psychic aspects, the individual thing with the social thing, and the preventive and curative actions. Finally, planned attention and with permanent educational intention” [6].
Subsequently, as a result of the policies promoted by the military regime, reform of global neoliberal health system character that changed the role and importance of the state and promoted the private sector they were made. Since 1979 the state health sector was restructured, reorganized the Ministry of Health and the National Health Services System that currently governs (DL 2.763/1979) was created. Since 1981 the transfer of the management of establishments of primary care to the municipalities took [7].
Nationally administration most general, urban and rural public clinics and rural clinics, located in the municipalities through health departments or private corporations. The responsibilities, powers and interrelation with the health services, are regulated by the Statute of Primary care of Health Municipal (Law 19,378), which enables local applications nonstandard situation that produces a wide variety of officials races, with disparate salaries, programs training defined in each commune and other problems [8].
Regarding the strategy of decentralization of health, it would have been conceived as a disguised way to start the privatization of health systems, since after the transfer of health facilities to municipalities could subsequently transfer files private. Moreover, the autonomy of a portion of the health of the central government occurs, resulting in an inequity between a few municipalities with more resources at the expense of the poor majority [9].
As for the assessment by the Medical College of Chile, published in the book “Health Reform Project Country”, referring to the decentralization of primary care, establishing “know the many insurmountable difficulties showing the municipal administration of clinics the trailing from its creation ( ... ) it is worth mentioning, as an example: the rotation of professionals, the anarchy of wages, the multiplication of the bureaucracy, chronic underfunding, lack of coordination between primary and secondary care, difficulty enforcing technical standards, the problems of transparency in the management, conflict and, especially, inequality in the care of the needy”.
Moreover, municipal administrators in the document “Management model in primary care municipal health” described the community health system as “the basic organizational unit of the Primary care of Health, which forms part of a fully articulated global entity that is National Health System. It is the focal point of strategic planning and local management of primary care, and driving under the rules governing the central level, where global policies are formulated and where the technical and administrative requirements that require service delivery at the local level are defined”. In this context, it is established as a mission of the municipal health: “To ensure the development and operation of a primary care system integrated, resolute and timely health through design, installation, monitoring and evaluation of a plan of community health and efficient and rational use of resources for its implementation” [10].
General doctors for the primary care of health of Chile
The development of primary care physicians in Chile since the fragmentation of the NHS has been characterized by a substantial deficit, a constant turnover, lack of on-going training space, which could translate into a lack of a comprehensive policy medical resource for primary care. This constitutes a major weakness for any model of health system based on Primary care of Health and to achieve an increase in the response capacity of the health system.
In the 1998 study, the Research Unit of the Medical College concludes that among the consequences of the decentralization of Primary care of Health, lack of access to a civil service career that allows professional development and subsequent specialization is. Moreover, doctors have noticed that working conditions are not right for a professional performance ethic and technically appropriate. These have been the most powerful reasons put forward by the Chilean doctors to explain the lack of interest in working at the primary level under municipal administration.
Currently, the majority of primary care physicians in our country is governed by the Statute of Primary care of Health Municipal having a significant proportion of fixed-term contracts, racing officials unstable with variable remuneration, without clarity on training opportunities.
The working conditions described above would be encouraging a high turnover of doctors in primary care as well as a shortage of them to the needs of the population and developing health model. As for the relationship between the numbers of physicians per population, 2002, the Ministry of Health defined the reason for a full-time doctor (44 hours per week) for every 3,333 people [11]. However, so far a major shortage of professionals persists. According to the study by the World Bank and the Ministry of Health, of the 29 996 registered doctors in the Internal Revenue Service to December 31, 2007, only 9% work in APS, with an amount of 101.653 medical hours per week, corresponding to 2,310 complete medical days (Figure 1) [12].
The reasons for the gap of medical Primary care of Health could be explained by the persistence of a number of problems, such as; the shortage of places in the plant officials, the lack of medical graduates, the influence of the university medical education and the lack of a suitable profile to the needs of primary care. This drawback is relevant because of the importance that the primary care level has gained in recent years, why, for that primary care can be the basis of the health system requires doctors able to solve clinical problems disease, to establish promotion and prevention, to lead the health team to manage a coordinated action with specialists in the network, among other actions that have not been trained. Therefore, it would be necessary to develop a profile of skills relevant to the primary care physician, according to the needs and the model of health care in the country, because the current situation of the general practitioner “in excess of routine work and lack of appropriate training, appears “quixotic” [13].
The Doctors’ National group of Primary care of Health in “Gremiales priorities: Vision of the Doctors’ National group of Primary care of Health, “states the need” to create a comprehensive policy for Medical Resource Development of Primary Care, with the aim of making work attractive at this level of care and thus reduce the deficit and the high turnover of physicians in Primary care of Health. What will directly benefit the population served in the public health system, to improve the quality of care provided”. Determining measures regarding this policy, which include: improving yields care (at least 20 minutes to the attention of morbidity), increased problem-solving (continuous medical education and National Competition Specialties), allocate time for Prevention and Health Promotion, reduce job insecurity, and improve salaries, among others [14].
Although in recent years, information from the Ministry of Health show a decline in the large gap in previous years, the standard set for calculating the need for doctors in primary care is clearly inadequate when compared with those determined in other countries. In the case of Spain, it is considered that the number of doctors per population should be around 1,500 people assigned per doctor [15]. On the other hand, in the United States are estimated to be necessary for the care of chronic diseases and to deliver preventive care, 10.6 hours and 7.4 hours doctor a day respectively, considering a population of 2,500 people, which set to days 44 weekly hours, corresponding to 1 doctor for every 1,225 people [16].
Current figures to account for the persistence of a significant shortage of medical hours in this level of care, consisting of a range between 2818-7448 medical days 44 hrs (Table 1).
This deficit makes to itself Chile more relevant on having compared Chile with the rest of the integral countries of the Organization for the Cooperation and the Economic Development (OECD), where in average of the OECD it would belong 0,8 doctors of primary care of health for 1.000 persons, on the other hand only it would come to 0,2 doctors of primary care of health for 1.000 persons [17,18].
Proposal to improve the availability of general practitioners and specialists in the public health system
To diminish the gap of general doctors and specialists there is realized the following exposition that he considers to integrate the doctors newly gone away to the Public System of Health, in order that they initiate his professional exercise, across national contests, having three alternatives for his incorporation. The first option constitutes it the Program of Primary Scholarships of Specialization, followed by the Program of General Doctors of Zone (characterized by doctors who are employed at the rural zones of the country) that are nowadays in force. These would complement each other with the Program of General Doctors for the Primary care of Health.
In the new Program of General Doctors for the Primary care of Health there are contemplated that medical newly gone away are incorporated into the endowment of the Services of Health to be employed at the establishments of health. In this context they would count from the third year of professional exercise in Primary care of Health, with the possibility of postulating to a scholarship of speciality, and later with a period of work as specialist in the public network of health, ideally as specialists in Familiar Medicine or other specialties related to the Primary care of Health (unlike the General Doctors of Zone, who do not have this obligatory return period).
The development of these programs is plotted in the following diagram (Figure 2):
The immediate implementation of this program is feasible given the doctors’ current availability, since there are going away annually more than 1.400 doctors of the Chilean universities (Figure 3) [19]. Less than 40% of the doctors gone away join to the Programs of Primary Scholarships of Specialization and of General Doctors of Zone in Stage of Destination and Formation [20].
Conclusion
Primary care of Health and its relation to family health model within the current health reform, which raised to an unprecedented boost to Primary care of Health and to achieve the necessary to solve as many problems in medical practice with the implementation of coverage promotion programs, prevention, treatment and rehabilitation of community health, are affected by problems not addressed, as the absence of a National Policy for Primary care of Health Physicians, resulting that currently a significant gap persists hours Medical care at this level, and threaten the success of this process.
The lack of progress in developing the model of family and community health, as part of a system of social health, causes an inadequate response to the needs and expectations of the population. Maintaining low levels of user satisfaction and control of chronic diseases. In these situations, the shortage of doctors Primary care of Health plays a fundamental role.
Considering the proposals generated in countries characterized by having a quality Primary care of Health, with high levels of problemsolving and client satisfaction, as well as the need for progress in building a strategy that is consistent with the requirements of the Chilean population. Progress must be made in the construction of a comprehensive development policy physician Primary care of Health resource for improving the quality of care that is provided to the community, strengthening the permanence of doctors in Primary care of Health, in addition to the resoluteness that can provide Primary care of Health in our country.
Public Health and Primary care of Health need motivated and competent doctors who meet the health requirements of the community to achieve this goal is to establish a Program of General Doctors for the Primary care of Health. This proposal is a first step to contribute to this important task.
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