1. MATERNAL-CHILD HEALTH POLICY Regional Forum on Social Protection in Health for Women, Newborn and Child Populations in LAC – Lessons learned to prompt the way forward. Tegucigalpa, 8 -10 November 2006 DR. RENE CASTRO S.

2. “Maternal and child mortality is one of the demographic facts that can be influenced in a more or less serious way since it depends a great deal on the care that the mother and child receive before, during and after birth.” Dr. Salvador Allende, Minister of Health (1940 )

3. LA REALIDAD MEDICO – SOCIAL CHILENA “Chilean Medical – Social Reality”

4. REPRODUCTIVE RISK Each pregnancy implies a risk of Morbidity and Mortality for the mother and her child. The perinatal period represents the greatest vulnerability in the life of a human being.

5. Maternal, perinatal and child health indicators reflect a country’s economic, cultural, social and health development.

6. Risk of death in Latin America and the Caribbean ( compared to USA and Canada) Child Mortality Maternal Mortality Relative Risk 3 - 4 9 - 10

7. Until 1920, the health situation in Chile qualified as a “savage state”: the highest child mortality in the world. 1952: Life expectancy at birth - 54.9 years – among the lowest at the global level, reflecting the poor living conditions in the country.

8. INFANT MORTALITY PER 1,000 LIVE BIRTHS

9. CHILD MORTALITY AND YEARS OF LIFE LOST 1920-2002 LIFE EXPECTANCY AT BIRTH ANDHALF LIFE 1920-2002 MenWomenDifference 1919-22 264.0248.71.1 5453 - 1929-32 217.5198.71.1 4644 9 1939-42 205.4188.5 4542 1 1952-53 128.0112.41.1 3229 13 1960-61 125.6108.31.231262 1969-70 89.275.41.227214 1980-85 25.821.61.218129 1991-92 15.513.11.215103 2001-02 9.47.51.21282 3. Probability of dying under one year of age at the time referred to in the Mortality Table. Years of life lost from birth to age 85 4 Male Overmortality Infant Mortality 3 MenWomen PERÍODS MenWomenMenWomen 1919-22 30.9032.211.312829 1929-32 39.4741.752.284446 1939-42 40.6543.062.414850 1952-53 52.9556.833.886267 1960-61 54.3559.905.556370 1969-70 58.5064.686.186672 1980-85 67.3774.166.797278 1991-92 71.3777.275.907581 2001-02 74.4280.415.997783 1. The number of years a newborn would live if age-specific mortality rates at time of birth (shown in Table) continued throughout the child’s life. Sex Average Age 2 PERIODS Life expectancy at birth 1 1 Sex Differential 2. Age at which 50% of the survivors from a cohort of 100,000 live births are still alive; according to mortality observed at the time referred to in the Mortality Table. 4. Number of additional years that people who died should have lived. The difference between one period and another indicates the impact of the change in mortality on human life. 1.1

10. MATERNAL-CHILD CARE 1901 National Children’s Board 1924 Workers’ Insurance Law 1942 Health Units (district-level) 1952 National Health Service 1980 National Health Service System: Ministry – Social Security – Regional Ministerial Secretary (Seremi) (decentralization) 2000 Sector reform ( ongoing )

11. 1925 – 1938 Health Welfare State (Liberal state): from Beneficence (“medicine-charity,” for indigent people) to Social Welfare (for society as a whole). 1924, Law 4.054 for Compulsory Insurance: covers risks of invalidity, old age and death, with a tripartite financing: State, employer, worker. Workers’ Compulsory Insurance Fund (Caja de Seguro Obrero Obligatorio) (the first in the Americas): ambulatory care, care at doctor’s offices and home care for all workers, their wives and children under 2 years old. EVOLUTION OF THE STATE

12. 1938-1952 Popular Unity governments Protective welfare state (“paternalistic”): Committed to economic and social policies; humanization of the People before the State 1939 to 1960: period of “awareness of social issues,” of “the second transformation of the State”: An organic commitment to an assistentialist State (Welfare State).

13. August 1952 Law 10.383: creates the SSS and the National Health Service (SNS): “political will” for the search for social balance and institutional justice – newsocial pact - will allow the working and proletariat classes to be integrated into the system. Wide national agreement; support of the University (School of Public Health) and the Medical Association. Social Medicine: incorporates the fundamental principle of the WHO, created in 1948: health as “a right and obligation of every human being and of countries as a group.” NATIONAL HEALTH SERVICE (1952–1979)

14. Chile was the second country at the global level (4 years after England); it integrated 6 institutions that addressed different areas of social security and health management. Objectives: - reduction of maternal and child mortality, - control of infectious diseases, - eradication of malnutrition and, - coordination with other social sectors that have links to health determinants.

15. MATERNAL MORTALITY BY CAUSE CHILE 1951-2000

16. INFANT MORTALITY CHILE 1980 – 2003 * (*) Rates per 1,000 LB

17. PERINATAL MATERNAL CONTROL (CLAP) LOW RISK PRENATAL CONTROL HIGH RISK PRENATAL CONTROL HOSPITALIZATION DURING PREGNANCY DELIVERY CARE AMBULATORY PUERPERAL CARE MONITORING OF CHILD GROWTH AND DEVELOPMENT

18. WOMEN’S HEALTH PROGRAM Years Prenatal Family Plan. Skilled Care Maternal Mortality Check-Up Coverage at Birth Rate x 10,000 L. B. % % % 1965 50.1 6.0 75.527.9 1970 52.0 13.7 81.1 16.8 1975 55.0 23.7 87.4 13.1 1980 57.4 26.7 91.4 7.3 1985 69.2 23.6 97.4 5.0 1990 85.0 17.3 99.1 4.0 1995 92.5 22.2 99.5 3.1 1998 92.6 22.5 99.7 2.0

19. S.N.S.S. CARE NETWORK PRIMARY CARE General Doctor’s Offices Urban250 Rural150 Rural Posts > 1,100 HOSPITAL-BASED CARE : 162/177

20. FAMILY PLANNING IN CHILE 1967: POLICY BASED ON HEALTH OBJECTIVES a.Reduce Maternal Mortality due to Induced Abortion (Avoid Unwanted Pregnancy) ; b.Reduce Child Mortality associated with high fertility; c. Promote Family Well-being (Responsible Parenting)

22. Abortion-related Mortality 1960 - 2000 Year Number Rate % Maternal Deaths 196030210.735.7 1970185 7.142.1 1980 71 2.838.4 1990 23 0.718.7 1998 14 0.525.4 2000 13 0.4926.5 2001 4 0.1513.3

23. Foundation for a Family Planning Policy “The Government of Chile recognizes the benefit that the population achieves through Family Planning activities, which allow individuals to have the number of children with the desired spacing and timing. For this reason, it maintains its support for Family Planning activities in order to promote the achievement of adequate comprehensive reproductive health.” October 1990

24. PROFESSIONAL DELIVERY CARE YEAR % 196574.3 197587.4 198597.4 199899.6 “ From empiricism to professionalism in delivery care” Prof. F. Mardones-Restat

25. Maternal Mortality and Professional Delivery Care 1950 - 2001

26. MATERNAL-CHILD HEALTH 1960 – 2000 Rates per 1,000 LB 1960 2000  Birth Rate 35.5 17. 2  Total Maternal Mort. 2.99 0.2  M.M. due to Abortion 1.07 0.05  Infant Mortality 125.1 8.9  Neonatal Mort. < 28 d. 36.2 5.6

28. REDUCTION OF MATERNAL MORTALITY IN CHILE : LESSONS LEARNED 1950-2000 Ministry of Health, CHILE Universidad de la Frontera Pan American Health Organization PAHO/USAID

29. Creation of the SNS Existence of Health Plans Increase in Service Coverage Service Network Early Prenatal Care Prevention of Pathologies Standards of Care Increase in Therapeutic Methods Strengthening of HH.RR. Creation of New Schools for Obstetricians (regional) Training of G-O doctors Decline in fertility Increase in the % urban population Availability and Distribution of Midwives Expansion of Primary Care Prenatal Care PNAC – Supplementary Feeding Program Technological Advances Antibiotics Home for the Rural Woman Professional Delivery Care Family Planning program Development of the Country Increase in schooling Improved living conditions Increased access to health services Decrease in excessive work Decrease in family violence Existence of evil COMPARATIVE RESULTS Experts Users Mapuches Common Areas

30. Steps for Reducing Maternal Mortality Consider M.M. to be a human rights and social justice problem. Recognize that every pregnancy has some level of risk. Assure that skilled personnel attend births. Promote maternal health as a vital economic and social investment : Postpone motherhood. Prevent unwanted pregnancy. Prevent unsafe abortion. Facilitate access to maternal health services. Improve the quality of maternal health services. Supervise and evaluate changes.

31. ...the decade in Chile...

32. PEDIATRICS, 10 April 2006

33. MATERNAL – CHILD HEALTH SITUATION  Stable health policies during the last 50 years  Institutionalized National Health System  Human resources that are committed to their work  Culture of health among the population

34. “Chile is better - Health Reform”

36. SEXUAL AND REPRODUCTIVE HEALTH “DESIGN AND IMPLEMENTATION OF HEALTH PRIORITIES Chilean Programmatic Reform”

37. “ …the possibility of a human being to have gratifying and enriching sexual relationships, without coercion and fear of infection or unwanted pregnancy; to be able to regulate her fertility without the risk of unpleasant or dangerous secondary effects; to have a safe pregnancy and delivery and, to raise healthy children” Sexual and Reproductive Health PAHO,1995

38. REPRODUCTIVE HEALTH PRECON- CEPTION CARE PRENATAL CARE DELIVERY AND POSTPARTUM CARE HEALTHY MOTHERS AND NEWBORNS NEONATAL CARE ++ = +

39. Improve the health objectives attained –Child health, women’s health, infectious diseases Confront the challenges that result from aging and other changes in society –Determinants of the health situation, primary causes of death and disability Reduce health inequalities –Living conditions and determinants, health situation, access to health Provide services according to the population’s expectations –Financial justice, care according to expectations, quality of care Health Objectives: Cornerstone of the Reform “Health Objectives for the Decade 2000-2010”

40. Model for Comprehensive Health Care Primary Care constitutes the strategic axis for Health Reform Entire life cycle Inter-sectoral Service network Disease prevention Targeting by risk PHC Welfare component Community component Health promotion Management team FamilyFamily Humanized

41. DALYs * : 15 leading causes Percent distribution and ratio per 1,000 inhab. Congenital anomalies DALY % Ratio Both sexes103.6545.867.53 Women 52.020 6.637.47 Men 51.634 5.247.58 Source: Estudio Carga de Enfermedad, MINSAL 1996 Disability-Adjusted Life Years: years of life lost due to premature death and disability (measures the relative importance of diseases).

42. Congenital Anomalies Health Objectives and Goals for Congenital Anomalies Impact Goals: Prevent the occurrence of certain congenital anomalies (neural tube defects) Improve the quality of life of children with congenital anomalies Development Goals: Fortify flour with folic acid Improve the problem-solving capacity of national referral centers with regard to the treatment of congenital cardiopathies Implement a national registry of congenital malformations Program for the integral treatment of children with cleft lips or palates

43. The study found a reduction of 42% in the prevalence of anencephaly at birth during the fortified period, compared to the period immediately prior to fortification (1999-2000).

44. Unwanted Pregnancies Health Objectives and Goals for Unwanted Pregnancies Impact Goals: Decrease the gap between desired and observed fertility: the gap between desired and observed fertility should be under 20% By age group, maternal educational level, socio-economic level, experience with use of contraceptive methods (methods used, duration of use) Reduce pregnancies in adolescents: see Chapter 2 on Risk Factors, Sexual Behavior Reduce abortion-related maternal mortality by 50% (over the level in 2000) Counseling on Sexual and Reproductive Health for the population at greatest risk of abortion (detected using predictive instrument) Coverage for Fertility Regulation: by five-year age groups Audit of complicated abortions by cause at the level of hospitals and/or primary care establishments

45. ObjectiveDegree of progress Reduce maternal mortality by 50% From 1.9 in 2000 to 1.2 en 2010 (per 10,000 L.B.) Advance of 29%. 2004 Rate: 1.7 Reduce abortion-related maternal mortality by 50%. From 0.5% in 2000 to 0.25% in 2010 (per 10,000 L.B.) Reached. 2003 Rate: 0.2 Reduce mortality due to obstetric complications.  47% 1999 Rate: 0.53 ; 2003 Rate: 0.28 Reduce adolescent pregnancies by 30%. Fertility rate from 65.4 to 46 per 1,000 women age 15-19 years old. Advance of 77% 2003 Rate: 50.3 Reduce the gap between desired and actual fertility: Gap between desired and actual fertility under 20%. Reached. Global fertility rate of 1.9 children per women in 2003. SO 1: Maintain the achievements attained Maternal and abortion-related mortality, Chile 1990-2004 Maternal Mortality Abortion-related mortality Rates x 10,000 LB

46. SO 1: Maintain the achievements attained Salud Infantil con avance ObjectiveDegree of progress Reduce infant mortality by 25%, from 10.1 in 1999 to 7.5 en 2010. Advance of 65%. 2003 Rate: 7.8 (2004: 8.4) Reduce neonatal morbi-mortality.  Mortality by 12.5%. 2000 Rate: 5.6 2004: 4.4 (per 1,000 L.B.) Reduce late fetal mortality: Rate under 3 per 10,000 L.B.Advance of 62%. 1998 Rate: 4.3 2003: 3.5 (per 10,000 L.B.) Prevent the occurrence of congenital anomalies (neural tube defects).  40% incidence of N.T.D. In the maternity wards of hospitals w/ RM base, bet. 1999 and 2005. Infant mortality and its components, Chile 1995-2004 Infant Post neonatal Rates x 10,000 LB

47. Millennium Development Goals Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability GOAL 1 GOAL 2 GOAL 3 GOAL 4 GOAL 5 GOAL 6 GOAL 7

48. GOAL 1 ERADICATE EXTREME POVERTY AND HUNGER Minimum Indicators, Millennium Development Goals Additional Indicators - MDGs 1. Proportion of Population Whose Income Is Below $1 (PPP) per Day Target 1 Target 2 2. Coefficient of the Poverty Gap Ratio of $1 per Day (incidence by depth) 3. Share of Poorest Quintile in Total Monetary Income 4. Percentage of Children Under 6 Years of Age Who are Malnourished 5. Proportion of Population Below Minimum Level of Dietary Energy Consumption Target 1 Target 2 1. That the families in Solidarity Chile have incomes above the poverty line 2. That at least one adult member of the families in Solidarity Chile has a regular job with stable remuneration 3. Obesity rate in children under 6 years of age 2015 Goal

49. “This is how the AUGE works: explicit health guarantees”

50. 12 September 2004 “The regime of General Health Guarantees is a health regulation instrument that is an integral part of the Health Services Regime.”

51. 12 September 2004 “The Explicit Guarantees relate to access, quality, financial protection and timeliness.”

52. What if a boy or girl is born with an operable congenital cardiopathy? What if a boy or girl is born with an operable malformation of the spinal cord? What if a woman needs preventive services for a premature birth? What if a girl or boy is born with a cleft lip and/or palate?

53. Government Program “ A good social protection system accompanies people throughout their life cycle, protecting their first steps, …”

54. “My goal, at the end of the Administration, is that we will have achieved the implementation of a child protection system aimed at leveling the development opportunities of Chilean children in the first eight years of life, independent of social origin, gender, geography or household structure. A task of this magnitude far exceeds the reach of traditional social policy approaches and will require a set of programs and instruments...” Constitution Ceremony of the Presidential Advisor for the Reform of Childhood Policies, 30 March 2006.

55. Comprehensive focus on social determinants Social Protection System for Childhood under development Link activities for support and social services, considering childhood to be the final subject of the intervention, including protection networks that favor the role and participation of the family. PUBLIC SERVICE NETWORK AND COORDINATED PROGRAMS FAMILY DEVELOPMENT AND SOCIAL INTEGRATION OF THE BOY/GIRL BOY OR GIRL Simultaneous approach to the distinct areas of the life of the boy or girl and his/her family, understanding that each one represents a fundamental aspect: Identification, learning, health, family environment, living conditions, income and work. WHO definition of health

56. The logic of the intervention The following matrices have been developed for each stage of the boy’s or girl’s life cycle: Baby from gestation until 3 months. From 3 months to 3 years. From 4 to 5 years. From 6 to 10+ years (4 th of basic). The matrices have a logic of continuity: the boy/girl enters the System at the gestation stage and the System accompanies him/her from that moment throughout the different stages of the life cycle.

57. “The future of children is always today Proposals by the Presidential Advisor for the Reform of Childhood Policies”

58. 13.10.06 “Chile grows with you”

59. System for the Protection of Childhood Chile Grows With You Pregnancy control will mark the entrance of women into the public health system. Automatic one-time family subsidy for the entire gestational period (R.N. Subsidy). Pregnancy and delivery manual, organized by weeks of gestation. Program for the integrated development of doctor’s visits (complement to prenatal and healthy child controls). Humanized delivery care (AUGE 2007)