HSPH Students Observe
Doctors had been striking against the health reform laws two weeks before we arrived. Newspapers were full of debates over the proposed reform. We’d organized a course for 15 Harvard School of Public Health Masters students to experience this remarkable and exciting period of innovation in Chile for public health issues. The students came to see first hand the process of reforming health systems and innovations in community medicine approaches, including the assessment of social capital initiatives—the two major public health issues in Chile today.
Chile was one of the first countries on the continent to significantly reform its health system in the 1980s. It introduced new programs of public and private social insurance schemes, promoting the growth of private sector providers and decentralizing their public health services. Chile has been a model for health reform in many other countries. Since the restoration of democracy in the 1990s, many in the health sector have been proposing new reforms to correct many of the problems that emerged in implementation of the initial reforms.
A leader in promoting community-oriented health systems, Chile is also a laboratory of innovations in outreach programs, community participation, 24-hour emergency service units and special programs for the elderly and other specific risk groups. The Universidad Católica has implemented pilot programs with recent innovations in community medicine around Santiago. Complementing these programs is a research project to assess the role of social capital (trust in others and participation in voluntary groups) in health care services and health status.
As the faculty member in charge of the course, I have had considerable experience in Chile—beginning with my Ph.D. dissertation research on the Allende regime in 1973 and continuing over the last ten years in various public health research and consulting activities. I was able to draw on many of my contacts and friends who are now major actors and observers of the health reform process and community medicine initiatives.
The course came at a critical time in the health reform debate. We could not have had a better opportunity to observe the process of health reform in practice since we were there during an intense period of debate over the new reform laws, including strikes and demonstrations by the Colegio de Médicos. And, as we were nearing the end of the third week one of the key pieces of reform legislation passed the Congress just as we were having a celebratory group dinner with some key reform advocates. We were able to congratulate them collectively in person over food and wine.
The 15 masters students were a great mix of medical students (who were complementing their program with a year for an MPH) and other social scientists (many of whom were taking courses mainly on the U.S. health system in our Health Policy and Management program). They quickly caught up on the system issues and consistently surprised me and the Chileans with their welltargeted and penetrating questions and comments. In addition, they were a friendly and cooperative group who were very supportive and good-natured throughout the program—a chemistry that does not always happen in these kinds of courses. Since four of the students did not speak Spanish, the others took it on themselves to do whispering translations that worked out better than we expected. We also had three Chilean medical students in the Universidad Católica family medicine residency program who were fully integrated into the course. They gave useful detailed commentary, but also found that the course helped them to better understand their own system and the reforms.
Four HSPH alums devoted enormous energy and time to getting key officials to speak to the students and to organize field trips to hospitals, clinics, insurance companies, mayors and community groups. The alums included officials in key ministry positions, as well as a university professor who got her MPH degree in 1978. We also had a stimulating interview with the editor of the leading newspaper, El Mercurio, who is also an HSPH alum.
The program began with an overview of Chilean politics and urban planning by two Harvard alums, one from the Graduate School of Design and the other from the Kennedy School. The students then attended a day of lectures on the Chilean health system, focusing on epidemiological trends and the history of health reforms beginning in the early 20th century. This overview, led by a former Minister of Health, now head of the Department of Public Health of the Medical School at Universidad Catolica, was followed by another day of lectures at the Ministry of Health where the Minister began to inform the students of the new proposals for health reform. All the key officials involved presented different aspects of the reform package. The next day we met with two officials from the major opposition, the Colegio de Médicos, with passionate defense of their position and an introduction to the intensity of debate in Chile. Then we met with the editor of El Mecurio and other outside observers who outlined several key issues and offered thoughtful evaluations of the nature of the debate over reform.
With this introduction to the current debate, we spent the following week visiting the actual facilities in several municipalities in the Santiago metropolitan area and in rural areas in the Aconcagua region. At these visits we were introduced to a new model for community health programs based on segmenting the community into territorial districts with a team of health professionals responsible for an integrated program of health care for the community. The students were able to observe the conditions in both public and private facilities, discuss the reforms and community health issues with health providers, with insurance providers and with mayors. They were even treated to traditional Chilean hospitality with local children performing “cueca” dances for them and with generous lunches in beautiful surroundings. We were constantly surprised and often overwhelmed with the generosity and warmth of our Chilean hosts and their willingness to share balanced observations and thoughtful opinions with us.
During the final week the students worked on individual and group projects and presented the results in a seminar that was attended by the key alum organizers. Some of the projects were so professionally done that they will be taken into consideration by local officials—particularly one impressive survey of patient satisfaction in a local clinic that will be used to guide changes there. One team did a political feasibility study using a computer program developed at Harvard to assess the political feasibility of the reform package and to develop innovative strategies for increasing support. Evaluations of the family medicine programs, decentralization at municipal level, private insurance, pharmaceutical problems and social capital research were also topics of the individual projects. Another project may lead to collaborative research on cancer with the faculty of Universidad Católica.
The course could not have been a success without the wide support and participation of the Harvard community and the tremendous work of the Santiago office of the David Rockefeller Center for Latin American Studies. Steve Reifenberg’s network and excellent reputation made it possible to contact some of the key alums and to call on others who knew and worked with him. He put his staff, particularly Alejandra Méndez, at our disposal for the initial organizing and for many of the detailed logistics needed throughout the course. The Center was an invaluable resource for students to do their independent work and for some of the classroom activities. Steve also generously had the final group dinner at his house and led a discussion of the students to elicit what they had gained from the Chilean visit.
I think with this success, we will be planning to do the course again next year—to observe the first year of reform implementation. All the Chilean participants are enthusiastic about continuing this collaboration. We are also planning other collaborations—having just joined with Universidad Católica in our proposal to National Institutes on Aging to form a Center for the Study of Adult Health in Middle and Low Income Countries.
Spring 2004, Volume III, Number 3
Thomas Bossert is the Director of the Politics and Governance Group at the Harvard School of Public Health.
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