Oscar Arteaga, Director of the School of Public Health of the University of Chile: The proposed constitution “recognizes public order”

Oscar Arteaga, a surgeon and Master of Health Administration from the University of Chile, took up his position on December 15, 2021 as Director of the School of Public Health at the same university. In addition to being an academic, the specialist is part of the National Epidemiological Response Committee that advises the Ministry of Health regarding Covid-19.

In the face of the constitutional proposal on health, Arteaga has no fundamental objections and explains that in practice, the system is already largely public. At the same time, it highlights that cooperation between the public and private worlds is necessary to meet the needs of the population. In this context, the doctor supports the agreement that has already been resolved and confirms that he is on the way to obtaining approval.

Article 44 approved by the Convention provides for the establishment of a national health system of a global, general and integrated character. What are the highlights of this achievement?

What the convention proposal does is acknowledge what is there. We have a public health system in terms of existing resources. For example, there are about 40,000 hospital beds, less than a fifth, private. From a health benefits point of view, we as a country get about 110 million visits a year, of which 80 million are generated by public service providers. Of the thirty million made by private companies, Fonassa funds half. So, strictly speaking, we have a system that is said to be mixed and it is true that there are public and private actors, but in practice it is preferable that the system be public, in terms of insurance and benefits. What the motion does is acknowledge it. In addition, I think it is important to recognize that it is an integrated system, that is, there are public and private actors, which are put in place to solve the health problems of the population.

Is what has been approved so far in the agreement valid in terms of health?

From a performance standpoint, we’re already doing that. I think it is important to distinguish between two areas when analyzing the health system. The first is how to pool resources to provide health, which is a function of insurance and financing. Another thing that is different is how the benefits are delivered. During our discussion this year, the two functions are usually linked. When the isapres defend their position, they admit in their conversation that they are the ones who allow access to private providers. Strictly speaking, whether insurance is Fonasa or isapre, it is a mechanism through which people can access what really matters to them, which is the care provided by public and private providers. It is done. What the agreement proposal does is answer a question about funding, a question that has taken me more than 40 years, which is whether or not isapres is part of Social Security. isapres benefits from having this mandatory contribution and can do so, but what is not part of Social Security is that it discriminates, because if the beneficiaries are older or if the woman is fertile, she has to pay a plus. The law has allowed this since the creation of isapres, which makes our system an anomaly in the international context. What the agreement did was that contributions would be pooled to create a system based on solidarity, that is, the richest people funded the less. Healthy people finance the sick.

Do you think one fund will solve the health system’s problems?

The main problem that we have in the country, in the health system, is funding, but that also limits how health care is delivered, and that is that we have a socially separate system, where people’s income level requires access to health care. This happens because on the issue of insurance financing, we have a coexistence of public insurance and other private entities that manage this compulsory insurance, but are empowered to discriminate on the basis of individual risk. isapres collects the mandatory contribution and also charges an additional fee to provide you with a health plan and this leads to social separation. What the agreement proposes is the pooling of contributions and thus ending social segregation and allowing the building of a solidarity system. Subsequently, the entity that will have to be formed to manage the insurance will be able to establish relationships with service providers from the public and private sectors, which will allow to improve the relationship between the actors for the benefit of the population.

According to the numbers, people from Fonasa are still accessing the private system. why?

There is a lot of history with the freedom to choose the provider. It’s been around since 1968, when a National Service Act allowed employees to offer treatment benefits through this arrangement where Fonasa-registered providers and beneficiary employees can choose a provider and make co-payments. This system is inherited with the current Fonasa and continues to exist. Therefore, there is a culture of using the free-choice method that must be taken into account when redesigning the system. It is important that people have the possibility to choose a provider. What one hopes is that this pattern of relationship between the person who finances and the person who pays uses a smarter purchasing mechanism.

Will the public system be able to accommodate the needs of the entire population?

There is a misconception here. It’s not that public order will accommodate. What the new constitution proposes is a way of regulating finances and a way of regulating provisions, and leaves the way in which they are to be regulated to future laws. The most obvious result is that by regulating financing by pooling contributions, what is achieved is a financing system unique to all, which is why isapres came into being. Now, from a healthcare point of view, the constitution recognizes both public and private providers and indicates that under the leadership of the state, the conditions in which private providers participate will be determined. It seems to me that all the comments that have been made about whether public order will not be able to accommodate it are not true, because that is not what the proposal says. It is a wrong interpretation. Because there is the possibility of having public and private providers with an organization that provides us with the possibility of maximizing our system to solve people’s health problems.

Do you have any objection to what is proposed in Health?

No, what the proposal for a new constitution does is to propose great concepts that leave the regulatory part to be determined by law, i.e. it gives the legislature the responsibility to pass laws that allow the guiding principles to take effect. There are very specific aspects one could have brought up that were not in the proposal. One could say ‘why more specific aspects of mental health and not cancer or other diseases are raised’, but that is not an objection.

Will you vote yes or no?

I support the proposal for a new constitution and will agree to it. There are elements I would prefer something different, particularly on some matters of the political system, because I disagree with immediate re-election to the presidency, for example. But, to have a proposal crafted by elected citizens with gender equality and for there to also be representation of indigenous peoples, is already a value in itself. This proposal strengthens democracy, and I would agree beyond what one might consider critically.