Limitations when conducting research on migration and SDH in Chile

The previous chapters have illustrated limitations related to research on migration (Chapter 2, section 2.7) and research on migration and health (Chapter 3, section 3.5). This chapter will describe particular research limitations on the SDH that have been reported in the past in Latin America and Chile (Arteaga et al., 2002a; Martiny, 2000).

1. The current information available from datasets to conduct studies on inequalities in health has been limited in terms of accessibility, and in some instances, quality. Because the transparency of budgeting has been considered a key element in promoting fair public services, it is vital that this information is complete, accurate and readily available to the public. This is not the case in Chile.

2. There has been a lack of household-level information to combine the analysis of demographic, socioeconomic and environmental information on the quality behaviours and health service utilization of the health system at the level of households or

individuals.

3. Much of the publicly available governmental information has been published in printed versions. There has been a lack of information on the variability of the summary figures and estimates given in the literature. In addition, printed publications did not always include the denominators, or references to them, that have been needed for later statistical analysis.

4. Any study that requires the analysis of information from various sectors of the public health organization in Chile has had to face the difficulty that the boundaries of administrative units of the different public health sectors did not always coincide in territorial units below the regional level. This has been an obstacle to combining information from the records of one type of unit (e.g. health services) with data from another field (e.g. the Provincial Department of Education). This issue has been controlled in the CASEN survey since 2003 by the creation of geographical “sections”

by the National Institute of Statistics in 2002 that stay the same over time (more detail in chapter 5).

135

databases involved in the various public departments. Not infrequently, some

municipalities, especially those with combined names, have had several alternatives in the records, causing difficulty and delay in data analysis.

6. The difficulties of comparing public and private health care have also placed a limitation on the study of important aspects of health equity in Chile. When public and private sectors have been compared, which together constitute the health sector in Chile; there have been even greater variations than those observed in this study for the public sector.

7. Additionally, although ultimately both sectors have been subject to public policies that affect them, it has been much more difficult to obtain information about the private than the public sector.

Despite all the existing limitations mentioned above, there are some strategies in Chile to promote better use of information to support and advance public policy through research. For example, the Ministry of Health has been reviewing and strengthening its information systems. The government has been implementing a National System of Municipal Indicators with the purpose of systematizing a set of indicators reflecting the performance of the local authorities in key areas (health, education, social development, spatial development, administration and finance). This would provide useful information to support research, management and decision making for all those involved in the municipality in the future.

Moreover, in the past few years, several government agencies have made information available on their websites. Nevertheless, no study on Social Determinants of Health (SDH) in Chile has focused on the immigrant population. Efforts to improve research on SDH in the country remain at a basic level and are focused on the general population. Systematic studies on SDH among the immigrant population would allow the development of future policy strategies to reduce the health inequalities that might exist in this group when compared to the local Chilean population.

136 recognised?

The social determinants of the average level of health in a population are not necessarily the same as those that influence the health of specific vulnerable groups (Rose, 1985; Graham, 2004b). This distinction is important from the health policy viewpoint, as it might be possible to promote initiatives related to the SDH of those who are vulnerable and not only for the average. As clearly stated by Marmot et al. (2008, p. 1661):

“The poor health of poor people, the social gradient in health within countries, and the substantial health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people's lives—their access to health care and education, their conditions of work and leisure, their homes, communities, towns, or cities—and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a natural phenomenon but is the result of a combination of poor social policies and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions of daily life constitute the social determinants of health and cause much of the health inequity between and within countries.”

The growing health and socioeconomic inequalities in the world make evident the need for greater support for policies aimed at reducing their causes, and redistribution of resources to the vulnerable population, thus improving the health status of these groups (Marmot and Bell, 2009). Health can be influenced by other variables modifying the relationship between socioeconomic status and health outcomes. Among them, the role of public health policies should be stressed. Countries with similar living standards may differ markedly in the state of health of their populations, according to the quality of their interventions in public health and other social policies. Three specific challenges for health inequalities in Chile have been especially discussed in the past and are posed in the next paragraphs. They build up from the detailed previous discussion on explanatory pathways and models on the SDH and how they affect health, in combination with current debates in Chile on how to improve the health of the populaitron in this country. These are income, occupation and access to health care, and they will be explored in detail in the immigrant population in Chile in the following chapters, as they are considered key variables for policy implementations for reducing health inequalities in the country (Jadue & Marin, 2005).

In terms of income, Chile has been defined as a middle income nation (Vega et al., 2001;

Espejo, 2005) with an urgent need for redistribution. This is not only necessary to ensure adequate consumption by vulnerable groups, but also because it contributes to reducing the gaps in health and quality of life. Encouraging direct interventions in the health problems of the poor also affects the income generation capacity of these groups, helping them to overcome poverty. Spending on health not only helps prevent and treat disease, but also helps people to develop more productive lives. In this way, it influences the reduction of

137

of health, Solar et al. (2005) have proposed that the occupational health system in Chile has not incorporated changes in work organization and labour relations, resulting in a lack of coverage and a quality system that has not been adequately evaluated in the country. The challenges of real interdisciplinary work are central to the development of public policies on the health of workers. The participation of different stakeholders and the empowerment of employees, especially those in low-paid occupations, is central. The evaluation of the relationship and integration of health systems and occupational health has been considered an important aspect of health reform in Chile. There are also challenges for research into the conditions of employment and work as a social determinant of health in the country. This involves, for instance, improving the understanding of contractual status, working hazards, time spent at work, working conditions specific to gender and their relationship to health, and others (Solar et al., 2005).

Chile has developed several efforts to reduce inequalities in access to health care. The most notable policies in the last 40 years are: Maternal and child health programme since the 1960s; National food supplement programme since the'70s; Expanded immunization programme since 1974; National Acute Respiratory Infections programmes in 1990;

Tracking preterm or low birth weight programme in 1995; Neonatal Surfactant Programme in 1997; and Fortification of flour with folic acid in 2000. Despite these achievements in access to health care and service utilization, other important elements to consider are the need for implementation of modern information systems in at least two areas: (1) the management of health institutions; and (2) the monitoring of the health status of the

population through the availability of epidemiological data obtained from local levels in real time (Hernandez, Sandoval and Delgado, 2005).

Overall, action on the SDH must involve the government, civil society, local communities, business, and international agencies. Communities must be empowered at local levels to achieve success (Syme, 2004), but also ministries are crucial to the realisation of change and the commitment of international agencies (Marmot et al., 2008; Exworthy, Blane and Marmot, 2003; Lurie, 2002). Chile has initiated a significant process of transformation in the public health system and has recognised the relevance and urgency of tackling health

inequalities in the local population. However, research is needed on the SDH among the immigrant population in Chile. This research will try to shed the light on this particular problem, for later work on policy interventions, to protect this potentially vulnerable group.

138