"Scientific knowledge has been one of the basic pillars of our proposal for reform, especially the knowledge about equity," according to National Committee for Health Reform executive secretary Hernan Sandoval, a chief health adviser to Chilean president Ricardo Lagos.
Such evidence about health inequity is having an impact on health policy in Chile, according to Sandoval
This is in no small part due to the work of a small team of researcher/advocates called the Chilean Health Equity Gauge
, a group actively involved in the reform process.40 The team in Chile is part of an international network focused on monitoring national inequities in health and health care services and committed to closing the gap
in health status between different socioeconomic groups.41
The work of the Equity Gauge includes an innovative fusion of research, advocacy, and direct participation with stakeholders, and it has been described as an "extraordinarily effective alliance,"42 particularly in terms of building relationships between researchers and key decision makers.
As part of its work, the group has produced and disseminated several reports on the problem of health inequities in Chile, as well as potential solutions.43 "The combination of advocacy and knowledge is very powerful," says Sandoval
, who has worked with the group since 1999.44 A key achievement of the Equity Gauge was helping to develop and write specific health objectives for the Chilean government for the 2000–2010 decade.
It has also been officially commissioned to monitor and disseminate data on health inequities as the government attempts to close the health status gap between different socioeconomic groups in Chile.45
Asked whether individual pieces of research evidence had been utilized directly in specific policy decisions, Sandoval
said the impact of the evidence about health inequity was more cumulative and indirect—what might be called an "enlightening" use of evidence.
Describing an interdependence between research and policy, he
pointed to the fact that one of the major slogans of the Lagos party in Chile is "Desarrollo con Equidad" ("Development with Equity").46
One practical strategy for reducing health inequity being used in Chile's current reforms is a dramatic boost to the role and funding of primary health care.
In 2000, at the time of the election of the Lagos government, primary care in Chile received just 12 percent of the health care budget and was still widely viewed as a "second-class system," mainly there to service the poor—essentially the poor cousin of the hospital and specialist sector.
Yet in just four years, primary care's share of the national health budget has jumped to 18 percent, and there are plans to increase that to perhaps as much as 30 percent with ambitious programs involving 60 new facilities across the nation.47
Reformers such as Sandoval
who believe social determinants play a key part in health see the new role of primary care as a critical interface between society and the medical system, between "public action for health" and "specific health services," as he
The reforms are about enhancing the role of primary care, integrating it better with other parts of the system, and trying to change public perceptions about health and health care services.
"One of the big problems is people still think they are going to find health solutions with specialists or in hospitals.
We have to show that improving primary care can improve health."48
A senior health aide to President Salvador Allende in the early 1970s, Sandoval is enthusiastic about the current prospects for health reform in Chile and the use of evidence in the process.
In February 2004 Sandoval
attended a seminar in London, sharing the Chilean experiences of reform with policymakers in the National Health Service.
Adding a historical perspective to the current changes, he
explains that, in his
view, although many of Chile's physicians and their representative organizations had fought hard for an end to dictatorship and the return of democratic political reform, the push for fundamental reform of the health system took a backseat—until now.49
37Author's interview with Hernan Sandoval, executive secretary, National Committee for Health Reform, 2004 (hereafter Sandoval interview).