Abstract

The article analyzes the implementation of integrated healthcare networks (RISS) and the strategies for care coordination by PHC in the Chilean public health system. Semi-structured interviews were conducted with policymakers from the public health system and academics, complemented by documentary analysis and bibliographic review. The country stands out for the institutionalization of care coordination instruments widely recognized, such as referral maps, demand manager physician, electronic records and, mainly, definition of protocols, under the strong leadership of the Ministry of Health and conduction by the Servicios de Salud managers, regional space for the construction of RISS. However, segmentation and fragmentation’s degrees within the public subsystem were identified, with the maintenance of free-choice for specialized medical appointment and double waiting lists - one for procedures with explicit access guarantees and another for others cases. The Chilean experience demonstrates the need for a greater role for PHC so it will be able to take on the leadership of RISS. In the country, the network seems to orbit around large and powerful hospitals. Elements of a broader context of the health system also condition advances and impasses in the development of the analyzed strategies.

Systems integration; Primary health care; Chile

Introduction

Health care fragmentation is one of the main obstacles to achieving better results in access, quality, rational and efficient use of resources and user satisfaction, among other aspects¹1. Organización Panamericana de la Salud (OPAS). La Renovación de la Atención Primaria de Salud en las Américas. Redes Integradas de Servicios de Salud. Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2010.. The search for integrated care is a central component for coping with the increased burden of chronic diseases in the context of public investment constraints²2. European Union. Tools and methodologies to assess integrated care in Europe. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union; 2017.. In addition to its relevance, there is a certain consensus about the relative insufficiency of tools, methodologies and indicators and recognition of the complex transition from “fragmented care” to “integrated care” in all its components: design, implementation and evaluation²2. European Union. Tools and methodologies to assess integrated care in Europe. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union; 2017..

In line with the concept of regionalized networks of public systems, the Pan American Health Organization¹1. Organización Panamericana de la Salud (OPAS). La Renovación de la Atención Primaria de Salud en las Américas. Redes Integradas de Servicios de Salud. Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2010. developed a conceptual framework for the operationalization of Integrated Health Services Delivery Networks (IHSDNs) in Latin American countries led by Primary Health Care (PHC). No less relevant is how integrated care is designed and implemented to fit local contexts and needs²2. European Union. Tools and methodologies to assess integrated care in Europe. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union; 2017..

Evidence on the results of organizational and structural reforms for better performance of the IHSDNs is scarce and still poorly explored in health systems of the Region, as well as their impact on the coordination between care levels³3. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, Albuquerque P, Eguiguren P, Cisneros AI, Rovere M, Bertolotto F. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasiexperimental study protocol. BMJ Open 2015; 5(7):e007037.,⁴4. Vargas I, Mogollón-Pérez AS, De Paepe P, Ferreira da Silva MR, Unger JP, Vázquez ML. Barriers to healthcare coordination in marketbased and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan 2016; 31(6):736-748.. Thus, the unequivocal relationship between integrated network design and care coordination is reaffirmed – which can be taken as one of the intermediate results for the analysis of IHSDNs performance³3. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, Albuquerque P, Eguiguren P, Cisneros AI, Rovere M, Bertolotto F. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasiexperimental study protocol. BMJ Open 2015; 5(7):e007037..

Coordination of care can be defined as the articulation between several services, actions and professionals in health care, so that, regardless of the place of provision, it is synchronized, aimed at achieving a common objective and without conflicts⁵5. Núñez RT, Lorenzo IV, Navarrete MLV. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit [Internet]. 2006; 20(6):485-495. [acessado 2017 Dez 22]. Disponível em: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S021391112006000600012&lng=es
http://scielo.isciii.es/scielo.php?scrip... ,⁶6. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica 2016; 50:80.. It is supported by the existence of integrated actions between networked providers and professionals, led by PHC⁷7. Boerma WGW. Coordenação e integração em atenção primária europeia. In: Saltman RB, Rico A, Boerma WGW, organizadores. Atenção Primária conduzindo as redes de atenção à saúde: reforma organizacional na atenção primária europeia. Berkshire: Open University Press; 2010. p. 25-47.. Integrated care is a principle and a means to achieve user-centered, more efficient and safe care²2. European Union. Tools and methodologies to assess integrated care in Europe. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union; 2017..

In Latin America, with few exceptions such as Cuba and Costa Rica, health care networks have been set up in parallel for segregated population groups⁸8. Barrios OA, Devia OT, García AF, Hein AA, Herrera OA. Gobierno de redes asistenciales: evaluación de los Consejos Integradores de la Red Asistencial (CIRA) en el contexto de la reforma del sector salud en Chile. Salud Pública de México 2013; 55(6):650-658.. The high segmentation levels in Latin American health systems complicate the conception and scope of coordination between care levels, given the need to incorporate the coordination among different subsystems⁹9. Haggerty JL, Yavich N, Báscolo EP, Grupo de Consenso sobre un Marco de Evaluación de la Atención Primaria en América Latina. Un marco de evaluación de la atención primaria de salud en América Latina. Rev Panam Salud Publica 2009; 26(5):377-384..

The Chilean health system’s experience is paradigmatic and complex in that it appears as the first in the Region to follow the recipe proposed by multilateral organizations (IMF and World Bank) for developing countries and later systematized in the Consensus of Washington, establishing itself as a field of experimentation of the most orthodox neoliberal policies¹⁰10. Meller P. Un siglo de economia política chilena (1890-1990). Santiago de Chile: Uqbar editores; 2016..

While in the 1950s, the National Health Service (NHS) based on the English model was the second world experience of this type¹¹11. Labra ME. La reinvención neoliberal de la inequidad en Chile. El caso de la salud. Cad Saude Publica 2002; 18(4):1041-1052., radical change was produced with the military dictatorship in the 1980s, with privatization of insurance and promotion of private medical care¹²12. Goic AG. El Sistema de Salud de Chile: una tarea pendiente. Rev. Med. Chile 2015; 143:774-786.. Labra¹¹11. Labra ME. La reinvención neoliberal de la inequidad en Chile. El caso de la salud. Cad Saude Publica 2002; 18(4):1041-1052. highlight that even the most austere neoliberal reforms of the 1980s failed to extinguish the institutional legacy established in the face of right expansion in the 1950s, a legacy that is expressed in the permanence of a powerful network of public hospitals to this day (2016): 68% of Chilean hospital beds are public¹³13. Clínicas de Chile. Dimensionamiento del sector de salud privado en Chile. Actualización a cifras año 2016. Santiago de Chile: Clínicas de Chile A.G.; 2016..

After the end of the military regime in the 1990s, the center-left coalition initially did not implement a significant reform in the health system, although it has promoted a significant increase in public funding, especially for hospitals¹⁴14. Bossert TJ, Leisewitz T. Innovation and change in the Chilean Health System. N Engl J Med 2016; 374:1.. Subsequently, during the Lagos government (2000-2006), the sectoral reform strengthened the public system. However, the dual configuration of the system was maintained with the public insurance component – National Health Fund (Fonasa) and the private sector – consisting of Social Security Health Institutions (ISAPRE), profit-making private companies intermediating the purchase and sale of health plans¹⁵15. Cid C, Uthoff A. La reforma a la salud pendiente en Chile: reflexiones en torno a una propuesta de transformación del sistema. Rev Panam Salud Publica 2017; 41:e170., in general for the lower-risk-high-income groups, thus decapitalizing the public sector¹⁶16. Koch K, Johanna K, Pedraza CC, Schmid A. Out-of-pocket expenditure and financial protection in the Chilean health care system: A systematic review. Health Policy 2017; (121):481-494..

The search for greater integration and articulation of the network was one of the main pillars of the Chilean health system reform, with the definition of the Explicit Health Guarantees (GES) for the entire population as the main flag⁸8. Barrios OA, Devia OT, García AF, Hein AA, Herrera OA. Gobierno de redes asistenciales: evaluación de los Consejos Integradores de la Red Asistencial (CIRA) en el contexto de la reforma del sector salud en Chile. Salud Pública de México 2013; 55(6):650-658.. Among the key elements that enabled the GES Reform was the definition of clinical prioritization strategies, linkage with specialty societies, securing funding and coordination within the health care network¹⁷17. Urriola C, Infante A, Aguilera I, Ormeño H. La reforma de salud chilena a diez años de su implementación. Salud Publica Mex 2016; 58(5):514-521..

In addition to the guarantees of access, the country promoted an intense reform in the PHC model. With a prominent centrality in the political agenda, the Comprehensive Family and Community Health Care Model explicitly incorporated elements of Alma Ata’s expanded approach, which is the basis for the establishment of a health system focused on people, families and communities, as well as on comprehensive and continued care¹⁸18. Vega Romero R, Acosta Ramírez N. Mapeo y analisis de los modelos de atención primária en salud en los países de América del Sur. Mapelo de la APS en Chile. Rio de Janeiro: Isags, 2014. [acessado 2018 Jan 2]. Disponível em: http://www.isags-unasur.org/uploads/biblioteca/7/bb%5B160%5Dling%5B2%5Danx%5B521%5D.pdf
http://www.isags-unasur.org/uploads/bibl... .

Taking the scope of integrated care as a component of the reform processes and the primary objective of health systems, this paper analyzes aspects of the implementation of integrated networks and strategies and tools for the coordination of PHC care in the framework of a segmented and dual system such as the Chilean Model. It is hoped that this study, from a specific case, will contribute to apprehend lessons that can be debated and analyzed in similar contexts.

Methods

This is an exploratory, descriptive-interpretative and qualitative study whose information sources are semi-structured interviews with key informants, complemented by thematic documentary analysis and bibliographic review. Conill et al.¹⁹19. Conill EM, Giovanella L, Almeida PF. Listas de espera em sistemas públicos: da expansão da oferta para um acesso oportuno? Considerações a partir do Sistema Nacional de Saúde espanhol. Cien Saude Colet 2011; 16(6):2783-2794. emphasize the importance of analyzing coherence among actions at macro levels, which include political decisions about rights, funding and macro-regulation; at meso or management level, with the implementation of operational mechanisms that support practices; and at micro-social level, in which care is implemented to comprehend the overall dynamics of health systems. Thus, interviews were conducted with policymakers at the macro (MC) (6), meso (M) (4), micro (MI) (5) levels, and four academy representatives (Chart 1). The 19 interviews were held at the respective work places – lasting approximately one hour – recorded and transcribed.

For the documentary analysis, the main laws and regulatory frameworks of the Chilean health system reform process from 2003 to 2017, summarized in Chart 2 were selected.

For the production of results, the thematic content of all the material was analyzed with its respective stages of categorization, description and interpretation. Although the analytical framework of the IHSDNs developed by PAHO¹1. Organización Panamericana de la Salud (OPAS). La Renovación de la Atención Primaria de Salud en las Américas. Redes Integradas de Servicios de Salud. Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2010. and studies that design a certain logical model for the attribute of care coordination²⁰20. McDonald KM, Schultz E, Albin L, Pineda N, Lonhart J, Sundaram V, Smith-Spangler C, Brustrom J, Malcolm E, Rohn L, Davies S. Care Coordination Atlas Version 4. Rockville: Agency for Healthcare Research and Quality; 2014. were used in an inductive perspective, there was an attempt to capture categories that emerged from the experience of the subjects involved. We sought to guarantee the quality and validity of findings by triangulating the information from the documentary and bibliographic analysis with the perception of the different groups of informants from the three levels of the health system.

The presentation of results begins with a brief characterization of the Chilean health system and the Comprehensive Family and Community Health Care Model, further analyzed in other publications²¹21. Giovanella L, Ruiz G, Feo O, Tobar S, Faria M. Sistemas de salud en América del Sur. In: Giovanella L, Feo O, Faria M, Tobar S. Sistemas de salud en Suramérica: desafíos para la universalidad, la integralidad y la equidad. Rio de Janeiro: ISAGS; 2012. p. 21-69.,²²22. Giovanella L, organizadora. Atención primaria de salud em Suramérica. Rio de Janeiro: ISAGS; 2015., highlighting stakeholders’ perception on subjects directly affecting the discussion about the IHSDNs and coordination. Next, network integration initiatives and the main tools and strategies of coordination of care developed within the scope of the public subsystem are analyzed.

Context – The Chilean health system

The Chilean health system is characterized by duality in the form of affiliation to protection, with formal workers given the possibility of choosing to contribute to private insurance (Isapres) or to public insurance (Fonasa) through compulsory social contributions of 7% of their salary. However, most of the population is affiliated with Fonasa and access the public services network (Chart 3).

According to Chart 3, the public health subsystem is composed of the National Health Services System. The Ministry of Health is responsible for formulating and implementing health policies, which within the Sub-Healthcare Networks Secretariat establishes guidelines for municipalities and Health Services (HS)²⁶26. Vega Romero R, Acosta Ramírez N. La atención primaria em sistemas de salud basados en el aseguramiento: El caso de Chile, Colombia y Perú. In: Giovanella L, organizadora. Atención Primaria de Salud en Suramérica. Rio de Janeiro: ISAGS; 2015. p. 195-254.. The public system is unitary, centralized and organized in 29 HS, with own budget and responsible for the provision and management of specialized and hospital services, as well as network integration strategies. They are regional territories where hospitals and health centers managed by municipalities are articulated. The country has established six macro networks, consisting of more than one HS, which provide for a comprehensive resolution of health problems. The respective HS directors are the local authority for the provision of care services, but SEREMI is the health authority.

The main post-dictatorship sector reform was the definition in 2004 of the Explicit Guarantees Scheme that provided timely access and financial protection to a list of specific problems (Chart 2). Before its establishment, access was conditioned to hospital proximity or the health professional’s judgment to define priorities (E6). Protocols were set incrementally and times for timely care defined through GES. Explicit guarantees are well evaluated by users, especially due to the legal guarantee of access and care follow-up, with specific channels in health services to “claim” the benefits (E6, E10). Nevertheless, it was pointed out that, from the model viewpoint, the GES rationale reinforces fragmentation and targets the resolution of a pathology, without a broader approach to its determinants (E6).

Public system beneficiaries affiliated to Fonasa can choose two types of service: Institutional, provided by public establishments; and Free Choice, with direct access to private establishments contracted to Fonasa, with co-payment. In this case, there is no PHC gatekeeper mechanism. With the possibility of free choice, many users use direct access to experts as a first contact, which strengthens the maintenance of competing models. Illustrative statements of contradictions in the use of free choice services are shown in Chart 4.

PHC reform in the country began in 2005 with the implementation of the Comprehensive Family and Community Health Care Model, which is characterized by three principles: people-centered, providing comprehensive care and ensuring continuity²⁷27. Chile. Ministerio de Salud (MS). Modelo de atención integral en salud. Santiago de Chile: MS; 2005. [Serie cuadernos Modelo de Atención Nº1].. The operation of the model has undergone transformation of clinics and traditional health centers into Family Health Centers (CESFAM) and Community Health Centers (CECOSF), smaller structures and with greater territorial proximity; strengthening of basic teams; networking and intersectoral work; local management; and social participation²⁶26. Vega Romero R, Acosta Ramírez N. La atención primaria em sistemas de salud basados en el aseguramiento: El caso de Chile, Colombia y Perú. In: Giovanella L, organizadora. Atención Primaria de Salud en Suramérica. Rio de Janeiro: ISAGS; 2015. p. 195-254., valuing “family” and “community” components in the system design (E5).

The Ministry of Health is responsible for formulating and implementing PHC policies. Municipalities are autonomous in management and provision, in accordance with the legal framework²⁸28. Chile. Ministerio de Salud (MS). Estatuto de la Atención Primaria en Salud. Lei Nº19378. Establece Estatuto de Atención Primaria de Salud Municipal. Chile: MS; 1995. [acessado 2017 Dez 28]. Disponível em: https://www.leychile.cl/Navegar?idNorma=30745
https://www.leychile.cl/Navegar?idNorma=... . Central financing, passed on to the HS and from these to municipalities represents almost all PHC funding and provides the national manager great inductive power in the conduction of networks and PHC (E2). National law regulates the PHC service portfolio and there are no co-payments.

Two strategies are in place for urgent care in PHC, namely, the Primary Care Urgent Services (SAPU) and, as of 2014, the High Resolution Emergency Primary Care Services (SARS), with greater problem-solving capacity, expertise and diagnostic support. While both are within the scope of PHC, poor integration of urgent services and health centers was mentioned, as well as integration initiatives by monitoring user entry in urgent services to prevent them from becoming a regular search for care option.

Efforts are made to strengthen the PHC team (head teams) as responsible for the health of the population, although there is high medical rotation. CESFAM also have “cross-sectional” teams at work, strengthening health promotion and prevention actions (Chart 3). In addition to supporting teams, some centers have ophthalmology services, which serve as a reference for others, a strategy positively evaluated in relation to improved access and increased interprofessional communication.

In some health centers, members or community leaders with a role similar to a “community health worker” act voluntarily. There is no consensus regarding the maintenance of the voluntary nature of these workers (E10) (Chart 4). Historically, the country has traditionally had voluntary workers, an experience interrupted during dictatorship and reactivated more recently with the CESCOF.

The country faces difficulties for the provision of doctors (Chart 3), operating with about 50% of foreign doctors in some health centers, according to MINSAL informants. In 2016, the country had 41,623 doctors enrolled in the Superintendence of Health, of which 15% were foreigners, a proportion that has increased in recent years, especially with the arrival of professionals from Venezuela, Colombia, Ecuador, Bolivia and Cuba. About 45% of all doctors work in the public system¹³13. Clínicas de Chile. Dimensionamiento del sector de salud privado en Chile. Actualización a cifras año 2016. Santiago de Chile: Clínicas de Chile A.G.; 2016.. The staging of the National Medical Examination has been mandatory since 2008 and is required in order to work in the public system.

Health professionals are civil servants, with career plans defined in the PHC Statute²⁸28. Chile. Ministerio de Salud (MS). Estatuto de la Atención Primaria en Salud. Lei Nº19378. Establece Estatuto de Atención Primaria de Salud Municipal. Chile: MS; 1995. [acessado 2017 Dez 28]. Disponível em: https://www.leychile.cl/Navegar?idNorma=30745
https://www.leychile.cl/Navegar?idNorma=... . There are initiatives for the training of specialists in family and community medicine, mainly from the Ministry of Health. One of them is the Allocation and Training Stage for the deployment of doctors in remote areas with assured additional points in residences (E16). For the fixation and attraction of professionals, the national manager performed a risk classification for the areas of the country, which implies better wages and adjustments per capita.

An active user registration is required in order to receive care in a PHC service, which determines the transfer of resources and goals’ monitoring. Respondents evaluated that active and voluntary enrollment generates lack of care for the small percentage of the most vulnerable population (living in the streets, cultural and educational barriers).

PHC’s clientele continues to be the poorest, the lowest income strata groups A and B of Fonasa and the elderly. Groups C and D (somewhat higher income strata) that include workers often opt for free choice services. In addition to competing for resources, free choice establishes a care model competition (E10), either with prescriptions, not subject to standards and protocols of the public system; or the worsening of some cases, the follow-up of which becomes impracticable through free choice due to co-payment and impossibility of remaining in the public network (E16). Illustrative statements are shown in Chart 4.

There are two major tool for PHC assessment: health goals and the Primary Care Activity Index (PCAI), which generates the outlay of resources to municipalities. Health goals are agreed with professional corporations and generate pay-for-performance to professionals when they achieve 90%. There is also an associated pay-for-performance mechanism related to the user’s evaluation. Incentives are defined according to established priorities, but they can lead to targeted actions and work process to achieve goals and not model principles and objectives.

Health system reforms in recent years have been generally evaluated positively. In relation to PHC, noteworthy are the implementation of the people oriented Comprehensive Family and Community Health Care Model stands out; improved health centers’ infrastructure; achievement of satisfactory results in relation to health indicators; quality of guides and protocols. Nonetheless, it was reported that a “reform of the reform” is desired, a discussion that is increasingly present in the agenda of the different stakeholders, creating several spaces of participation and mobilization in order to promote “social value” around PHC.

Integrated Health Services Networks

PHC reform followed pari passu measures to build integrated health care networks operated by Health Services. Since the Primary Care Statute²⁸28. Chile. Ministerio de Salud (MS). Estatuto de la Atención Primaria en Salud. Lei Nº19378. Establece Estatuto de Atención Primaria de Salud Municipal. Chile: MS; 1995. [acessado 2017 Dez 28]. Disponível em: https://www.leychile.cl/Navegar?idNorma=30745
https://www.leychile.cl/Navegar?idNorma=... , the national manager is expected to prepare a normative framework for network programming and planning. Among management commitments signed between MINSAL and HS in the period 2014-2017, the highlighted objective is integrating health services network in healthcare, governance, finance and human resources. The most recent proposals are strongly influenced by PAHO’s proposed Integrated Health Services Delivery Networks³²32. Chile. Ministerio de Salud (MS). Orientaciones para la Planificación y Programación en Red. Santiago de Chile: MS; 2017..

The network’s territory are the Health Services, through the figure of the network manager, who is responsible for defining referrals and counter-referrals to ensure continuity of care, monitoring of goals and promotion of coordination between PHC and specialized care, where the latter is the more challenging (E10).

Depending on the assigned population, the HS can be divided into micro-networks, which are organized around their respective reference hospitals, most of which are public. MINSAL also has a national bed center, with national high-complexity reference services (Institutes).

Hospital centrality is found in the design of networks and micro-networks, which seem to be organized around these institutions, which also lead the proposal of strategies for network integration, more developed depending on the size of the hospital institution (E1; E10, E11, Chart 4). This arrangement ratifies a health care model with a strong curative character, from a symbolic and financial viewpoint (E10). The hospital receives all PHC referrals, labeled as “inter-consultations”, and is responsible for resolving them and handling waiting lists (E1).

As of 2002, the Care Networks Integration Councils (CIRA) (Chart 5) were established with the role of contributing to the articulation of the stakeholders, diagnosis and work proposals for network integration. Some HS directors have increased participation and integrated representatives of civil society and community leaders in this council. However, there is no participation of SEREMI, health authority of the territory.

CIRA’s design is strategic. Nevertheless, some councils would have assumed a bureaucratic paper, becoming an informative space. Greater council empowerment is dependent on the leadership of the network manager (E6) and search for greater legitimacy by drawing up work plans with concrete proposals (E9). Although it has no decision-making and executive power, CIRA has been an important mechanism to strengthen social participation (Chart 4).

It was categorically stated that waiting lists were the most discussed topic by the CIRA, as well as the referral and counter-referral process. Advances were identified in the integration of the two worlds – PHC and hospitals – but the waiting list theme prevails, with little room for discussion of the care model. Integration is harder in areas where references are large hospitals (with more than 400 beds), since these services would show a more autonomous dynamic, which does not allow us to visualize the importance of PHC. The tension for meeting hospital waiting times also facilitates their self-centered functioning, with little capacity for systemic performance.

Regarding the centrality of PHC in networks, it was emphasized that it is part of the ministerial rhetoric, but it is not based on reality, although the strengthening of the family health model has contributed to the paradigm shift of the care model. Statements in Chart 4 strongly confirm this assertion.

Strategies and tools for the coordination of care

Health Services establish “derivative maps” (Chart 5). Patient is referred through a computerized system that enables to locate, from the very health center, supply at the hospital of reference, although coordination and follow-up of users by the PHC does not happen on a regular basis.

The turnover of professionals, especially physicians in PHC, implies constant training efforts on network operation, derivative map, flows and clinical protocols. Information and Communication Technologies seek to minimize problems related to turnover, with the availability of clinical practice guides and derivative maps in the office computers, as well as provide information coordination.

Non-GES waiting lists began to be monitored more systematically through the creation of a national repository, with information on waiting times, fed and monitored by the HS. Waiting lists for specialties are identified throughout the territory, which makes it necessary to define clinical priorities, generally performed by hospitals.

There are differentiated teams and times (larger non-GES) for the management of the two lists (GES and non-GES), which impairs the overall care view. Over time and with political pressures, non-priority pathologies and benefits without scientific evidence were incorporated into the GES coverage in the different governments. In addition, the GES patient accounts for the highest percentage of hospital funding.

MINSAL and HS monitor PHC referrals percentage, which are satisfactory (Chart 5). In someworse performing places, it would reach 15%. The “demand medical manager” in PHC was an initiative of the national manager to qualify referrals. They are doctors who were already in the teams and who receive additional compensation to evaluate team’s referrals.

Health care protocols were evaluated as the main tool to ensure coordination of care, mainly by establishing the referral and counter-referral flows to ensure access and coordination of non-GES pathologies (E8) and define the functions of each system level. An adverse effect of the high degree of normatization would be a certain “routine” or repetition, which would characterize PHC work, making it unattractive.

Telemedicine initiatives are also adopted in the country by MINSAL (Chart 5), for example in urgent neurological care. National and local initiatives, promoted by reference hospitals, the hub of development and incorporation of technologies for the health system are also found. Other initiatives led by some hospitals are cared shared with CESFAM with rehabilitation, for example, of children with chronic problems and training for minor emergencies. This type of action is institutionalized and included in the agreed training plan (E8) (Chart 5).

The leadership of managers to define coordination goals, especially the management of HS and some hospitals, was mentioned as a key element for coordination (E2).

Referral and counter-referral guides are fragile tools, mainly because they are not computerized, in the majority of the cases. Few places provide shared records. The common situation is information return by the very user. Respondents recognize insufficient counter-referral as an obstacle to the coordination of care (E10). Progress has been reported in the standardization of a single medical record communicated through computerized systems.

Final considerations

This study sought to analyze aspects of the experience of implementation of integrated networks and tools of the coordination of care in the Chilean health system, highlighting reform and strengthening of PHC, which is one of the most powerful strategies to achieve a continuum of care³³33. Bodenheimer T. Coordinating Care - a Perilous Journey through the Health Care System. N Engl J Med 2008; 358(10):1064-1071..

Initially, we intended to resume the setting of the Chilean system, not to discuss the already known segmentation, recognized cause of fragmentation¹1. Organización Panamericana de la Salud (OPAS). La Renovación de la Atención Primaria de Salud en las Américas. Redes Integradas de Servicios de Salud. Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2010., but to highlight two aspects. Attempts to establish some regulation of the private sector under the principles of social security in the last presidential term, which ended in March 2018, were unsuccessful. The government’s own political crisis (2014/2015) has created a scenario that is even more hostile to more structural changes in the configuration of the health system³⁴34. Tetelboin C. Tendencias y contratendencias en el sistema de salud de Chile en el marco de la situación regional. In: Tetelboin C, Laurell C, organizadores. O direito universal à saúde: uma análise agenda latino-americana e controle. Buenos Aires: CLACSO; 2015. p. 75-97.. Thus, the discussion of integrated networks and coordination is limited to the public health system, but does not face the lack of integration and coordination between subsystems⁹9. Haggerty JL, Yavich N, Báscolo EP, Grupo de Consenso sobre un Marco de Evaluación de la Atención Primaria en América Latina. Un marco de evaluación de la atención primaria de salud en América Latina. Rev Panam Salud Publica 2009; 26(5):377-384..

A second aspect refers to the layers of fragmentation within the public subsystem. The possibility of a free choice for Fonasa users was highlighted, which dialogues with both the maintenance of some degree of freedom of choice and a certain accommodation of the demand for specialized consultations. Thus, inadequacy of this mechanism is discussed, by the drainage of public resources to the private network and by the introduction of yet another degree of fragmentation that is also symbolic. Users make a care mix for outpatient consultations, in a model that departs from the perspective of a renewed PHC. Not least, it is the postponement of care in the early stages of illness by attempting to resolve within the free choice up to exhaustion of own financial resources.

In this same perspective, another degree of fragmentation covers the main reformist action – explicit guarantees. Analysis of GES results can be performed from various aspects³⁵35. Parada M, Reyes C, Cuevas K, Ávila A, López P, Carrasco V, Moraga F, González JF, Riquelme P, Llancapichun L. Transformaciones del Sistema de Salud Público post Reforma AUGE-GES en Valparaíso. Rev Chil Salud Pública 2014; 18(2):127-139.,³⁶36. Frenz P, Delgado I, Kaufman JS, Harper S. Achieving effective universal health coverage with equity: evidence from Chile. Health Policy Plan 2014; 29(6):717-731.. From the viewpoint of network integration, it weakens the system’s organization by the establishment and management of two waiting lists, with differentiated attributes. While it also ensures timely access to serious pathologies, it does not address the determinants of the disease process.

Regarding the care model, results were synergistic towards the leading role of hospitals in the structuring of networks. While in the official discourse the direction of the system must take place from the Comprehensive Family and Community Health Care Model, networks orbit around large and powerful public hospitals, from where the main initiatives of integration and coordination with the PHC emerge, which, while promising, ratify the hegemonic hospital-centric paradigm.

The analysis of the Chilean experience shows the need for advances in the leading role of PHC, however, the growing public sector in the country stands out positively. Experiences with potential to qualify primary care as support, the availability of high-demand specialized services in health centers and the structured system of performance evaluation were mentioned strategies. Urgent services in PHC have the potential for increased resolution and access, depending on the level of horizontal integration. As highlighted by Vergara³⁷37. Vergara IM. Propuesta de reformas a los prestadores públicos de servicios médicos en Chile: “fortaleciendo la opción pública”. Rev Med Chile 2015; 143(2):237-243., PHC resolution only operates comprehensively if connected to the network.

In the analysis of the strategies for the establishment of the IHSDNs, the national manager is the main actor, based on PAHO’s proposal¹1. Organización Panamericana de la Salud (OPAS). La Renovación de la Atención Primaria de Salud en las Américas. Redes Integradas de Servicios de Salud. Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2010., while Health Services are responsible for the organization and implementation. In the HS, the authority responsible for the architecture and leadership of networks is identified, elements that literature points out as necessary for the coordination of care¹1. Organización Panamericana de la Salud (OPAS). La Renovación de la Atención Primaria de Salud en las Américas. Redes Integradas de Servicios de Salud. Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2010.. It is not incumbent upon PHC teams or local managers to design users’ path and to agree on the service provided, as observed in other contexts³⁸38. Vargas I, Mogollón-Pérez AS, Unger JP, Silva MRF, De Paepe P, Vázquez ML. Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice. Health Policy and Planning 2015; 30(6):705-717., although high waiting times and coordination problems of care are still a reality.

The lack of integration between care and public health, under the responsibility of SEREMI is another obstacle to effective networks¹1. Organización Panamericana de la Salud (OPAS). La Renovación de la Atención Primaria de Salud en las Américas. Redes Integradas de Servicios de Salud. Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2010.,³⁹39. Almeida PF, Fausto MCR, Giovanella L. Fortalecimento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados. Rev Panam Salud Publica 2011; 29(2):84-95.. CIRAs were evaluated as potentially innovative spaces for networking, strengthening social participation in health and creating an organizational culture favorable to integration, particularly important in a context where the system’s guidelines are highly centralized, as in the case of Chile.

Given the systematic presence in the stakeholders’ discourse and relevance in the process of the Chilean system reform, the issue of magnitude of waiting times, a frequent problem in public and private health systems stands out¹⁹19. Conill EM, Giovanella L, Almeida PF. Listas de espera em sistemas públicos: da expansão da oferta para um acesso oportuno? Considerações a partir do Sistema Nacional de Saúde espanhol. Cien Saude Colet 2011; 16(6):2783-2794.. The GES faces this challenge, in line with the concept of timely access for specific pathologies. It is equally important to underline the economic, political and corporate disputes and interests around this issue due to the electoral appeal¹⁹19. Conill EM, Giovanella L, Almeida PF. Listas de espera em sistemas públicos: da expansão da oferta para um acesso oportuno? Considerações a partir do Sistema Nacional de Saúde espanhol. Cien Saude Colet 2011; 16(6):2783-2794., as was observed in the pressure for an expanded GES list. The management of non-GES lists has been improved in a more recent period.

The implementation of new coordination strategies was not observed, but rather the institutionalization of tools widely recognized as capable of optimizing this attribute²⁰20. McDonald KM, Schultz E, Albin L, Pineda N, Lonhart J, Sundaram V, Smith-Spangler C, Brustrom J, Malcolm E, Rohn L, Davies S. Care Coordination Atlas Version 4. Rockville: Agency for Healthcare Research and Quality; 2014.,⁴⁰40. Aller MB, Vargas I, Coderch J, Calero S, Cots F, Abizanda M, Farré J, Llopart JR, Colomés L, Vázquez ML. Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Serv Res 2015; 15:323.. Protocols seem to be the most consolidated strategy, which along with the strict evaluation systems can minimize the creative potential of PHC teams or even generate selectivity effects, leaving regional and territorial diversities in the background.

Finally, it is necessary to emphasize that strategies to cope with the fragmentation of care are carried out in specific contexts²2. European Union. Tools and methodologies to assess integrated care in Europe. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union; 2017., and the decision on which tools to adopt depend on the problems identified and the degree of development of initiatives underway. This study sought to contribute from this perspective. From a unique experience, we sought to analyze elements of the broader context of the health system and PHC in Chile that condition somehow the progress and impasses in the development of network integration strategies and coordination of care in the difficult transition from “fragmented care” to “integrated care”.

Acknowledgments

This paper is part of the study “Health systems in a comparative perspective: contrasting European and South American experiences”, and its subproject “Coordination of Primary Health Care in regionalized networks: contrasting South American experiences”, financed by the Productivity Grant and the CNPq Junior Doctoral Program, respectively.

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