UC Berkeley

The role of the public primary care network in accessing primary care services in Chile

by

Maria S Martinez Gutierrez

Doctor of Philosophy in Health Services and Policy Analysis

University of California, UC Berkeley

Professor William Dow, Chair

The present study examines the hypothesis that patients receiving care in the public sector in Chile have better access to primary care services, especially preventive services, than patients in the private sector. Although the hypothesis might appear counterintuitive, since worldwide public health facilities are typically underfunded, overcrowded and present deficiencies in quality, Chile's strong network of public primary healthcare facilities (similar to other Latin American countries such as Costa Rica and Uruguay), may help to explain this hypothesis.

This dissertation addresses the following over-arching research question: is using the public system as a preferred venue for accessing primary care services associated with higher utilization of primary care services?

First, it was determined that type of health insurance could be used as a proxy of choice of private provider i.e. being enrolled in a public health plan directed to the poor which restricted provision of services only to the public sector (Fonasa A) was associated with choosing a public provider most of the time. Next, the association of type of health insurance with utilization of primary care services, controlling for all relevant variables from the Andersen model of healthcare access, was analyzed. Regressions were fitted using nationally representative survey data. In depth interview and focus groups were conducted with patients and healthcare providers to complement quantitative findings.

Regression results for utilization of services showed that, in terms of preventive care utilization, using the public system was associated with higher utilization of preventive services in adult and older women, but there was no association found for other age/sex groups. Since people who use the private sector may have been getting their preventive care in other settings such a specialty care clinics an ambulatory care indicator was added as a dependent variable as a sensitivity analysis. For both infants and older people-groups that use intensively the healthcare system-there are no differences in ambulatory healthcare utilization across insurance types. For other age groups using the public healthcare system was associated with lower utilization of ambulatory care services.

In summary, the evidence found in this dissertation suggests that 1) Isapre members and people enrolled in public health plans other than Fonasa A use the private healthcare sector more frequently and 2) although some population groups that use the private system have higher utilization of ambulatory care services there are no differences in preventive services utilization for any population group. In light of these findings, proposals to further expand private health insurance coverage or use of private providers in the Chilean population should take into consideration that this could lead not only to care focused on curative versus preventive services but also to a less efficient distribution of primary care services, since some of the people that need primary care services may be substituting preventive services for specialist services, which are more expensive and less comprehensive than preventive visits.