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标题：Inequities in Mental Health Care After Health Care System Reform in Chile
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作者：Ricardo Araya ; Graciela Rojas ; Rosemarie Fritsch 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2006
卷号：96
期号：1
页码：109-113
DOI：10.2105/AJPH.2004.055715
语种：English
出版社：American Public Health Association
摘要：Objectives. We compared differences in mental health needs and provision of mental health services among residents of Santiago, Chile, with private and public health insurance coverage. Methods. We conducted a cross-sectional survey of a random sample of adults. Presence of mental disorders and use of health care services were assessed via structured interviews. Individuals were classified as having public, private, or no health insurance coverage. Results. Among individuals with mental disorders, only 20% (95% confidence interval [CI]=16%, 24%) had consulted a professional about these problems. A clear mismatch was found between need and provision of services. Participants with public insurance coverage exhibited the highest prevalence of mental disorders but the lowest rates of consultation; participants with private coverage exhibited exactly the opposite pattern. After adjustment for age, income, and severity of symptoms, private insurance coverage (odds ratio [OR]=2.72; 95% CI=1.6, 4.6) and higher disability level (OR=1.27, 95% CI=1.1, 1.5) were the only factors associated with increased frequency of mental health consultation. Conclusions. The health reforms that have encouraged the growth of the private health sector in Chile also have increased risk segmentation within the health system, accentuating inequalities in health care provision. Most governments aspire to ensure equitable provision of health care services, regardless of citizens’ ability to pay. Universal health insurance systems seem more likely to fulfill this goal, but such systems have been criticized for being inefficient and unresponsive to the needs of consumers. Opening health care systems to expanded roles on the part of private providers might bring about more competition and choice, which in turn might spur greater efficiency and consumer satisfaction. 1 During the past 2 decades, Latin American countries have experienced considerable governmental pressure to increase the involvement of private entities in health care. 1 ^, 2 Between 1952 and the beginning of the 1980s, Chile had in place a publicly funded national health service with universal coverage, and there was a small fee-for-service private sector for the country’s most affluent citizens. In the early 1980s, the Chilean military regime introduced radical reforms of the health system; among other changes, new legislation was introduced to encourage the development of private health insurance plans. Under this new legislation, workers could choose whether to invest their mandatory health contribution of 7% of their income in private or public coverage. Anyone who chose the public-sector option had to be accepted regardless of health status or income, but in the private sector individuals were accepted only if their financial contribution matched their estimated health risk. (Health insurance companies used whatever means they deemed useful to estimate health risks and determined premiums accordingly. In addition, each year they reviewed contracts and adjusted premiums if necessary.) As a result, the country’s richest and healthiest residents were attracted to the private sector, and the public health system was deprived of the financial contribution of these high-income earners. In spite of these problems, Chile has often been cited as a virtuous model of a more pluralistic health care system. 1 However, little research has compared provision of private and public health care services in Chile. Here we focus on mental health, because it is a rather neglected field of public health, and the experiences of other countries with large private mental health sectors reveal many shortcomings. 3 ^, 4 To our knowledge, ours is the first South American study to investigate the relationship between private or public insurance coverage and the need for and use of mental health services.