Summary. Gloria Molina M. 2

Transcription

1 Tensions in the decision making processes on public health programs and policies within the managed competition model of the Colombian health system, Gloria Molina M. 2 Summary Health sector reforms promoted during the 1990s as part of the Washington Consensus, involved the implementation of privatization mechanisms and competition model among health insurers and providers, in order to improve quality and coverage of health services. The Colombian health system introduced a depth reform in 1993, based on managed competition model, and increasing participation of the private sector. However, within this model, public health indicators became worse, and people tackle difficulties the access services. Objective: To get better comprehension of the decision-making process on public health policies and programs System, and the aspects that influencing decisions at several governmental and private sector, within the managed competition model of the Colombian Health. Methodology: A qualitative research, using Grounded Theory, was carried out in six Colombian cities. 102 individual interviews were conducted to health professionals working in developing public health policies and programs, at different levels of governmental and private institutions and organizations, under their informed consent. Also and 14 focus group were conducted with community leaders. In interview guide was defined including topics such as: personal, institutional, labor, political, economic and social aspects that influence decisions on public health issues. Main findings: There are tensions in decision-making processes linked to conflicts between values promote human rights established by the political national constitution of 1991 in opposition with the values and goals of t managed competition model that promote the health systems. Public health programs and services do not produce financial profit to the health insurers and providers, which has generated lack of provision of this kind of programs and therefore people tackle limitations to access to services, especially the 1 This article is a summary of the findings of a research published in the book: Molina G, Ramirez A, and Ruiz A. (Eds). Tensiones en las decisiones en salud pública en el sistema de salud colombiano: El bien común en confrontación con los intereses y prácticas particulares. It was co-financed by The University of Antioquia, COLCIENCIAS; the University of Santo Tomas (Medellín), The National University of Colombia (Bogotá), the University of Illinois (Chicago). 2 Professor, the National of Public Health, University of Antioquia, Medellín-Colombia. gloria.molina@udea.edu.co 1

2 poorest, which are attended mainly by the public institutions. The labor conditions of the personnel working on public health programs are limited, characterized by short term contracts, high turnover, lack of training programs, low salaries and labor instability, which is also linked to labor flexibility policies that governments have put in place. Each local government put in place several policies and programs, according to their particular interests, which has resulted in lack of continuity of them and therefore lack of significant impact on the health of the population. Introduction From the 1980s decade health sector reforms started within a context of economic, political, institutional, social and technological changes. There have been several international forces related to the health sector reform such as: Recognition of human rights. There is a growing international interest in reducing poverty and illness and in extending the concepts of rights to social benefits such as health care (Bloom, 2001). This trend is based on the recognition of human rights as a principle that should address social, economic and political development. Throughout the world there has been an increased interest in public sector reform, involving the health sector in order to reduce inequity and tackle disease more efficiently. There has been a growing awareness that health and human rights are closely related (Legemaate, 2002). Sen (1999) states that countries can substantially improve health and contribute to poverty reduction by ensuring the availability of certain basic health services. As a consequence, since the 1980s governments have introduced new policies, creating new legislation 3 on public and social services in order to increase the well-being of the population. 3 Legemaate (2002:110) argues that the legal approach is a fundamental mechanism for the establishment and implementation of health policies that address both social human rights (e.g. the right to health care) and individual human right (e.g. the right to integrity). Health law should be used as an instrument for: (a) the protection and promotion of individual human rights in health care; (b) the protection of individuals against social discrimination on the grounds of health status; (c) implementing national health policies and supporting the development of health systems; (d) providing equal access to health care facilities of good quality. Law is an instrument of social policy. Health law intends to regulate our social system in which the promotion of health goes hand in hand with the protection of individual rights and the general principles of equality and justice. Health law may be defined as the body of rules that regulate the promotion and protection of health, health services, equitable distribution of available resources and the legal position of all stakeholders. 2

3 Introduction of the Neo-liberal economic model and the requirements of the international donor agencies. Health reforms are frequently ideologically driven, based on the hegemony of Neo-liberalism, 4 with an emphasis on market, privatization of care provision and moving responsibilities for financing services away from government towards users (Exworthy and Halford, 2002; Blas and Limbambala, 2001; Vega, 2001; Collins et al., 1998; Bennett et al., 1997; North and Bradshaw, 1997). Islam and Tahir, (2002:152) also highlight the fact that that in many developing countries, social sector reform is dictated more by donor agencies, primarily the World Bank and the International Monetary Fund, than by any national rational decision. Therefore, these reforms often do not take into account specific social, economic, demographic and epidemiological context which has serious implications for the health sector. Economic policies and reduction of public expenditure. Many countries have faced problems in providing adequate quality and coverage of health care to their population within a national and international environment of economic constraint and reduction of public expenditure. Therefore, different governments are in the process of implementing health sector reforms providing a response to the call for enhanced health resources (Cassels 1995; Cassels and Janovsky 1996). Thus, from the 1980s and throughout the 1990s many countries around the world from Europe, Asia, Africa and Latin America started to reform their health care systems. Berman (1995:15) states that, health sector reform has been described as sustained, purposeful change to improve the 4 North and Bradshaw (1997) point out that there are four strands or schools of thought implicated in Thatcherite neo-liberalism or New Right, and in each one the role of the market is crucial: (a) the Austrian (Hayek, 1960): minimal state intervention and a free market was the situation most likely to create and encourage freedom through choice; government power should be limited so that the market may respond freely to consumer choice. The components of the market should stand or fall economically on their ability to satisfy the consumer. (b) The Chicago (Friedman, 1962). For Friedman monetarism indicated that the fiscal prudence of providers of goods and services should actually shape the market, the state should play a more residual role. (c) The Public Choice (Buchanan and Tullock, 1965; Niskanen, 1971). The theorists of the strand noted that the interests of those running state services were best served by having a large public sector; this they argued was inherently inefficient as it challenged the hegemony of the market. Where complete removal of the public sector was impossible, they argued for the introduction of pseudo-market discipline and constitutional limitations to the activities of public sector organisations. Public choice perspectives were of growing influence in Britain through the second Thatcher government. (d) The Anarcho-Capitalist (Nozick, 1974). This strand advocates unrestricted freedom, the abolition of the state and a grassroots democratic policy based on individual choice: an atomised market. 3

4 efficiency, equity, effectiveness and quality of the health sector. The financial sustainability of existing health systems has been a dominant theme of the health reform agenda and the major focus of these reforms has been on how to finance health services, get financial soundness and generate new resources for health care (González-Rossetti and Bossert, 2000; Islam and Tahir, 2002; Bossert, 1999, 2000; Agyepong, 1999). Improving capability of the state. Capability of the state is an important basis to introduce reforms of the public sector. According to the World Bank (1997:3) for human welfare to be advanced, the state s capability defined, as the ability to undertake and promote collective actions efficiently must be increased. It typically involves two strategies: matching the state s role to its capability and raising state capability by reinvigorating public institutions. 5 Thus, in 1987 the World Bank introduced the Agenda for Reform and the Report on financing of health services in developing countries. These reports defined the main policies that would guide the health sector reform, which were thereafter launched and spread throughout the world. International health policies and trends. There have been international agreements that have influenced the policies and content of health sector reform, such as the promotion of cost-effective investment in primary care initiated at the Alma Ata Conference in 1978, which was reinforced in the World Bank s 1993 Development Report (World Bank, 1993; 1996, 1998a, 1998b); also the Ottawa Charter (Griffiths and Crump, 1998), 6 among others. Technological advance. The scientific technological advances in health and information (e.g. medical equipment, medicines, Internet, computer system) produced mainly in 5 Matching the state s role to its capability entails to assess where state capability is weak and how the state intervenes and where. This means to choose what to do and what not to do and how to do it as well. Raise state capability by reinvigorating public institutions. This means designing effective rules and restraints, to check arbitrary state actions and combat entrenched corruption. It means subjecting state institutions to greater competition to increase their efficiency, increase the performance of state institutions, and improve pay and incentives. It also means making the state more responsive to people s needs, bringing government closer to the people through broader participation and decentralisation (World Bank, 1997:3). 6 The Ottawa Charter stated that the fundamental requirements for good health were: peace, shelter, education, food, income, a stable economic-system, sustainable resources, social justice and equity (Griffiths and Crump, 1998:26). 4

5 developed countries have affected the health sector throughout the world. More sophisticated medical equipment, medicines and products which may improve diagnosis and treatment of different types of patient and illnesses have had implications for the quality and cost of services and the whole feasibility of the health system. According to several writers (Islam and Tahir 2002; Mills et al. 2001; Granados and Gomez 2000) during the decade of 1990s, the health reforms involved strategies such as: a) introducing financial changes such as moving from collective tax-based systems to more individual ones (user charges and compulsory health insurance) and a wide range of resources for health; b) changing in allocation of resources and paid systems, linking performance and reward; c) establishing policy priorities for the allocation of public resources for a target population; d) separation of purchaser and provider, introduction of internal market, contracting out and competition between them; e) definition of a basic package of services based on cost-benefit criteria; f) encouraging a wider role to the private sector, both for and not-for profit; g) transferring policy decision-making, resource management and provision of services from the central to sub-national governments. The mean aims of health sector reforms were to improve coverage, quality, accessibility, efficiency and effectiveness of health services. Within this international context each developed and developing country has introduced specific health sector reforms and carried out several and different policies and strategies to organize the provision of health services to the population. Public health policy and programs Public health actions such as prevention and monitoring of transmissible diseases, quality of water supply, sewerage, quality of air and environmental contamination, among others, are considered public good and services (Scott 2001:26-7; Batley 1996:728) due to their characteristics of no-rival, no-exclusion (Yadón et al. 2006:12) and also their externalities. In this sense, with some strategies of the health reforms, such as decentralization of the health sector, the municipal and regional authorities are accountable for the provision of 5

6 public good and services, according to population needs. Therefore, it is expected that the decentralization of the health sector generates: a) more efficiency in providing services according to the needs of the local population; b) innovation and adaptation of services according to the local conditions; c) better accessibility and quality of services, transparency, accountability and legitimacy related to more community participation in decision making and surveillance processes; d) more equity in the distribution of resources among regions (The World Bank, 1995, 1998c). The health reforms also involved a major participation of the private sector in order to increase coverage, accessibility, quality, efficacy and effectiveness in the provision of health services. Main characteristics of the Colombian Health System Based on the international trends described above, the Colombian government introduced a big and deep reform of the health system, mainly in 1993, which involved a managed competition model, privatization, strengthening decentralization, constrains of public sector, financial profitability of the providers and insurers, among others. Other characteristics are the following: Stewardship, monitoring and control The current structure of the Colombian health system is composed mainly by the Ministry of Health (MOH), the Regional/Departmental and Municipal Health Directorates, the Superintendency of Health, The National Institute of Health, the private and public health insurers (Health Promoter Enterprises: Empresas Promotoras de Salud, EPS) and providers (Instituciones Prestadoras de Servicios de Salud, IPS), the Solidarity and Guaranty Fund (FOSYGA). The Ministry of Health (MOH) leads the system and establishes policies and general legislation. With decentralization, MOH no longer operates hospitals; the Departmental Health Directorate is responsible for the health sector and the public hospitals of second level of complexity. Municipal Health Directorate and Mayors are responsible for the municipal public hospitals and health centers to provide primary health care. Mayors 6

7 became the political and managerial leaders of the health sector and coordinators of multisector activities in their municipalities. The National Superintendence of Health must accomplish surveillance and control functions of the whole system throughout the country, with the co-operation of the MOH, and the Departmental and Municipal Health Authorities; the EPS manage the subsidy and contributory scheme. Act 715 of 2001 created the general system of fiscal resources; the central level retained the role of planner and policymaker, coordinator and monitor of the municipalities on the health matters (Law 10 of 1990; Law 60 of 1993; Law 100 of 1993). Financing and provision of services The Colombian health system has a mixed financing, which is managed by the Solidarity and Guaranty Fund (FOSYGA). Its resources come from compulsory contributions by 12,5% of the monthly salary (8,5% of the employers and 4% of the employees) to the contributory scheme; compulsory insurance to traffic accident SOAT (Spanish initials), weapon taxes, Cajas de Compensación, National Budget Counterpart and petroleum/oil revenues, among others (Law 100, 1993). There are also Municipal Participations of the National Revenues allocating as following: 30% for education; 25% for health (to subsidy scheme and to the poor population s non affiliates to the social security system and to public health programs); 20% for water and basic sanitary services; 5% for sports, recreation and cultural activities; 20% for free investment in public services (Law 60 of 1993, Art. 10 and 22). Health services are provided by public and private institutions (IPS). Since 1993 the number of private providers has increased significantly, especially those of high technology and cost services that generate high profitability. At the same time, the provision of primary health care services and especially public health programs have decreased due to these services are not profitable to private providers. Public hospitals became autonomous (called Empresas Sociales de Estado), and compete with private ones for the provision of services, through contracting out process with private and public insurers, Departmental and 7

8 Municipal Health Directorate. Public health programs to the poorest people are provided mainly by the public hospitals paid by the municipal government. This paper presents the main findings of a study carried out in six Colombian cities, whose objective was to get a major comprehension of the decision making process related to public health policies and programs at the local level, within the context of the Colombian Health System characterized by a wide participation of the private sector and a market and competitive approach, among others. This paper presents a summary of the most relevant findings of this research, related to the aspects that are linked to the decision making on public health policies and programs and its relationship with accessibility and quality of these programs. Methodology This study was conducted from 2012 to 2014 in six Colombian cities: Barranquilla, Bogota, Bucaramanga, Leticia, Medellin and Pasto, which have different levels of economic and institutional development. Qualitative research methodology (Denzin and Lincoln, 2012), based on Grounded Theory (Strauss & Corbin, 2002) was adopted; its theoretical and philosophical foundation is the Symbolic Interactionism. 102 individual interviews were conducted mostly to health professionals involved in decision-making, management and operation of public health programs, within various public and private institutions, both insurers (EPS) and institutions providing health services (IPS). These professionals should have at least 5 years experience in this field. 14 focus groups with 64 participants, an average of 5 people per group, were also conducted. All interviewees were informed about the study objectives, were asked informed consent and also were guaranteed the confidentiality of their identity and the institution for which they worked. These aspects were in line with the guidelines of the Ethics Committee of the National School of Public Health at the University of Antioquia that approved this investigation. The interviews were semi-structured and were conducted using a guide which included aspects such as: the career of the interviewed, their experience in public health, 8

9 characteristics of decision-making in public health at the municipal level, technical, institutional, political, economic, ethical and legislative aspects affecting public health. The interviews were recorded, transcribed and analyzed using a systematic coding and categorization process (open, axial and selective coding), according to the method of Grounded Theory. Through this analysis codes were generated, from which 13 analytical categories emerged. The results were validated in forums held in each city, with the participation of some respondents, health professionals, academics and representatives of the community organizations, involved in public health issues. This process allowed us to verify that the results represented the reality lived and perceived by them (Moral, 2006; peace Sandin, 2000). For analysis software packages Microsoft Word, Microsoft Excel, and CmapTools version 4.16 were used. Main Findings 1. Weakness and uncertainty stewardship and governance in public health Stewardship and governance are related to weakness in the technical capacity of the Ministry of Health and the departmental and municipal Health Secretariats, which is linked to patronage practices and institutional constraints. The analysis showed a weak steering role of the national and municipal health authorities (Ministry of Health and local authorities), regarding the conduction of the institutions, regulation, harmonization of actors relationship, and lack of appropriate funding for public health. These aspects are linked to the lack of development and institutional capacity, fragmentation of responsibilities and powers between different institutions and levels of government; the interference of private interests in the development and implementation of public policies, patronage infiltrating in key policy processes and health management. The patronage practices contribute to the recruitment of non-qualified personnel in several areas, and at the strategic level of management and operation of public health programs, which is configured in a way to capture the state health institutions by of political parties. 9

10 There are also difficulties in the intersectoral and interagency cooperation; gaps in the health information system, which affects the decision-making processes, governance and stewardship capacity in public health. 2. Diversity of theoretical and methodological approaches in Public Health In the formulation and management of policies and public health programs, health professionals have used multiple theoretical and methodological frameworks; however, these approaches have been applied in disintegrated way, hampering the interdisciplinary and intersectoral interaction. For example, five of the six cities the public health policies and programs have been grounded on Primary Health Care with different theoretical concepts, methodologies and scope. They have also used others theoretical approaches such as: human rights, human vital cycle, and gender, among others. In the six cities the following aspects that limit the development of public health were identified: The predominant curative and morbidity approach, and the for profit management model of the health system, which gives low priority to prevention of risks and health promotion actions. Separation of the individual actions from the collective ones, which limits access, integration and continuity of care, and prevent rationality in using resources. The actors of the health system, health personnel and the community in general, know little about the meaning and scope of the public health, Primary Health Care and Health Promotion, given the predominance of clinical and curative care. Lack of continuity of policies and programs due to periodic changes of the local governments. Fragmentation of policies and public health programs, which creates duplication of effort, low efficiency and effectiveness. The prioritization of the population and allocation of resources in specific groups, which limits the coverage of other groups with similar needs that also require attention, which generates new forms of exclusion. 10

11 3. Policies and programs in public health are centered and fragmented into separate specific topics During the last six years there has been an active dynamics of health authorities of the six cities, in formulating and implementing public health policies and programs on topics such as: disabilities, children, adolescents, elderly, sexual and reproductive health, chronic diseases, infectious diseases, maternal care and mental health. However these policies and programs are developed independently of each other, making it difficult to provide a comprehensive care for individuals and populations, and also limiting rational use of resources. 4. Difficulties of access to public health programs There has been a concern of some of the health authorities to improve access and quality of public health programs; with this aim, they have developed strategies such as improving the physical infrastructure, strategies of extramural care, prioritizing the most vulnerable populations, among others. However, despite the development of these strategies, and in addition to the high coverage of the population with health insurance, the achievement of this aim is hindered by administrative, geographic, economic and insurance barriers. These barriers are related to market mechanisms, competition and interest of financial profitability of the actors of the health system; also socioeconomic and political (influence of parties), cultural, institutional aspects are affecting access to public health programs. The supply of public health programs is insufficient, especially for the poorest people, who are at the expense of the provision of public sector services, given the reluctance of private insurers in providing these. Insurers and providers of private services are more interested in obtaining financial returns from curative and high cost services. The segmentation of the population by ensuring approach hinders the integrate care to families. Furthermore, the fragmentation of policies and programs, separation of individual and collective services, limited qualification and high turnover of the personnel working in public health programs and services, as well as infrastructure deficiencies are affecting access to and quality of public health programs. 11

12 Similarly, there are limitations of the regulations issued by the central government to meet the needs of local communities; limited capacity of stewardship and governance of health authorities to enforce the public and private actors to carry out the public health policies and programs. 5. Difficulties in Human Resource Management The adequacy of human talent working in public health is linked to their personal and institutional principles and values, technical-scientific training, access to continuing education, experience, the selection process oriented by skills, and transparency or not in the recruitment process. It was found that there is variability and inequality in working conditions according with the level of competence and responsibilities of personnel related to the administrative guidelines, the national labor policies and limitations in the planning and management of human talent; also availability of financial resources of the health institutions and the patronage environment. The high turnover of human talent and suitability issues in public health generate technical and political institutional limitations to address and position public health issues on the political agenda. Additionally, there are gaps in surveillance the quality and efficiency of management processes, limitations in decision-making and implementation public health policies and programs, which affect the credibility of the communities. 6. The political dimension of decisions in Public Health: The influence of patronage and private interests Public health management is linked to a series of political and economic events, so it is no stranger to be influenced by interests and motivations of political actors and economic groups. Due to political patronage, some people appointed in institutional positions do not meet the technical and axiological requirements to ensure the proper performance of their duties. Moreover, many jobs are unstable allowing political parties to maintain their quotas, what 12

13 presses the turnover of this staff. Some practices of political parties influence the development of plans, programs and projects on public health, resulting in inequities and exclusion of other vulnerable groups, who are not represented by politicians in power, which create mistrust and lack of credibility of the community. In practice, policy decisions and management in public health are permeated by individuals and political-economic interests through professional, technical and decision-makers named in their positions through political quotas. The lack of continuity of far-reaching public policy is due to the periodic changes of local governments. Each mayor comes with specific plans and programs according to their interests, which not necessarily meets the health priorities of the population; also they unknown policies and ongoing programs implemented by the previous government. 7. Community participation in public health issues There are varieties of institutionalized scenarios for community participation in health; however there are serious limitations to community organizations be able to influence decision-making. Generally, participation is limited to consult communities on decisions already taken by the health authorities, allowing them minimum intervention in management, implementation and evaluation of public policies and decision-making. Likewise, social control has no impact due to the dispersion and lack of technical ability of organizations to monitor and evaluate results. Apparently, the community participation is encouraged, but in practice there is no political will of health authorities and private decision makers to share power in decision-making. It is recognized that strengthening participation is necessary to improve capability of human talent and the community organizations, given them support from the academia and research, facilitating access and ownership of knowledge available; and support them with social communication processes. 8. Moral and ethical tensions Public health decisions are debated on two approaches. 1). The neoliberal approach, which is a base of the Colombian Health System. This approach emphasizes free markets, competition and financial profitability of the actors of the health system, and its policies, 13

14 programs and services. 2). The model based on health as a fundamental human right, which focuses on ensuring access of all people to goods and services in order to achieve and maintain good health. The neoliberal approach encourages the actors of the health system to work in seeking financial returns, and therefore designed and put in place several administrative, geographic, economic and regulatory mechanisms and barriers to limit access of the population to health services; in this way the insurers reduce expenditure on services and increase their economic gains. In contrast to this model, some health professionals involved in development public health policies and programs, made resistance. They struggle every day to ensure that population, especially the poorest, access to these programs and services. Their decisions and practices are based on values such as equity, fairness, adequacy, quality, transparency, communication and educational work to and with the community. They try to enforce the sense of the public and constitutional values, defending the common good and life from the purely private interests. However this constant struggle made some them exhausted, which generates conflicts and leads some of them to abandon their profession. Main conclusions 1. Stewardship and governance in public health show structural constraints grounded on lack of institutional capacity, limited leadership of health authorities and the patronage influence of political parties. These factors prevent that the health authorities performance of their duties effectively, affect their credibility and make difficult to exercise a counterweight to the private entities and interests. Some private actors influence strongly the public sector as a way of cooptation of the state. 2. In the six cities studied, health authorities have adopted different theoretical and methodological approaches on public health, such as health promotion, disease prevention, the primary health care; human rights based approach, human life cycle and gender, among others. However, the development of public health policies and 14

15 programs, based on these models is blocked by free market and competition model and the dominant financier and curative approach in the Colombian health system. 3. The development of policies and programs on public health is interfered by different political parties and private agents that deviating them from the common good. The public health policies and programs are focused on relevant specific issues, however their fragmentation affects their integrity, efficiency and effectiveness. 4. There is a concern of the Ministries of Health to improve access and quality of public health programs by developing several strategies. However, achieving this goal it has been limited by the existence of administrative, geographic, economic and insurance barriers; the limited institutional and technical capacity, the difficulties of working conditions and high turnover of human talent. 5. Although the health system has established rules and space to facilitate community participation, its exercise is limited by factors such as little technical knowledge in health of the community organizations, and the lack of effective support of the managers from the public and private institutions. 6. According to the findings, there is a prevailing understanding of health as a source of financial profitability, which is linked to the neoliberal model of the Colombian health system. This stand goes in detriment of the constitutional understanding of health as a human right, which encourage to some health professionals that make resistance and struggle to implement public health policies and programs that guarantee health as a fundamental human right. References Agyepong, I.A. (1999) Reforming health service delivery at district level in Ghana: the perpective of a district medical officer. Health Policy and Planning; 14: Batley, R. (1996). Public-Private Relationships and performance in Service Provision. Urban Studies, Vol. 33 No. 4-5:

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