Ministry of Social Protection Republic of Colombia

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1 Ministry of Social Protection Republic of Colombia General Human Resources Analysis and Policy Unit Luis Carlos Ortiz M., Hernando Cubides Z. March, 2009

2 HUMAN RESOURCES FOR HEALTH REGIONAL GOALS COLOMBIA

3 INITIAL REMARKS Primary Health Care has not been adopted in Colombia as a national strategy or policy of the Social Security for Health System. This is based on an insurance model that allows each insurance company or benefit planning administrator to define and implement the health model that they deem most adequate to care for their affiliated population; as long as it guarantees the health services included in their corresponding Plan. The Benefits Plans or Health Plans, include a mandatory component of health promotion and prevention of diseases. The National Public Health Plan was approved in 2007, with a design that includes elements characteristic of the Primary Health Care model. Due to this, the Regional goals that are framed in the Primary Health Care strategy initially do not apply for Colombia. However, in some cases, approximate information is provided that may be useful to examine the situation in Colombia with regard to the Regional issues that we would want to observe.

4 INITIAL REMARKS National Public Health Plan Approaches Population: Interventions directed towards the general population that seek to modify the accumulated risks of each of the moments of the life cycle. Determinants: Environmental, behavioral, hereditary and health services response. Intervention of modifiable risk factors. Social Risk Management: Solutions addressing the causes for risk in specific populations. Policy Lines Health promotion and quality of life. Risk prevention. Recovery and overcoming health damages. Health surveillance and knowledge management. Comprehensive management for the operative and functional development of the National Public Health Plan.

5 CHALLENGE 1 Build long-range policies and plans to adapt the work force to the changes in the health system.

6 Challenge 1: Build long-range policies and plans to adapt the work force to the changes in the health system. Goal 1: All countries of the Region will have achieved a human resources density ratio level of 25 professionals per 10,000 inhabitants Baseline for Colombia. Human Resources density per 10 thousand inhabitants: 23.8 Variable Data Source 2008 Population 44,450,260 Departamento Administrativo Nacional de Estadística, DANE, Proyecciones de población con base en el Censo Physician Stock 70,079 Recursos Humanos en Salud en Colombia. Balances, competencias y Prospectiva. Tercera Edición Ministerio de la Protección Social-Cendex Nurse Stock 35,627 Recursos Humanos en Salud en Colombia. Balances, competencias y Prospectiva. Tercera Edición Ministerio de la Protección Social-Cendex.

7 Challenge 1: Challenge 1: Build long-range policies and plans to adapt the work force to the changes in the health system. Goal 2: The Regional and Subregional proportions of primary health care physicians will exceed 40% of the total medical workforce. This goal does not apply for Colombia. The indicator of the proportion of physicians that work in the first level of care is presented Baseline for Colombia. Percent of physicians in the first level of care: 54.4% Variable Value Source Number of Physicians 70,079 Number of Physicians in the first level of care. 38,123 Recursos Humanos en Salud en Colombia. Balances, competencias y Prospectiva. Tercera Edición Ministerio de la Protección Social-Cendex. Ministry of Social Protection Projections based on the Model of Offer and Demand, MSP- University of Antioquia.

8 Challenge 1: Challenge 1: Build long-range policies and plans to adapt the work force to the changes in the health system. Goal 3: All countries will have developed primary health care teams with a broad range of competencies that systematically include community health workers to improve access, reach out to vulnerable groups, and mobilize community networks. Does not apply to Colombia. According to the characteristics of the General System of Social Security in Health of Colombia, the main strategy to improve the access of the population to health services is improving insurance coverage. Insurance through the subsidized regimen guarantees that the poorest and most vulnerable population can have access to a Health Plan that is complemented with the collective public health actions directed towards the entire population. Regimen Number of affiliates/posts Source Total Population Subsidized regimen posts 22,485,211 Contributive regimen posts 17,476,025 Total (*) 39,961,236 Departamento Administrativo Nacional de Estadística, DANE, Proyecciones de población con base en el Censo Sistema de Gestión y Seguimiento a las metas del Gobierno, SIGOB (*) Affiliated population to excluded regimens is not included.

9 Challenge 1: Challenge 1: Build long-range policies and plans to adapt the work force to the changes in the health system. Goal 4. The ratio of qualified nurses to physicians will reach at least 1:1 in all countries of the Region 2008 Baseline for Colombia. Ratio of qualified nurses per physician: 0.51 Variable Number Source Number of physicians 70,079 Recursos Humanos en Salud en Colombia. Balances, competencias y Prospectiva. Tercera Edición Ministerio de la Protección Number of nurses 35,627 Social-Cendex.

10 Challenge 1: Challenge 1: Build long-range policies and plans to adapt the work force to the changes in the health system. Goal 5: All countries of the Region will have established a unit of human resources for health responsible for the development of human resources policies and plans, the definition of the strategic directions and the negotiation with other sectors Baseline for Colombia. Value of the indicator: 4.2 TOTAL The unit exists. The General Human Resources Analysis and Policies Unit at the Ministry of YES Social Protection. Hierarchy level in the Ministerial Organization: on behalf of the Ministry of Health, in advisory 1 roles, or as a part of the Develop human resources for health policies for the entire health system. 0.7 Plan the number and type of required human resources in the health system 0.3 Strategic direction of the management of human resources for health, education for the work 0.7and the approach towar Counts with an updated information system that includes an inventory of the human resources 0.5 in health, number, typ Utilizes negotiation for the intersectoral relationships with the educational, employer and union 1 sectors. Total 4.2

11 Density ratio of HRH of 25 per 10,000 95% Establish a HRH Unit 100 % 88% The regional and subregional number of PHC physicians will exceed 40% of the medical work force 49% Ratio of Nurses vs. Physicians 4:1 Establish primary health care teams with a wide range of competencies

12 CHALLENGE 2 Place the right people in the right places, through the distribution of the suitable personnel in the best positions and in the most appropriate areas for the countries, in order to achieve an equitable distribution in the number and competencies of the health personnel in the different regions so they are at the level of the specific health needs of these populations.

13 Challenge 2 Put the right people in the right places, achieving an equitable distribution according to the health needs of the population. Goal 6: The gap in the distribution of the health personnel between urban and rural areas will have been reduced by half in Comment: There is no available recent information about the distribution of the human resources for health in urban/rural areas. The following indicators about equity in the access of health services show the differences among the rural and urban areas for the years 2000 and It is pertinent for Goal 6 to examine the percentage of use of the health services according to need for causes related with offer. Percent of people that required care for diseases or injury Zone/Year Urban Rural Percent of people that received care for a health need Zone/Year Urban Rural Percent of lack of use of health services according to the cause Causes Offer Bad Quality Lack of Money Zone/Year Urban Rural Source: Advances and challenges in equity of the Colombian health system. Corona Foundation, DNP, Universidad de los Andes Universidad del Rosario (Based on the Demographics and Health surveys (DHS) of 2000 and 2005)

14 Challenge 2 Challenge 2 Put the right people in the right places, achieving an equitable distribution according to the health needs of the population. Goal 7: At 70% of the primary health care workers will have demonstrable public health and intercultural competencies. This goal does not apply to Colombia (See Initial Comments)

15 Challenge 2 Put the right people in the right places, achieving an equitable distribution according to the health needs of the population. Goal 8: 70% of the nurses, nursing auxiliaries and health technicians including community health workers, will have upgraded their skills and competencies appropriate to the complexities of their functions. No information available on this goal. The competencies for the health auxiliaries were defined in 2005: nursing, pharmacy, public health, dentistry and administrative work. The educational institutions are currently adjusting their curricular programs to the defined competencies. Due to this, we expect a progressive strengthening of the competencies of the human talent for health in the technical and auxiliary levels.

16 Challenge 2 Challenge 2 Put the right people in the right places, achieving an equitable distribution according to the health needs of the population. Goal 9: 30% of health workers in primary health care settings will have been recruited from their own communities. This goal does not apply for Colombia (See initial comments)

17 Reduce by half the gap between the distribution of HRH in the urban and rural areas 30% of the health personnel in the primary health settings will have been recruited from their own communities 100 % At least 70% of the PHC workers will have demonstrable intercultural and public health skills 70% of nurses, auxiliaries, technicians and health agents would have updated their skills and competencies

18 CHALLENGE 3 Promote national and international initiatives for countries affected by migration to retain their health workers and avoid personnel deficits.

19 Challenge 3 Challenge 3 Promote national and international initiatives for countries affected by migration to retain their health workers and avoid personnel deficits. Goal 10: All countries of the Region will have adopted a global code of practice or developed ethical norms on the international recruitment of health care workers. A Global Code of Practice or Ethics has not been adopted. Colombia is awaiting the development of the code proposal on the recruitment of foreign personnel for health, being developed by the World Health Organization. Comments have been submitted on it already. Currently, the entry of foreign physicians is only been allowed on a temporary basis, for the development of social, humanitarian or scientific missions, with previous permission of the Ministry of Social Protection as long as the activities are developed under the responsibility of a Colombian Health Institution.

20 Challenge 3 Challenge 3 Promote national and international initiatives for countries affected by migration to retain their health workers and avoid personnel deficits. Goal 11: All of the countries of the Region will have a policy regarding selfsufficiency to meet its needs in human resources for health. Comment on the goal: The Colombian Educational and Social Security for Health Systems, are characterized by the autonomy of its institutions. In the framework of their autonomy, the educational institutions must address the evolution of the demand of health services and the conditions of the labor market, in a frame of quality of the institutions and the programs whose guarantor is the State. The last years have observed a substantial growth in the offer of health training programs at the auxiliary, technical, professional and postgraduate levels, reflected in the increase in the number of enrollees and graduates from these programs. Work is being carried out in the normative and instrumental development that allow for greater visibility in the signs that the educational, labor and health services systems send, to improve their development, as well as the appropriateness and opportunity of their responses.

21 Challenge 3 Challenge 3 Promote national and international initiatives for countries affected by migration to retain their health workers and avoid personnel deficits. Goal 12: All sub-regions will have developed mechanisms for the recognition of foreign-trained professionals. Resolution 5547 of 2005, of the National Ministry Education in Colombia, defines the requirements to validate higher education degrees given by legally recognized institutions abroad. This norm is fully valid and is being applied. The agreements on mutual recognitions are being discussed at the free trade agreements negotiations that are currently being carried out in Colombia.

22 The country will have adopted a global practice code Development of mechanisms for the recognition of foreign trained professionals Existence of a HRH self-sufficiency policy

23 CHALLENGE 4 Achieve healthy workplaces and promote a commitment of the health workforce with the mission of providing quality services to the whole population

24 Challenge 4 Challenge 4 Achieve healthy workplaces and promote a commitment of the health workforce with the mission of providing quality services to the whole population. Goal 13: The proportion of precarious, unprotected employment for health service providers will have been reduced by half in all countries. Comment: The social security norms in Colombia mandate that all workers be linked with the Comprehensive Social Security System independent of their designation or labor association. In this manner, the health workers that are employed or are selfemployed are covered by the Systems of Pensions and Social Security for Health. The self-employed workers are not under the obligation to be insured against occupational risks.

25 Challenge 4 Challenge 4 Achieve healthy workplaces and promote a commitment of the health workforce with the mission of providing quality services to the whole population. Goal 14: 80% of the countries in the Region will have in place a policy of health and safety for the health workers, including the support of programs to reduce work-related diseases and injuries. Law 100 of 1993, Decree 1295 of 1994 and other complimentary norms created and organized the General Professional Risk System destined to prevent, protect and care for workers from the effects of diseases and accidents that they may incur in due to or as a consequence of the work they carry out. Employers, Cooperatives of Associate work and Companies of Temporary Services are mandated to affiliate their employees to the System of Professional Risks independent of their designation. This system establishes the mandatory nature of the prevention and mitigation of risks, accidents and work-related disease programs. The norms concerning the habilitation also establish policies and mechanisms to protect the health and safety of the health workers.

26 Challenge 4 Challenge 4 Achieve healthy workplaces and promote a commitment of the health workforce with the mission of providing quality services to the whole population. Goal 15: At least 60% of the health services and program managers will fulfill specific requirements for public health and management competencies, including ethics. This information is not available. Norms exist for the public sector that establish requirements to obtain a leadership role in the health institutions. In most cases, training in management, administration or health economics is necessary. In some cases, these programs include topics related with public health or ethics. It is also necessary that the candidates do not have a criminal or disciplinary record that prevent them from carrying out the position.

27 Challenge 4 Challenge 4 Achieve healthy workplaces and promote a commitment of the health workforce with the mission of providing quality services to the whole population. Goal16: of the countries of the Region will have in place effective negotiation mechanisms and legislation to prevent, mitigate or resolve labor conflicts and ensure essential services if they were to occur. Colombian legislation establishes mechanisms to prevent, mitigate or resolve labor conflicts and ensure the delivery of essential services. The right to strike is ensured except in cases where the delivery of essential public health services are threatened and a permanent commission exists, composed by the Government, employer and worker representatives, to reach consensus on wage and labor policies, the promotion of good work relationships and the search for solutions to possible labor conflicts.

28 Reduce to half precarious and unprotected employment Count with negotiation mechanisms to mitigate labor conflicts Existence of a policy to cover health and security of the health workers 60% of the health service managers and health programs will fulfill specific requirements for public health and management competencies

29 CHALLENGE 5 Develop mechanisms of cooperation between training institutions and the health services institutions to produce sensitive and qualified health professionals.

30 Challenge 5 Challenge 5 Create mechanisms of cooperation between training institutions and health services institutions to produce sensitive and qualified health professionals. Goal 17: 80% of schools of clinical health sciences will have reoriented their education towards primary health care and community health needs and adopted interprofessional training strategies. This goal does not apply for Colombia. (See initial comments) The law guarantees the autonomy of Higher Education Institutions for the definition of their curricular programs. Some schools of clinical health sciences have included topics related with Primary Health Care in their curricular programs and others are developing Family Medicine postgraduate programs, but not as a part of a national policy in this sense. Currently, 5.3% of the Higher Education Institutions that offer degrees in the health field have Family Medicine and/or Public Health programs.

31 Challenge 5 Challenge 5 Create mechanisms of cooperation between training institutions and health services institutions to produce sensitive and qualified health professionals. Goal 18: 80% of schools in clinical health services will have adopted specific programs to recruit and train students from underserved populations with, when appropriate, a special emphasis on indigenous, or First Nations, communities. This information is not available.

32 Challenge 5 Create mechanisms of cooperation between training institutions and health services institutions to produce sensitive and qualified health professionals. Goal 19: Attrition rates in schools of nursing and medicine will not exceed 20%. Baseline for Colombia. 2000/2006 Average attrition rate for schools of medicine: /2006 Average attrition rates for nursing schools: 16.8 School Average Source Nursing 16.8 Medicine 30.4 Recursos Humanos en Salud en Colombia. Balances, competencias y prospectiva. Tercera edición Cendex-Ministerio de la Protección Social

33 Challenge 5 Create mechanisms of cooperation between training institutions and health services institutions to produce sensitive and qualified health professionals. Goal 20: 70% of schools of clinical health sciences and public health will be accredited by a recognized accreditation body. Baseline for Colombia. Percent of medicine and nursing programs with an accredited registry: Percent of accredited medical programs: 35% Percent of accredited nursing programs: 30% Program Total Programs Accredited Programs Source Medicine National Ministry of Nursing Education The accreditation registry provided by the corresponding National Ministry of Education responds to the fulfillment of basic quality requirements for the functioning of the higher education programs. It is obligatory. High Quality Accreditation is provided to institutions and programs that count with superior quality standards. It is voluntary.

34 80% of the health science schools will have reoriented their training towards primary health care 70% of the health science and public health schools will be accredited 100 % 46% 80% of the health science schools will have adopted specific programs to recruit and train students from underserved populations 95% The attrition rates of the medical and nursing schools will not exceed 20%

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