Giovanni Apráez Ippolito is Professor of Public Health at School of Medicine, National University of Colombia and Adviser in Primary Care in Cauca Region, Colombia. Carlos Sarmiento Limas MD MPH is Head of Public Health at School of Medicine, National University of Colombia, and ex-medical officer in Ministry of Health in Bogota-Colombia
Colombia pioneered primary health care (PHC) in the Latin American Region from the 1950s until the beginning of the 90s. There was then a crisis in PHC due to reform of the national Health system (by law 100 in 1993), which adopted a system based on the insurance model. This led to two decades of debate without any structural changes, and Colombia became the focus for international discussions on PHC and Health Organization models. During the past 60 years there was also a war in Colombia that appears to have ended during the current national government (2014-2018).
The international consensus is that health systems based on PHC have better results, lower costs, guarantee the right of health of individuals and communities, promote comprehensive care, promote health, and contribute to achieving the Millennium Development Goals (MDGs), among many other benefits. Primary care is organised according to the individual circumstances in each country (WHO 2008) but, in our opinion, this structure must be predominantly public.
There is renewed interest in PHC in Columbia for several reasons: a search for solutions to the critical financial situation in the new social security system, gaps between results and invested resources, working conditions of health workers (“work in the black economy”, casual labour, and out-sourcing) and the delay in achieving the heath goals of the MDGs.
Colombia is now living in a new era for the PHC. In 2012 the new law (Law 1438 of 2011 and 2012) made PHC the core of the system, but, unfortunately, without changing the structure and mechanisms for flow of resources. There is a huge gap between the practice and the limited number of groups and researchers.
What should be the priorities for research? From our experience, we propose five areas in training and research and at different levels (local, regional, national):
- Historical and conceptual framework: conceptual developments and recovery of experiences and its protagonists.
- Methodologies and tools for its implementation.
- Construction and characterization of integrated problems to approach or intervene.
- Intervention which should include the planning, the monitoring and the evaluation
- And finally, the systematization in perspective of comprehensive and integrated management in all levels (individual, family, community and population) related with policies, strategies, programmes and projects.
This requires an integrative approach, a kind of ABC or essential fundamentals, that before 2003 were known as principles, characteristics and programmatic areas and, after 2007 have become the values, principles and essential elements of the “renewed PHC” (OPS 2007). These perspectives must be harmonized into an operational approach in each part of the country.
Finally, during the last year the national public health policy was approved- the decennial plan of health 2012-2021- which creates an honest dialogue among the PHC local and regional experiences, national government, key players in the insurance system, and the population. This offers hope and opportunity for many regions where the war has been especially harsh (for example, in Cauca, one of poorest areas of the country). The reform that was needed to take forward PHC, with its noble past, into this present era of peace and equity, seems to have begun.
This blog is part of a series on global primary care research hosted on CMAJBlogs.com to coincide with NAPCRG’s Annual Meeting (2014)
I agree with the authors that the development of primary health care in Colombia is of great interest and expanding the research base is an important aspect. Despite difficulties of access for disadvantaged groups in a predominately private insurance based system there are interesting models of comprehensive care in a resource limited context. In 2012 I have the good fortune to visits Colombia to attend a forum on chronic disease and also to see the system provided by Javesalud. It was fascinating to see how integrated multidisciplinary primary health care was being provided on quite limited resources.
Professor of General Practice
UNSW Sydney Australia