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Evaluation of a primary health care strategy implemented in a market-oriented health system: the case of Bogota, Colombia.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7134-8256
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Despite Colombia having adopted a health system based on an insurance market, Bogota in 2004, as part of a left-wing government (elected for first time in the city), decided to implement a Primary Health Care (PHC) strategy to improve quality of life, level of population health and reduce health inequities. The PHC strategy has been implemented through the HomeHealth program by three consecutive governments over the last eight years in the context of continuous political tension stemming from differences between national and district health policies.

This thesis is an attempt to provide a better understanding of the overall experience of implementing a PHC strategy in the context of a market-oriented health care system. The research aimed to evaluate results of the PHC strategy through the intervention of the Home Health program and to identify factors that have enabled or limited the on-going PHC implementation process in Bogota.

Methods: This study used a combination of quantitative and qualitative methods. A descriptive analysis was performed to assess direct results of the PHC strategy in terms of progress in the Home Health program coverage and increases in health personnel ratios reaching out to poor and vulnerable groups in Bogota. A cross sectional analysis was carried out to evaluate qualities of the delivery of PHC services through the attainment of PHC essential dimensions in the network of first-level public health care facilities. An ecological analysis was performed to estimate the contribution of the PHC strategy, through the Home Health program, to improve child health outcomes and to reduce health inequalities. A qualitative multiple case study was conducted to identify contextual factors that have enabled or limited the on-going PHC implementation process in Bogota.

Results: The descriptive analysis showed a notable initial increase and rapid expansion in the development of the PHC strategy between 2004 and 2007, followed by a period of slower growth and stagnation between 2007 and 2010. The cross-sectional analysis suggested that the Home Health program could be helping to improve the performance of first-level public health care facilities. Ratings assigned to PHC dimensions by different participants pointed out the need to strengthen family focus, community orientation, financial resources distribution, and accessibility. The ecological analysis showed that localities with high PHC coverage had a lower risk of under-five mortality, infant mortality and acute malnutrition as well as a higher probability of being vaccinated than low PHC coverage localities. The belonging to a high-coverage locality was significantly associated with risk reductions of under-five mortality (13.8%) and infant mortality by pneumonia (37.5%) as well as increases in the probability of being vaccinated for DPT (4.9%). Concentration curves and concentration indices indicated inequality reductions in all child indicators betwen 2003 and 2007. In 2007 (period after implementation), the PHC strategy was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-five mortality (24%), infant mortality rate (19%), acute malnutrition (7%) and DPT vaccination coverage (20%). The main facilitators of the results achieved so far by the PHC strategy were all related to the commitment and good will of actors at different levels. Longterm political commitment, support by local mayors and hospital managers, organized communities historically active in the process of social participation, as well as extramural work carried out by community health workers and health care teams were highly valued. Barriers to the implementation included the structure of the national health system itself, lack of a stable funding source, unsatisfactory working conditions, lack of competencies among health workers regarding family focus and community orientation, and limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation.

Conclusion: Despite adverse contextual conditions and limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has helped to improve the performance of first-level public health care facilities in the essential dimensions of PHC and has also contributed to improvement of child health outcomes and reduction of health inequalities associated with socioeconomic and living conditions. Significant efforts are required to overcome the market approach of the national health system. Structural changes to social policies at the national and district level are needed if the PHC strategy is expected to achieve its full potential. Specific interventions must be designed to have well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2014. , 98 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1627
Keyword [en]
Primary health care, outcomes assessment, health services evaluation, population health, health equity, health policy implementation, Bogota
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-86996ISBN: 978-91-7601-022-8 (print)OAI: oai:DiVA.org:umu-86996DiVA: diva2:705832
Public defence
2014-04-11, Sal 135, by 9A, Allmänmedicin, Norrlands Universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2014-03-21 Created: 2014-03-17 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota-Colombia: a cross-sectional study
Open this publication in new window or tab >>Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota-Colombia: a cross-sectional study
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2013 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, 315- p.Article in journal (Refereed) Published
Abstract [en]

Background: The high segmentation and fragmentation in the provision of services are some of the main problems of the Colombian health system. In 2004 the district government of Bogota decided to implement a Primary Health Care (PHC) strategy through the Home Health program. PHC was conceived as a model for transforming health care delivery within the network of the first-level public health care facilities. This study aims to evaluate the performance of the essential dimensions of the PHC strategy in six localities geographically distributed throughout Bogota city.

Methods: The rapid assessment tool to measure PHC performance, validated in Brazil, was applied. The perception of participants (users, professionals, health managers) in public health facilities where the Home Health program was implemented was compared with the perception of participants in private health facilities not implementing the program. A global performance index and specific indices for each primary care dimension were calculated. A multivariate logistic regression analysis was conducted to determine possible associations between the performance of the PHC dimensions and the self-perceived health status of users.

Results: The global performance index was rated as good for all participants interviewed. In general, with the exception of professionals, the differences in most of the essential dimensions seemed to favor public health care facilities where the Home Health program was implemented. The weakest dimensions were the family focus and community orientation-rated as critical by users; the distribution of financial resources-rated as critical by health managers; and, accessibility-rated as intermediate by users.

Conclusions: The overall findings suggest that the Home Health program could be improving the performance of the network of the first-level public health care facilities in some PHC essential dimensions, but significant efforts to achieve its objectives and raise its visibility in the community are required.

Keyword
Primary health care, Health services evaluation, Bogota
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-81011 (URN)10.1186/1472-6963-13-315 (DOI)000324068300002 ()
Available from: 2013-09-30 Created: 2013-09-30 Last updated: 2017-12-06Bibliographically approved
2. Primary health care contribution to improve health outcomes in Bogota-Colombia: a longitudinal ecological analysis
Open this publication in new window or tab >>Primary health care contribution to improve health outcomes in Bogota-Colombia: a longitudinal ecological analysis
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2012 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, 84Article in journal (Refereed) Published
Abstract [en]

Background: Colombia has a highly segmented and fragmented national health system that contributes to inequitable health outcomes. In 2004 the district government of Bogota initiated a Primary Health Care (PHC) strategy to improve health care access and population health status. This study aims to analyse the contribution of the PHC strategy to the improvement of health outcomes controlling for socioeconomic variables.

Methods: A longitudinal ecological analysis using data from secondary sources was carried out. The analysis used data from 2003 and 2007 (one year before and 3 years after the PHC implementation). A Primary Health Care Index (PHCI) of coverage intensity was constructed. According to the PHCI, localities were classified into two groups: high and low coverage. A multivariate analysis using a Poisson regression model for each year separately and a Panel Poisson regression model to assess changes between the groups over the years was developed. Dependent variables were infant mortality rate, under-5 mortality rate, infant mortality rate due to acute diarrheal disease and pneumonia, prevalence of acute malnutrition, vaccination coverage for diphtheria, pertussis, tetanus (DPT) and prevalence of exclusive breastfeeding. The independent variable was the PHCI. Control variables were sewerage coverage, health system insurance coverage and quality of life index.

Results: The high PHCI localities as compared with the low PHCI localities showed significant risk reductions of under-5 mortality (13.8%) and infant mortality due to pneumonia (37.5%) between 2003 and 2007. The probability of being vaccinated for DPT also showed a significant increase of 4.9%. The risk of infant mortality and of acute malnutrition in children under-5 years was lesser in the high coverage group than in the low one; however relative changes were not statistically significant.

Conclusions: Despite the adverse contextual conditions and the limitations imposed by the Colombian health system itself, Bogota's initiative of a PHC strategy has successfully contributed to the improvement of some health outcomes.

Keyword
Primary health care, Health outcomes, Population Health, Outcomes Assessment, Multivariate analysis, Bogota
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-66673 (URN)10.1186/1471-2296-13-84 (DOI)000314222300001 ()
Available from: 2013-02-26 Created: 2013-02-26 Last updated: 2017-12-06Bibliographically approved
3. The impact of primary healthcare in reducing inequalities in child health outcomes, Bogota, Colombia: an ecological analysis
Open this publication in new window or tab >>The impact of primary healthcare in reducing inequalities in child health outcomes, Bogota, Colombia: an ecological analysis
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2012 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 11, 66Article in journal (Refereed) Published
Abstract [en]

Background: Colombia is one of the countries with the widest levels of socioeconomic and health inequalities. Bogota, its capital, faces serious problems of poverty, social disparities and access to health services. A Primary Health Care (PHC) strategy was implemented in 2004 to improve health care and to address the social determinants of such inequalities. This study aimed to evaluate the contribution of the PHC strategy to reducing inequalities in child health outcomes in Bogota.

Methods: An ecological analysis with localities as the unit of analysis was carried out. The variable used to capture the socioeconomic status and living standards was the Quality of Life Index (QLI). Concentration curves and concentration indices for four child health outcomes (infant mortality rate (IMR), under-5 mortality rate, prevalence of acute malnutrition in children under-5, and vaccination coverage for diphtheria, pertussis and tetanus) were calculated to measure socioeconomic inequality. Two periods were used to describe possible changes in the magnitude of the inequalities related with the PHC implementation (2003 year before - 2007 year after implementation). The contribution of the PHC intervention was computed by a decomposition analysis carried out on data from 2007.

Results: In both 2003 and 2007, concentration curves and indexes of IMR, under-5 mortality rate and acute malnutrition showed inequalities to the disadvantage of localities with lower QLI. Diphtheria, pertussis and tetanus (DPT) vaccinations were more prevalent among localities with higher QLI in 2003 but were higher in localities with lower QLI in 2007. The variation of the concentration index between 2003 and 2007 indicated reductions in inequality for all of the indicators in the period after the PHC implementation. In 2007, PHC was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-5 mortality (24%), IMR (19%) and acute malnutrition (7%). PHC also contributed approximately 20% to inequality in DPT coverage, favoring the poorer localities.

Conclusion: The PHC strategy developed in Bogota appears to be contributing to reductions of the inequality associated with socioeconomic and living conditions in child health outcomes.

Keyword
Primary health care, Health status disparities, Inequality, Concentration index, Decomposition, Bogota
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-66425 (URN)10.1186/1475-9276-11-66 (DOI)000313624200001 ()
Available from: 2013-02-22 Created: 2013-02-19 Last updated: 2017-12-06Bibliographically approved
4. Challenges of implementing a primary health care strategy in a context of a market-oriented health care system: the experience of Bogota, Colombia
Open this publication in new window or tab >>Challenges of implementing a primary health care strategy in a context of a market-oriented health care system: the experience of Bogota, Colombia
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2014 (English)In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 29, no 4, E347-E367 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Although Colombia has a health system based on market and neoliberal principles, in 2004, the government of the capital-Bogota-took the decision to formulate a health policy that included the implementation of a comprehensive primary health care (PHC) strategy. This study aims to identify the enablers and barriers to the PHC implementation in Bogota. METHODS: The study used a qualitative multiple case study methodology. Seven Bogota's localities were included. Eighteen semi-structured interviews with key informants (decision-makers at each locality and members of the District Health Secretariat) and fourteen FGDs (one focus group with staff members and one with community members) were carried out. Data were analysed using a thematic analysis approach. RESULTS: The main enablers found across the district and local levels showed a similar pattern, all were related to the good will and commitment of actors at different levels. Barriers included the approach of the national policies and a health system based on neoliberal principles, the lack of a stable funding source, the confusing and rigid guidelines, the high turnover of human resources, the lack of competencies among health workers regarding family focus and community orientation, and the limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation. CONCLUSION: Significant efforts are required to overcome the market approach of the national health system. Interventions must be designed to include well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2014
Keyword
primary health care; barriers and enablers; qualitative study; Bogota
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-83481 (URN)10.1002/hpm.2228 (DOI)000344783200003 ()24254649 (PubMedID)
Available from: 2013-11-27 Created: 2013-11-27 Last updated: 2017-12-06Bibliographically approved

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