Primary health care systems (primasys): case study from Colombia

Case study from Colombia PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Case study from Colombia PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Jaime Hernán Rodríguez Moreno, Laura Julieta Vivas Martinez Colombian Health Technology Assessment Institute (IETS) PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) WHO/HIS/HSR/17.28 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Editing and design by Inís Communication – www.iniscommunication.com CASE STUDY FROM COLOMBIA Contents Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1. Background to PRIMASYS case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2. Overview of the PHC system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4. Overview of primary health care statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 5. Governance and health services architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 5.1 Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 5.2 Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 5.3 Planning and implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 5.4 Regulatory process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 5.5 Monitoring and information systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 6. The way forward and policy considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 iv PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Figures Figure 1. Change in percentage of Colombia’s population volume by sex and age, 2000–2010 . . . 8 Figure 2. Timeline for primary health care system in Colombia . . . . . . . . . . . . . . . . . . . . . . 10 Figure 3. Architecture of health care system in Colombia . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Figure 4. Distribution of health system resources, 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Figure 5. Distribution of health professionals in Colombia, 2011 . . . . . . . . . . . . . . . . . . . . . 22 Tables Table 1. Databases consulted to obtain quantitative data . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Table 2. Key informants identified for obtaining information . . . . . . . . . . . . . . . . . . . . . . . . . 4 Table 3. Identification of stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Table 4. Colombia’s main indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Table 5. Demographic, macroeconomic and health profile of Colombia . . . . . . . . . . . . . . . . . 8 Table 6. Public and private responsibilities for provision of health services . . . . . . . . . . . . . . . 14 Table 7. UPC contributory regime, Colombia 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 8. UPC subsidized regime, Colombia 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Table 9. UPC subsidized regime, indigenous population, Colombia 2017 . . . . . . . . . . . . . . . . 17 Table 10. Regional goals for human resources in health . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Table 11. Dimensions and their tracking indicators in PDSP . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 11. Human resources in Colombia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1 CASE STUDY FROM COLOMBIA Abbreviations and acronyms DANE National Administrative Department of Statistics ENDS National Demographic and Health Survey EPS health insurance entity GDP gross domestic product ICFES Colombian Institute for the Promotion of Higher Education IETS Institute of Health Technology Assessment INS National Health Institution IPS Public Providers’ Health Institution MDG Millennium Development Goal MIAS Health Care Comprehensive Model NCD noncommunicable disease OECD Organisation for Economic Co-operation and Development ONS-INS National Health Observatory PAHO Pan American Health Organization (of the World Health Organization) PAI Expanded Programme on Immunization PAIS Comprehensive Health Care Policy PBS Health Benefits Plan PDSP Public Health Ten-year Plan PIC Public Health Plan for Collective Interventions RETHUS National Unique Registry of Human Talent in Health RIPS Individual Registry of Health Services Delivery ROSS-MSPS registries, observatories, monitoring systems and situation rooms SGSSS General System of Social Security in Health SISMED Drug Price Information System SISPRO System of Information in Health and Social Protection SIVIGILA Public Health National Surveillance System UPC Capitation Payment Unit WHO World Health Organization 2 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 1. Background to PRIMASYS case studies Health systems around the globe still fall short of providing accessible, good-quality, comprehensive and integrated care. As the global health community is setting ambitious goals of universal health coverage and health equity in line with the 2030 Agenda for Sustainable Development, there is increasing interest in access to and utilization of primary health care in low- and middle-income countries. A wide array of stakeholders, including development agencies, global health funders, policy planners and health system decision-makers, require a better understanding of primary health care systems in order to plan and support complex health system interventions. There is thus a need to fill the knowledge gaps concerning strategic information on front-line primary health care systems at national and subnational levels in low- and middle-income settings. The Alliance for Health Policy and Systems Research, in collaboration with the Bill & Melinda Gates Foundation, is developing a set of 20 case studies of primary health care systems in selected low- and middle-income countries as part of an initiative entitled Primary Care Systems Profiles and Performance (PRIMASYS). PRIMASYS aims to advance the science of primary health care in low- and middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policy- makers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries. Furthermore, the case studies will serve as the basis for a multicountry analysis of primary health care systems, focusing on the implementation of policies and programmes, and the barriers to and facilitators of primary health care system reform. Evidence from the case studies and the multi-country analysis will in turn provide strategic evidence to enhance the performance and responsiveness of primary health care systems in low- and middle-income countries. 3 CASE STUDY FROM COLOMBIA 2. Overview of the PHC system Colombia is a tropical middle-income country, located in the north-west of South America and is the fourth country in territorial extension of Latin American countries. According to the projections developed by the Colombian National Administrative Department of Statistics (DANE), Colombia has 49 million inhabitants in its 1 141 748 sq.km territory. About 76% of the population lives in urban areas, while the remaining 24% live in rural areas (1). Life expectancy at birth in Colombia has increased from 57 years in 1960 to 74 years in 2014 (1). Colombia is geographically divided into departments (32), districts (1101) and municipalities (6). Municipalities are the smallest unit from the administrative point of view, and are further divided according to categories, from 1 to 6, and the capacity for management, income by taxes and the population. Municipalities of category 1 have more income, more capacity and a larger population. Municipalities have more or less responsibilities for activities to be developed in relation to public health and health provision management services in the territory. Departments are groups of municipalities that administratively assume the responsibilities of smaller municipalities and supervise larger municipalities to fulfil their functions optimally, verifying and monitoring population health conditions, and adequately managing assigned financial resources. Districts are territorial entities that are determined by the Colombian law as very large municipalities, with certain special management characteristics or stage of socioeconomic development. The functions of a district are a mix between those of a department and a municipality. Districts must report directly to the national government. Colombia is a centralized State, which assigns func- tions to departments and municipalities according to their management capacity, population and resource availability. The regulatory and governing body is the Ministry of Health and Social Protection, which is responsible for issuing the technical rules and reg- ulations that control the management, organization and monitoring of the health system, norms related with finances and relationships between the differ- ent entities (2). 4 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 3. Methods For elaboration of this primary case, a literature review was carried out in the Colombian context. Reports submitted by the Ministry of Health and Social Protection and other public entities for the national public or for international entities were reviewed, interviews undertaken with key actors at the national and territorial levels, and different entities of the health sector in Colombia taken into account. Quantitative data were obtained from official public sources (Table 1). Table 1. Databases consulted to obtain quantitative data Source of information Main area of expertise Institution SISPRO: System of Information in Health and Social Protection Indicators related to provision of health services in Colombia, and health outcomes. This integrates all information, affiliation, services provided, care costs and payment for services sources. Ministry of Health and Social Protection ENDS: National Demographic and Health Survey Population demographic data, use of health services perspective Ministry of Health and Social Protection DANE: National Administrative Statistics Department. Postcensal studies Population projection post-census studies. National, departmental, and municipal revision and population typology DANE World Bank Data Economic data, population indicators and health outcomes Data on the results of global goals for each country WHO: Report cards by country (Colombia) Health financial indicators World Health Organization SGSSS: Sources of funding and use of the resources of the General System of Social Security in Health Report on sources and uses of health resources Ministry of Health and Social Protection Source: Authors’ elaboration Table 2. Key informants identified for obtaining information Descriptor Main areas of expertise Main constituency represented Human Talent Directorate, Ministry of Health Human resources Governmental Health care provider outpatient services leader Outpatient health services provision Providers of health services Health promotion and disease prevention department officers, Ministry of Health Health promotion services Governmental Quality leader in a low- and medium- complexity public hospital Provision of quality services Health service providers Head of Public Health Programme Health education/Public health Academic Production guides and routes of care leader Institute of Health Technology Assessment (IETS) Academic, research, public health Academic Medicines and Technology Directorate Access to medicines Governmental Territorial health entity of Public Health Directorate Health promotion and disease prevention, public health Governmental /local Leader of family compensation entities Public health, health management Health-promoting companies Source: Authors’ elaboration 5 CASE STUDY FROM COLOMBIA For the identification of key actors, we took into account representatives of different organizations that intervene in the health sector, and are part of diverse elements addressed within the strategies of primary health care (Table 2). Selection of stakeholders, the structure of the health system in Colombia, and elements that constituted the primary health care process were taken into account. Later, actors were sought in each of the types of entities for provision of information and obtaining qualitative data for the case study (Table 3). Table 3. Identification of stakeholders Descriptor Main constituency represented Level of health system at which active Remarks Ambulatory entity providing health services Institutions providing health services Health service provision Private entity Ambulatory and hospital entities providing health services Institutions providing health services Health service provision Public entity Territorial health directorate Local government Local government Public entity Health-promoting companies Insurance Institutions Private entity Medication management representative National Goverment Central Government Public entity Human talent management representative National Goverment Central Government Public entity Promotion and prevention management representative National Goverment Central Government Public entity Public University Health Programme Leader Academia Health education Public entity Evidence-based policy-making process leader – IETS Investigation Investigation Mixed entity (public–private) Source: Authors’ elaboration 6 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 4. Overview of primary health care statistics Over the past 20 years, there has been a positive change in the performance of the health system in Colombia with respect to health expenditure, and the outcomes of implementation and provision of health services. In general, it is important to note that Colombia has had a substantial increase in life expectancy at birth, vaccine coverage of immunopreventable diseases, insurance coverage and effective access to health services, and an increase in the number of benefits available in health plans, among others. According to the Colombian Health Situation Analysis (ASIS) 2015, the main causes of consultation in the health services in Colombia are noncommunicable diseases (NCDs) (65.45% of doctors’ visits made between 2009 and 2014), followed by nutritional and communicable diseases (14.73%), injuries due to different causes (5.2%), and maternal and perinatal conditions (2.12%) (1). Regarding mortality, and according to ASIS 2015, the main cause of death was attributed to circulatory problems (29.92%), followed by neoplasms (17.79%), and external causes (injuries; 16.79%) during this period (1). Indicators related to the Millennium Development Goals (MDGs) have shown that maternal mortality has reduced from 104.9 to 55.2 maternal deaths per 100 000 live births; however, maternal mortality is higher in the poorest areas where there are major problems of equity in access to health services. Between 2005 and 2013, neonatal mortality fell from 9.9 to 7.3 neonatal deaths per 1000 live births. Similarly, mortality in children under 1 year of age fell from 19.5 to 11.6 deaths per 1000 live births. In children under 5 years, there has been a steady decline from 24.3 in 1998 to 14.1 deaths per 1000 live births in 2013. Vaccination coverage in the past 10 years in the child population has remained above 85%, and in the past 5 years has been above 90% (1). The main cause of mortality in Colombia has changed in the past 15 years, where violent deaths have moved from first to second place, and mortality associated with chronic NCDs has moved to the first place. According to the ASIS 2015, the highest mortality in Colombia is due to ischaemic heart disease, followed by cerebrovascular accidents and arterial hypertension. In fourth place is polytrauma caused by accidents, specifically traffic accidents (pedestrians and drivers) and, finally, gastric cancer deaths. The National Demographic and Health Survey (ENDS), which was conducted in 2015, shows that in Colombia, 98% of women who had deliveries received antenatal care by trained personnel (doctors and nurses); 92% of these women received four or more prenatal check-ups during their last pregnancy, and 78% of the women received postnatal care at their last delivery (3). In contrast to health indicators, Colombia is one of the countries with the highest inequalities in the region, the second after Honduras; the Gini index is 53.5 (2015). However, in the past 15 years, the prevalence of poverty in Colombia has decreased from 50% to 28.5%. Colombia’s gross domestic product (GDP) per capita is US$ 6056.1 (2015) (Table 4) (1). 7 CASE STUDY FROM COLOMBIA Table 4. Colombia’s main indicators Results Source of information Remarks Total population 49 million DANE (1) 2016 Distribution of population urban/rural 76% urban/24% rural DANE (1) 2016 Sex ratio: male/female 97.5/100 Ministry of Health (4) 2015 Growth rate 0.9% World Bank (5) 2015 Population density (people/sq.km) 42 Ministry of Health (4) 2015 Fertility rate 2.0 Ministry of Health (4) 2015 Life expectancy at birth 74 years World Bank (5) 2014 Infant mortality 11.6/1000 live births ASIS (4) 2015 Top 5 main causes of death (ICD-10 classification) I249, I64X, I10X, T07X, C169 ASIS (4) 2015 Under-5 mortality rate 14.1/1000 live births ASIS (4) 2013 Maternal mortality rate 55.2 /100 000 ASIS (4) 2013 Immunization coverage under 1 year Up to 90% ASIS (4) 2013 Skilled birth attendance (% of pregnant women) 98.6% ASIS (4) 2015 Four recommended antenatal care (ANC) visits 92% ASIS (4) 2015 Income or wealth inequality (Gini coefficient) 53.5 World Bank (5) 2015 Total health expenditure as proportion of GDP 7.2% World Bank (5) 2014 Primary health care (PHC) expenditure as % of total health expenditure 56% Ministry of Health (6) 2015 % total public sector expenditure on PHC 100% Ministry of Health (6) 2016 Total expenditure on health per capita US$ 962 OMS (7) 2014 Proportion of households experiencing catastrophic health expenditure N/A The health services are paid for by insurance enterprises Voluntarily health insurance as proportion of total expenditure on health 7.1% Fedesarrollo (8) 2012 Public expenditure as % of total health expenditure 75.2% The Bank of Republic (9) 2011 Out-of-pocket payments as proportion of total expenditure on health 15.9% The Bank of Republic (9) 2013 Source: Authors’ elaboration, with data from different entities Colombia’s health system structure is based on an inalienable right to health, with public health expenditure based on taxes from different sources. However, it is important to note that this condition has an impact on the expenditure of the main indicators in the Colombian population. In this sense, in Colombia, there is no report and no measurement of catastrophic expenditure on health by families. In Colombia, health spending associated with health policies – prepaid medical plans, complementary health plans and special insurance policies – are an additional expense for the system. This primarily affects the population with the highest income. Companies also offer additional benefit plans within welfare plans but these plans offer health benefits that are already included in Colombia’s mandatory health benefits plan. Prepaid health care and complementary health plans offer more – better 8 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) conditions during hospital stays, direct access to some health specialties or better opportunities for service provision. This health spending does not necessarily strengthen primary health care in these population groups; on the contrary, it moves them away from the basic programmes in the system. Within the health system in Colombia, activities that are part of collective primary health care are not subject to co-payments that regulate their use. Health conditions catalogued as being of public health interest are included, such as pregnancy care, childbirth and the puerperium, care of the healthy newborn, care of children under 5 years of age, diseases such as high blood pressure, diabetes mellitus, among others, as well as initial emergency care (10). Ambulatory care in general and specialized medicine, medicines and diagnostic procedures are subject to co-payments. However, current regulations state that payment of this money cannot be a condition for health service provision. In summary, out-of-pocket health expenditure in Colombia is basically determined by payment of these co-payments and moderating fees for provision of health services (Figure 1 and Table 5). -5.5 6 13.5 3.5 31.7 51.7 33.3 32.8 51.4 -5.6 9.3 17.8 4.1 30.3 47.6 33.5 25.5 49.8 -10 0 10 20 30 40 50 Percentage (%) Ag e gr ou p 80+ years 70–79 60–69 50–59 40–49 30–39 20–29 10–19 0–9 Men Women Figure 1. Change in percentage of Colombia’s population volume by sex and age, 2000–2010 Source: Colombia’s demographic ageing, 1951–2020 (11) Table 5. Demographic, macroeconomic and health profile of Colombia Summary Relevance for primary health care (PHC) Source of information Demographic profile Since the end of the 20th century, Colombia has undergone a series of changes in the demographic structure as a consequence of different elements and positive outcomes. These changes are leading to a transition where the Colombian population will progressively present demographic ageing (Figure 1). Factors that have influenced this include: • increase in life expectancy at birth • decrease in the fertility rate • decrease in infant and young adult mortality rates • social changes in the country, such as a decrease in violence. These demographic changes have a major impact on PHC. Since services must be modified to serve the elderly population, it requires the allocation of more resources for care of chronic diseases and complications of these. Specialized services have to be strengthened for the population with comorbidities. Minsalud (11) 9 CASE STUDY FROM COLOMBIA Timeline Colombia’s current health system was established in 1993 as a mechanism for implementation of the 1991 National Constitution, in which health is considered as a fundamental right. The health system was established based on the assurance of provision of health services to the population. Later in 1996, the conditions for population health care were defined based on collective activities under the Basic Attention Plan (Figure 2) (13). In 2000, regulations were issued in order to ensure effective and efficient care in activities of public health interest, such as prevention and control of common diseases and healthy population measures, including vaccination, maternal care, child health, and early detection of diseases such as breast and cervical cancer. As of 2004, specific protection activities, and implementation of activities related to early detection were assigned to municipalities and states. Performance in health is assessed against indicators related to the coverage of these activities (see Figure 2). Development of the health system in Colombia had two problems related to the low level of compliance with the objectives. The first was related to insurance Summary Relevance for primary health care (PHC) Source of information Macroeconomic profile Colombia is the third-largest economy in Latin America. This is due to elements such as stabilization of inflation and its human development index (0.719). Colombia is a country whose main sources of income are mining and hydrocarbons, construction and agricultural activity. Colombia is a country that produces raw materials, rather than one that transforms these materials with added value. For the past four years, negotiations on peace process agreements have begun. The country can expect a notable increase in investment and will be subject to an economic transition. In the post-conflict setting, there is potential for change in social policies, economic growth and economic goals of the State. Health care processes and health model planning for the Colombian population should consider aspects of changes related to key factors, such as greater difference in accessibility, economic strengthening, higher employment rate and population growth conditions. These aspects will lead to a change in population distribution in large rural areas, reorganizing health services and providing processes where there is foreign investment. OECD (12) Health profile Colombia is in the process of epidemiological transition. It is a susceptible country with a high burden of acute infectious diseases and with a growing prevalence of chronic noncommunicable diseases, to the point that, at present, when analysing general morbidity in Colombia, they occupy the first place as the main cause of health services use. However, it is very important to note that, given the geographical location of Colombia and the characteristics of a tropical country, Colombia has a high prevalence of vector- borne diseases and other diseases prevalent in the region. The analysis of the main causes of consultation and morbidity of the population show that the most prevalent conditions are hypertension, diabetes mellitus, dental caries, injuries (accidents, violence or self-inflicted), and prevention of maternal and perinatal diseases. However, when analysing population conditions by age group, it must be taken into account that in the child population, prevalence of preventable communicable diseases such as acute diarrhoeal disease and respiratory infections, and noncommunicable infections such as malnutrition are still important, so they should not be left out. Likewise, in adulthood, the prevalence of diseases such as cancer is of greater importance in the care process. Efforts should be made so that the Colombian population is seen as a whole, but also understanding the characteristics of each of the regions and the different age groups. Changes in the Colombian health profile and in the causes of morbidity and mortality have led to health processes focused on the care of a population that has a higher rate of ageing and that suffers from diseases of the adult population. On the other hand, the maintenance of a strong structure of support and care for the young population, which largely suffers from communicable diseases, requires a much more social dynamic interaction with other sectors in order to ensure that health activities have a greater impact, and must be built on the basis of environmental health. The Colombian health profile shows that work must be done within the standards of complex care that guarantees supply of medicines and new health technologies. This supposes an increase in health resources, by increasing the frequency of use of the health services. Minsalud (4) Source: Authors’ elaboration, with data from different sources 10 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) coverage, which did not reach the proposed goal of 100%, as the contributory regime did not reach the expected levels and resources for the subsidized regime were not sufficient. The second problem was related to the low impact of health promotion, disease prevention and early detection of diseases. This latter situation was generated due to lack of clarity in terms of commitment to carry out specific activities, and the low level of articulation between the collective interventions plan and the one for individual health. In 2002, the National Government decided to remove some basic activities (vaccination, cervical cancer early detection programme, family planning programme, including contraceptive delivery and intrauterine device insertion) from the responsibility of the subsidized regime. Administration and regulation of these activities were then handed over to the territorial entity. Provision of these health services should preferably be contracted to the low complexity public providers’ health institutions (IPS in Spanish) of each municipality. In the contributory regime, this did not change (14). In 2007, a law was passed mandating that the national government must issue national public health policies and plans, in order to ensure integration of actions and implementation of long- term programmes to improve the health of the Colombian population, including in relation to emerging infectious diseases (see Figure 2). Among the situations that led to the enactment of this law was information asymmetry between the knowledge of health expenditure of the health insurance entities (EPS in Spanish) and the poor knowledge of the IPS in this respect. There was a lack of regulation of the contractual relationship between the EPS and IPS, problems related to the flow of resources between payers and health service providers, and delays in auditing processes among stakeholders (15). Problems accumulated related to the quality of health services, resulting from the lack of updating Figure 2. Timeline for primary health care system in Colombia 1993 Health care system establishment based on assurance, individual activities (different for workers and non- workers) and collective health 1996 Establishment of a Basic Care Plan (health promotion, risk factors control, and disease prevention of public health importance) 2001 Reorganization of functions in municipalities and states 1991 Political Constitution: health as a fundamental right 2000 Release of policy information related to health promotion, specific protection targets and early detection of diseases 2007 Primary care approach re-establishment; National Public Health Information Development Plan 2008 By court order, the same health plan for workers and non-workers (poor population) must be unified 2011 Primary health care model development by law is deployed, reorganizing health roles and responsibilities 2014 Articulation of a new model and health policy for Colombia, based on the determinants of health and primary health care 2016 Health Care Integration Policy and Comprehensive Health Care Model (MIAS) development 11 CASE STUDY FROM COLOMBIA of a benefit plan. To protect the fundamental right to health care, the judicial system in 2008 passed Judgment T-760 of the Constitutional Court, which mandates, among other actions, equality in health benefit plans for the entire population, and a review and update of the benefit plans, in accordance with technological advances in health care (16). In 2011, as part of compliance with Judgment T-760, a law was issued ordering the creation of a health model strengthening primary health care, organizing a permanent functional structure for updating health plans, and formulation of a policy for the national pharmaceutical industry (see Figure 2). It ordered the development of clinical guidelines and care protocols to strengthen decision-making and clinical interactions between hospitals of low-, medium- and high complexity. Law 1438 of 2011 establishes that in Colombia, health care processes based on primary health care will be strengthened. It recognizes the need for intersectoral and transectoral collaboration with other national and territorial agencies that, although they do not provide health services, are key actors in health decision-making. One more element included in this law was related to the regulation of the operation of insurance. After reaching an insurance coverage of more than 95%, it would be necessary to regulate the mobility of the system and to anticipate situations that can occur when users change their domicile or decide to change their insurer. In addition, a person may change his location, if he obtains a new job or, on the other hand, loses his job, which forces him to move from a subsidized to a contributory regime or vice versa (17). Another important aspect included in Law 1438 of 2011 relates to adjustments to the financing of the health system. This law regulates the use of resources from created taxes to strengthen the provision of individual health services and funding. It includes a plan to clean up the debts of public hospitals, in order to strengthen the process of service delivery in the most vulnerable municipalities and departments. In 2014, due to an initiative by medical professionals, a new law was created that amended the fundamental right to health care, and made it an inalienable right that should be guaranteed by the government at the same level as the right to life. The law mandates the creation of a health model based on the social determinants of health, taking into account the geographical characteristics of the Colombian territory. Additionally, it created an unlimited health plan, by which the Colombian population is entitled to any technology available in Colombia, which should be paid for using public resources of the health system, except those technologies that are extravagant, cosmetic or experimental, or lack evidence of effectiveness and safety. In compliance with these laws, in 2016, a new model of health care, the Health Care Comprehensive Model (MIAS in Spanish), was introduced, which strengthens primary health care delivery, including through increasing the responsibility and decision-making capacity of health teams. It is a model that improves access of the population to health, aims to achieve user satisfaction and optimizes the fulfilment of health system goals (see Figure 2) (18). The process of regulating this law is still under development so it is necessary to wait for possible outcomes, especially as it predicts that two years of transition must occur, which end in 2017. One of the problems that must be regulated and strengthened through the implementation of this law is improvement of the flow of financial resources in health, to avoid the growing portfolio for service provision and to strengthen the quality of provision of health care services. 12 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 5. Governance and health services architecture The structure of the General System of Social Security in Health (SGSSS in Spanish), established by the 100 Law of 1993, has been reformed through different standards, particularly Laws 1122 of 2007 and 1438 of 2011. Likewise, the public health component was developed by Law 9 of 1979; Law 10 of 1990 defined the model of decentralization, and Law 715 of 2001 established the powers and the decentralized financial structure. In addition, Law 1164 of 2007 regulated the conditions of human resources talent in health. To these standards, Law 1751 of 2015 or the Statutory Health Law and the National Development Plan – Law 1753 of 2015 – were added. This set of rules has determined a social insurance model, with public and private integration and two insurance schemes: subsidized for those without the ability to pay and contributory for the population in the formal sector and independent persons with the ability to pay. Nominally, in Colombia, the entire population can access all health technologies through two administrative mechanisms: insurance and a non- mandatory health plan (refund). Central objectives of the 1993 reform emphasized: (i) expansion of protection for families against catastrophic expenditure associated with the health services; and (ii) improvement in access through extension of insurance. Rules and technical regulations controlling the functioning of entities seek to harmonize the relationships between payers and service providers, to provide patient-centred care, good-quality service delivery, and the best clinical practices. Development of studies on the effectiveness and safety of health technologies and procedures is financed by the Ministry of Health and Social Protection, which also produces clinical guidelines and protocols, to help those in the system improve the quality of health care services with a clear articulation of clinical management in different health conditions. Within the Colombian regulatory framework, the government must formulate policies that have a long-term horizon (10 years), called decennial plans. Among them are the 10-year Public Health Plan, the National Pharmaceutical Policy, the Comprehensive Health Care Policy (PAIS in Spanish), among others. It also states that in each presidential period (every four years) a government plan must be established, aligned with the above, indicating the programmes that will be developed to achieve the health goals of the Colombian population. At the territorial level, departments, districts and municipalities are responsible for health promotion activities, tracking of actions of public health interest, financing collective health activities, monitoring, control, inspection of the health services plan, and ensuring quality in providing these. The territorial entities are in charge of certification of health providers, monitoring health indicators of the population and facilitating relationships between the health sector and allied sectors, such as education, culture and infrastructure. Organization of health service networks is under the charge of the health insurance entities, which have the function of connecting to Colombian inhabitants (national or foreign), manage population risk of disease, and supervise financial resources for the provision of individual health services to the population. The EPS’s function of surveillance is done by the National Superintendent of Health, a State agency, independent of Colombia’s Ministry of Health. Health services are provided by public and private hospitals, as well as independent health professionals. Service networks are in conformity with general medical services (general practitioners, nursing, dentistry, individual health education 13 CASE STUDY FROM COLOMBIA activities, vaccination, prenatal control and early detection activities). Referral to specialized services by doctors or dentists can be done but, in some cases, administrative authorization is required by the EPS. Activities developed within national programmes such as prenatal care, birth control, labour and delivery care, newborn baby care, healthy child care, adolescent health care, health care for the elderly, extended immunization programme, early detection of visual and hearing diseases, breast cancer, cervical cancer and special care programmes such as hypertension and vector-borne diseases are free and do not need administrative procedures (19). Hospitals and clinics that provide health services in Colombia are organized by levels of complexity: low, medium and high complexity. Low-complexity institutions provide services in general medicine, nursing, labour and delivery care, dentistry, pharmacy services, clinical laboratory services (basic tests) and, in some cases, nutrition and other therapies, such as physical and respiratory therapy services. Some institutions have basic hospitalization services and radiology as well. All the municipalities in Colombia have at least one headquarters of this type (Figure 3). Medium-complexity institutions include basic specialized services such as internal medicine, gynaecology, general surgery, orthopaedics, anaesthesiology and paediatrics. These institutions are supported by pharmaceutical services, clinical laboratory, diagnostic imaging, hospitalization, and physical therapy services. These types of institutions are geographically available in each of the departments and, in most of them, there is at least one of these services. High-complexity institutions include public and private hospitals, specialized surgical services, more complex medical and surgical specialties, high-level Figure 3. Architecture of health care system in Colombia Health promotion companies Local authorities Superintendence of Health Ministry of Health and Social Protection Stewardship and regulation Surveillance and control Quality and public health actions surveillance Population information Payment for services in PHC Operational authorization PHC Multidisciplinary health professionals Public teams in local government Ambulatory health services Private PHC institutions Public PHC institutions 14 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) clinical laboratory and diagnostic imaging – including magnetic resonance imaging, tomography, interventional radiology, and special care units such as intensive adult, paediatric, neonatal and obstetric care. In addition, they have specialized services such as cancer, dialysis units, transplant units, among others. These services are concentrated in the main cities of the country, with more than one in each city. High-complexity institutions are present in only 10 departments of the country (Table 6). Provision of health services for collective activities (information, education and communication), as well as public health surveillance activities, are carried out by territorial health entities (departments, districts and municipalities), through health service providers in each of their territories. For these to be carried out, each territorial government must formulate a territorial health plan for a period of four years, and establish an operational strategy with defined indicators and goals to improve population health conditions (Table 6). 5.1 Financing Colombia’s health system is financed by multiple sources. Some resources are through specific destination taxes and, in other cases, from project taxes and investment funds. In the past 5 years in Colombia, per capita spending on health has increased by 25%, from US$ 720 in 2009 to US$ 962 in 2014 (19), despite the fact that the percentage of GDP destined for health has been maintained at a constant 7% (± 0.2%). The population out-of-pocket health expenditure is 15.9% of the total health expenditure. In Colombia, the so-called family financial catastrophic effect due to health care is not measured, and according to the structure of the system, should not exist. This situation is explained by the characteristics of the health system, where there is a very broad health benefit plan, but additionally, where the services excluded from the plan are covered by other mechanisms through State resources. For access to these services, there are two mechanisms. The first mechanism is through request by the treating health professional of a service or technology outside the plan. The EPS delivers the service and recovers it from the State. The second mechanism is through a judicial structure called guardianship, where a judge orders the delivery of the service prescribed by the physician and, based on the judicial decision (15 days delay), the government pays for the health service. Colombia’s sources of funding for the health system are varied; however, the main source is taxes contributed by workers from public and private entities of Colombia. Given the way the State is organized, an important source is by the financial surpluses that are generated by the management of resources of the Colombian health system. In addition to the above, there are other sources derived from general taxes that are transferred to the health system, as part of the National General Budget. These are taxes from alcoholic beverages, gaming, tobacco and guns (22). Table 6. Public and private responsibilities for provision of health services Type of sector (public vs private) Nature of facility Mode of employment of providers Range of services provided Remarks Source of information Institutions providing public and private health services Individual benefit plan service provider Service contract with EPS. Can be capitation, payment for services, integral packages or prospective payment Individual health services provision: low, medium and high complexity 2016 Minsalud (20) Public health institutions Providing collective health services Contract for services Collective action plan for service provision 2016 Minsalud (21) Source: Authors’ elaboration with data from the Ministry of Health 15 CASE STUDY FROM COLOMBIA In order to understand the sources and uses of the financial resources of the health system, three scenarios must be taken into account: • financing service provision under the contributory regime • financing service provision under the subsidized regime • financing of public health activities or collective intervention activities. Simultaneously, health resources are used in other ways, such as coverage for traffic accidents – ECAT (vehicles, motorcycles and pedestrians), payment for services not included in the benefits plan, and other payments for support and development of the system. Figure 4 shows the distribution of these resources. Contributory regime Provision of individual health services under the contributory scheme (provision of health services for workers and their beneficiaries) is financed by a mechanism called the Capitation Payment Unit (UPC). This UPC is paid by the Colombian State per affiliate to each of the EPS in charge of each partner. The amount of the UPC is fixed annually by the Ministry of Health and is paid monthly to each EPS according to the number of affiliates it has. The amount of UPC depends on multiple factors, such as age and sex (newborns and older adults receive higher values of UPC, as well as women of reproductive age), the place of residence (with differential values for population in larger cities, remote or rural areas, and finally special populations such as indigenous people). Taking into account the above, for the contributory regime, an average UPC is established. For the year 2017, this corresponds to Colombian pesos (COP) 746 (approximately US$ 260) (23). However, according to the characteristics of the population, access conditions and use of services change in different regions and populations, as shown in Table 7. 100 90 80 70 60 50 40 30 20 10 0 85% 7% 5% 3% 0% Capitation Payment Unit (UPC) Services not included in the benefit plan Catastrophic event Public health Support providers Figure 4. Distribution of health system resources, 2014 Source: Authors’ elaboration, data obtained from Minsalud (1) 16 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Table 7. UPC contributory regime, Colombia 2017 Age group General population (US$) Scattered areas (US$) Department capitals and large municipalities (US$) Insular zone (US$) 1 year or less 763.51 839.87 838.80 1 052.89 1–4 years 245.17 269.68 269.34 338.08 5–14 years 85.64 94.21 94.09 118.10 15–18 years men 81.63 89.79 89.68 112.56 15–18 years women 128.99 141.89 141.71 177.88 19–44 years men 145.25 159.77 159.57 200.30 19–44 years women 269.48 296.43 296.05 371.61 45–49 years 266.54 293.20 292.83 367.56 50–54 years 339.97 373.96 373.49 468.81 55–59 years 415.57 457.13 456.55 573.08 60–64 years 534.84 588.32 587.57 737.54 65–69 years 665.29 731.82 730.89 917.44 70–74 years 798.35 878.18 847.50 1.100.92 75 years and more 1.003.23 1 103.55 1 102.14 1.383.45 Source: Data taken from Minsalud (1) and converted to US$ (representative exchange rates [TRM]: COP$ 2900) Resources that finance the contributory regime come from the following sources: • resources collected from workers’ contributions (worker´s income tax deducted by the employer on a monthly basis) • financial gains from performance of economic system • CREE tax (corporate income tax). Subsidized regime As in the contributory regime, in the subsidized regime, the State pays the EPS a monthly value in terms of population care. The average value for 2017, determined in Resolution 6411 of 2016, is COP$ 667 429.20, which corresponds to US$ 226 (TRM: COP$ 2950). However, it is important to note that in the subsidized regime, there are differential values for the indigenous population. The UPC values for the general and indigenous subsidized populations are shown in Tables 8 and 9. 17 CASE STUDY FROM COLOMBIA Table 8. UPC subsidized regime, Colombia 2017 Age group General population (US$) Scattered areas (US$) Department capitals and large municipalities (US$) Insular zone (US$) 1 year or less 636.45 709.45 731.92 877.67 1–4 years 188.24 209.83 216.47 259.58 5–14 years 75.19 83.81 86.47 103.69 15–18 years men 88.54 98.69 101.82 122.09 15–18 years women 146.86 163.70 168.89 202.52 19–44 years men 147.64 164.57 169.79 203.59 19–44 years women 233.69 260.50 268.75 322.26 45–49 years 238.80 266.19 274.62 329.31 50–54 years 298.57 332.82 343.36 411.73 55–59 years 362.21 403.75 416.54 499.48 60–64 years 447.98 499.37 515.18 617.77 6–69 years 555.23 618.92 638.52 765.66 70–74 years 677.19 754.86 778.77 933.84 75 years and more 841.77 938.32 968.03 1160.79 Source: Data taken from Minsalud (1) and converted to US$ (TRM: COP$ 2900) Table 9. UPC subsidized regime, indigenous population, Colombia 2017 Age group General indigenous population (US$) Indigenous population in scattered areas (US$) Indigenous population in department capitals and large municipalities (US$) 1 year or less 667.07 743.58 767.13 1–4 years 197.29 219.92 226.89 5–14 years 78.81 87.85 90.63 15–18 years men 92.80 103.44 106.72 15–18 years women 153.92 171.58 177.01 19–44 years men 154.74 172.49 177.95 19–44 years women 244.93 273.03 281.67 45–49 years 250.29 279.00 287.83 50–54 years 312.93 348.83 359.87 55–59 years 379.63 423.17 436.57 60–64 years 469.53 523.39 539.96 65–69 years 581.94 648.69 669.23 70–74 years 709.76 791.17 816.23 75 years and more 882.26 983.45 1 014.60 Source: Data taken from Minsalud (1) and converted to US$ (TRM: COP$ 2900). 18 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Resources that finance the subsidized regime come from the following sources: • contributions from workers in the contributory regime; • contributions from the family compensation boxes; • contributions from the nation’s general budget and from the general system of participation of specific destination taxes; • departmental and district taxes for consumption of alcoholic beverages. It is important to note that both the contributory and subsidized regimes, including that for indigenous populations, have the same health benefits plan. The explanation of the differences in values are as follows: • The additional contributory scheme for health benefits covers economic aid due to incapacity because of health-related problems and maternity leave of workers. • In the indigenous population, benefits related to the unique features of the population are covered, according to their beliefs. Public health resources Resources for collective activities, public health activities and basic sanitation are transferred to the municipalities, districts and departments through the national general budget in a scheme called the General System of Participations. This system allocates resources based on the study of population conditions, number of inhabitants, population with unsatisfied basic needs, special populations and the municipality category. The sources of these resources are: • contributions from the nation’s general budget and from the general system of participation of specific destination taxes; • departmental and district taxes for consumption of alcoholic beverages; • other resources for departmental, district or municipal use. According to the above and with the structure of the health system, primary health care activities have financing components from the contributory and subsidized regimes. In this case, it is estimated that about 56% of the UPC expenditure is destined for the activities of the population’s basic access to care for general medical and dental consultations, as well as other professionals, health promotion and preventive care, delivery care, access to diagnostics and use of medicines. 5.2 Human resources With the advent of social security reform and the enactment of Law 100 of 1993, which altered the entire manner of provision of health services, in 1996 the Inter-American Development Bank (BID) granted a loan to the Ministry of Health with the purpose of supporting the implementation and sustainability of the SGSSS. This credit was for a series of projects that would allow compliance with the principles of the Law, such as universal coverage, solidarity, efficiency and quality, principles that would have to be seen from the perspective of institutions, policies and human resources. At the same time, the report of the Harvard Mission was published, in which it was proposed to carry out studies that would implement the reform. Such studies would clarify the information system, human resources, insurance, provision of health services, and inspection, monitoring and control of the System. At the same time, a document on the study of human resources in the health sector (24) was prepared by the Education Commission of the National Academy of Medicine and formally presented to the Ministries of Health and Education, National Planning department, Colombian Institute for the Promotion of Higher Education (ICFES), DANE and other entities related to training of human resources. This document would serve as a basis for human resources for the Ministry of Health, and was divided into two major components that sought to respond mainly to the management and education of human resources. 19 CASE STUDY FROM COLOMBIA To the same degree and under the guidance of the Pan American Health Organization (PAHO/WHO), follow-up indicators in human resources have been defined to determine whether health challenges can be met, generating alerts regarding the degree of progress and establishing priorities to address the health needs of the country’s population (25) (Table 10). Table 10. Regional goals for human resources in health CHALLENGE GOAL DESCRIPTION 1 GOAL 1. The density ratio of human resources will be 25 professionals per 10 000 inhabitants. 1 GOAL 2. The proportion of primary care physicians will exceed 40% of the workforce. 1 GOAL 3. Primary health care teams, including community health workers, will have a wide range of competencies to improve access, reach vulnerable groups and mobilize community networks. 1 GOAL 4. The ratio of qualified nurses:doctors should be at least 1:1. 1 GOAL 5. Establish a health human resources unit or direction responsible for the development of policies and human resource plans, and define strategic management and negotiation with other sectors. 2 GOAL 6. The gap in distribution of health personnel between urban and rural areas will be halved by 2015. 2 GOAL 7. At least 70% of primary health care workers will have public health and intercultural education. 2 GOAL 8. 75% of nurses, nursing assistants, health technicians and community health workers will improve their skills and competencies. 2 GOAL 9. 30% of health staff in primary care settings will be recruited from their own communities. 3 GOAL 10. Adopt an international practice code or develop ethical standards on international recruitment for health workers. 3 GOAL 11. There will be a policy of self-sufficiency to meet the required needs in human resources. 3 GOAL 12. There will be mutual agreements and implementation of mechanisms for recognition of professionals trained abroad. 4 GOAL 13. The proportion of precarious and unprotected employment for health workers will be halved. 4 GOAL 14. Health and safety policies will be implemented for health workers, including supporting programmes to reduce illness and accidents. 4 GOAL 15. At least 60% of health service and programme managers will meet the required competencies for public health and management, including ethical requirements. 4 GOAL 16. Negotiate mechanisms and effective legislation to prevent, mitigate or resolve, and ensure delivery of essential services. 5 GOAL 17. 80% of health science schools will have reoriented their primary health care and community health needs. They will have incorporated strategies for interprofessional training. 5 GOAL 18. 80% of health sciences school will have adopted specific programmes to attract and train students from underserved populations, with emphasis, when appropriate, on indigenous communities or populations. 5 GOAL 19. Dropout rates of medical and nursing schools will not be more than 20%. 5 GOAL 20. 70% of health science schools and public health schools will be accredited by a recognized entity. Source: Ministry of Health and Social Protection (25, 26) Based on these conditions and the historical behaviour of different variables in Colombia, future development of the labour market is projected, which is directly related to availability of education and job opportunities, which are heavily dependent on changes in policy and market regulation. Resolution 1536 of 2010 defined the organization and operation of the Observatory of Human Talent in Health. It aims to generate knowledge and information on human talent in health in order to meet the following general objectives: 20 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) • Ensure that the country has suitable and committed human talent in health in optimal working conditions to respond to the health needs of the population. • Monitor the demographic, economic, political, social, and other supply and demand determinants of human talent in health in Colombia. • Study the structural and functional issues related to human talent in health from a multidisciplinary perspective. • Analyse general and specific aspects of the human talent policy in health, within the framework of education, health and work systems. • Propose, design and develop studies and projects related to training, performance and integral management of human talent in health. The Observatory is an important entity to provide information and manage knowledge on human talent in health, which is undergoing a process of strengthening and consolidation in Colombia. Colombia currently lacks a human resources information system at the national level. However, the Ministry of Health, through the Directorate for the Development of Human Talent in Health and the Observatory of Human Talent in Health, has been working on the identification of information sources. The application that has been developed for this purpose has been called RETHUS (National Unique Registry of Human Talent in Health). Through the Comprehensive Social Protection Information System (SISPRO) and its information exchange platform (PISIS), it is expected to obtain information on four aspects initially: personal data, academic data, mandatory social service and ethical–disciplinary sanctions. In this way, availability and distribution of human resource policies are generated. They obtain availability of the number and geographical distribution of human resources according to the requirements of the organizations and the service markets, according to the following characteristics: • Analyse the interrelationships and conflicts of interest between actors that determine the numbers and competencies of human resources in the labour market, and the capacity to guarantee a sufficient regional availability of resources and jobs. • Analyse the effect of incentives in promoting geographical distribution of human resources, guaranteeing acceptable conditions of quality of life and professional practice. • Strengthen the State regulatory capacity in relation to the educational and the health sector labour market. • Consolidate or transform the Colombian Institute for the Promotion of Higher Education – ICFES. In addition, it should carry out licensing, specializing in monitoring and controlling the quality of higher education, and regulating conditions of entry and permanence in the institutions. • Unify criteria and standards for institutional accreditation and programmes that will allow the National Accreditation Council to fulfil its role, in partnership with scientific societies, and national and international professional groups. • Design mechanisms that overcome restrictions derived from municipal contracting, looking forward to the use of broader markets with less political–administrative impediments. • Evaluate the feasibility and effectiveness of the role of the public offer of higher education, including its role in training for the poorest population. Work for education and human development Education for work and human development is part of the Colombian Educational Service, and is the driving force for training technicians. It leads to obtaining a Certificate of Occupational Aptitude. In health, it must respond both to the aims and objectives of education, and to the principles and norms that guide and regulate the training, exercise and performance of human talent in health. The occupational profiles of health assistants correspond to the functional activities of support and 21 CASE STUDY FROM COLOMBIA complement integral health care. They participate in an important way in the promotion of health, disease prevention, diagnosis, treatment, rehabilitation and palliation of disease. Among the actions initiated in the country, within the framework of the human talent in health Law, is the strengthening of training personnel in different modalities: assistants, technicians, technologists and professional training, including medicine, nursing, dentistry and other professions. There are credit grant programmes to encourage professionals to get trained in areas where there are fewer specialties in Colombia (Figure 5). The World Health Organization published in The World health report in 2006 an analysis of human resources in health. The global statistics of the situation indicated a major shortage of health personnel in most of the regions. In the particular case of the Americas, there is evidence of the need for more human resources in health. The number of professionals who graduated from medical specialties has been growing in the country from 1982 until 2011. In 1982, the series started with 99 graduates and then in 2011, 998 professionals had obtained a specialist degree (Table 11). There was a larger proportion of men who were medical graduate specialists in the country than women. However, the number of women within the medical and surgical specialties has increased gradually in recent years compared to men. The specialty with the highest proportion of practitioners in the country in 2011 was paediatrics (2345), followed by internal medicine (2178), then anaesthesiology (1977), gynaecology and obstetrics (1611) and finally general surgery (1471). Specialties such as aesthetic medicine and genetics had the lowest numbers. In 2012, Colombia had 26.01 professionals per 10 000 inhabitants; the density of doctors was 16.89/10 000 inhabitants and the density of nursing professionals was 9.19/10 000 inhabitants. According to the Observatory of Human Talent in Health, Colombia surpasses the goal of having more than 40% of existing medical staff dedicated to primary care activities. Table 11. Human resources in Colombia   Results Source of Information Remarks Number of physicians per 1000 population 1.471 http://apps.who.int/iris/ bitstream/10665/131953/1/9789240692695_spa.pdf?ua Information up to 2014 Number of nurses per 1000 population 0.616 http://apps.who.int/iris/ bitstream/10665/131953/1/9789240692695_spa.pdf?ua Information up to 2014 Number of community health workers per 1000 0.00–0.03 http://www.indexmundi.com/facts/indicators/sh.MED.CMHW.P3   Relative geographical distribution       Rural/urban distribution of doctors   DATA NOT AVAILABLE   Rural/urban distribution of nurses   DATA NOT AVAILABLE   Rural/urban distribution of community health workers   DATA NOT AVAILABLE   Proportion of informal providers, and practitioners of Traditional, Complementary and Alternative Medicine (TCAM), out of the total health care workforce   DATA NOT AVAILABLE   Source: Authors’ elaboration, data obtained from Minsalud (26) 22 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) However, there is a deficit in the ratio of nursing professionals/physicians in relation to the proposed goals, since the goal is of 1:1 and for 2011, the proportion was 0.55 nursing professionals per physician (26). It is important to note that Colombia has 1122 municipalities, and in all of these there are health professionals caring for the population. 5.3 Planning and implementation Health programme implementation in Colombia occurs within the framework of the current health system and is developed under the expansion of a health care model that allows understanding of the characteristics of each of the regions of the country. Linkages are established with other sectors within their areas of competence, and functions and responsibilities are defined according to the structure of the Colombian State. Planning and operational implementation of the health system in Colombia has changed and evolved. Since 1993, primary health care activities have been influenced by different elements, which respond to the country’s national and regional problems or to the local environment. For the implementation of health policies in Colombia, due to the State structure, the Central Government determines a series of activities that are planned based on the regulatory framework, where municipalities must obey the existing normative elements. In this sense, legislation establishes that it is the responsibility of the municipalities and districts to carry out the health diagnoses analysis in the population under their jurisdiction. Based on this, periodically (every four years) local authorities formulate their local health plans, which must be aligned with the municipality’s government plan and with those of the department to which they belong (27). Departments are responsible for being health leaders of their population. They have the preferred function of monitoring and controlling entities that provide services in their jurisdiction, and are the central reference for activities related to public health. They must establish a territorial health plan, which includes, based on a population diagnosis, social determinants and the socioeconomic conditions of the territory, and an approach to the health problems in the territory under their jurisdiction. Finally, at the highest hierarchical level, the Central Government of the country is responsible for establishing policies and strategies to be developed by all entities that are related to the health sector. The establishment of policies is done through two mechanisms: public policy documents, which have a long-term horizon, such as the national pharmaceutical policy (CONPES 155) (28), or the 10-year public health plan, which establishes 100 90 80 70 60 50 40 30 20 10 0 Physicians Nurses Dentists Nutritionists Therapists Bacteriologists Optometrists Pharmacists 32% 18% 17%17% 3% 9% 2% 2% Figure 5. Distribution of health professionals in Colombia, 2011 Source: Authors’ elaboration, data from Minsalud (26) 23 CASE STUDY FROM COLOMBIA the direction to be taken by the health system in Colombia in relation to the collective public health component. On the other hand, strategies are established through technical documents that can be adopted through laws or decrees issued by the Central Government. In order to support the decision-making process, and the operation and implementation of the system, the National Government has the National Health Observatory, which has within its functions the monitoring of activities, pathological conditions and situations of interest in public health. It also studies the local health conditions and illnesses, and provides information for the decision-making process. To implement the above, the National Government has a public health surveillance system (SIVIGILA) that allows active monitoring of outbreaks, epidemics or other changes that indicate that an immediate response from the State is required in specific situations. It also studies the sociodemographic characteristics of illnesses or health conditions subjected to surveillance, as well as the findings from the observatories and other structures described in the chapter on monitoring and information systems. Public health intervention Colombia faces a great challenge in achieving economic and social development. To overcome this, the National Development Plan 2010–2014 (29) was issued. It main purpose is to centralize prosperity through eight major pillars: convergence and regional development, growth and competitiveness, equal opportunities, peace-building, innovation, environmental sustainability, good governance and international relevance (30). There is poor technical capacity for the management and administration of public health to guide the formulation of territorial health plans, motivate actions on the social determinants that promote population health, guide integrated management of health risks, implement effective collective interventions, and coordinate public health actions with the individual activities performed by all the system actors (31). Hence, public health investment shows conditions of inefficiency; an evaluation of budget execution found that for October 2015, about 40% of the public health municipalities’ budgets had not been executed (31. Public Health Ten-year Plan (PDSP) 2012– 2021 The Public Health Ten-year Plan (PDSP) 2012–2021 is a social and civic mandate with medium-term objectives, established by the Ministry of Health and Social Protection rectory in compliance with Law 1438 of 2011 and articulated with the National Development Plan, which seeks to achieve equity through three strategic objectives: (1) guarantee the effective enjoyment of the right to health; (2) improve conditions affecting health; and (3) zero tolerance for mortality, morbidity and preventable disabilities. This is done through planning, execution, monitoring and evaluation of intervention strategies led by territorial institutions and involving both the health sector and other sectors. One of the major challenges of the Public Health Ten- year Plan 2012–2021 is to strengthen the concept of health as the result of a harmonious interaction between the biological, mental, social and cultural aspects of the individual, as well as the environment and society, in order to be able to access a better level of well-being as an essential condition for life (30). In aspects related to primary health care linked to the provision of individual services to the population, the National Government through the National Health Superintendence has developed a monitoring process that ensures that the current regulatory framework is followed in the national territory. In this sense, all entities that make up the health system in Colombia have the obligation to send periodic information reports (some semester-wise and others quarterly) that demonstrate the fulfilment of the proposed plans by each of the entities, and that show coherence between allocation of the budget and the activities carried out. 24 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) In addition, national strategic plans are taken into account, such as the Expanded Immunization Plan, the National Immunization Food and Nutrition Security Policy (2008), Integral Health Environmental Policy (2008), the Strategic Colombia Plan Free of Tuberculosis and Leprosy 2010–2015, the Strategic Plan for Vector-borne Diseases, Cancer and Orphan Diseases Policy (2010), the National Policy on Disaster Risk (2012), the National Pharmaceutical Policy and Blood Banks (2012) and the Mental Health Law (2013). The 2012–2021 PDSP is based on three complementary approaches and an explanatory model: • Rights approach: recognizes the universal, equal, irrevocable and inalienable right to health, understood as the “highest level of physical, mental and social well-being”, which extends to other rights (food, water, basic sanitation, safe work conditions, and a healthy environment). • Differential approach: recognizes the equity and inclusion of excluded citizens, identifying the diversity of individuals, including life-cycle approaches (early childhood and old age), sexual orientation or gender identity, ethnic communities (indigenous, Afro-Colombian, black, Palisade, raizales, and palenqueros communities, indigenous, gypsy people – ROM), and situations generating inequities (disability, conflict victims and institutionalized populations). • Population approach: defines relationships between the demographic, environmental, social and economic aspects of the territories, identifying their imbalances and advantages. The PDSP 2012–2021 defines three operational lines in which all dimensions will be developed: • Health promotion: projects aimed at generating conditions and capacities so that the population can modify the social determinants of health in its territory. It includes actions for the formulation of public policies, social mobilization, generation of healthy environments, and social and individual capacities, participation and health education. • Health risk management: projects aimed at reducing the probability of occurrence of an unwanted, avoidable and negative health event. It includes risk analysis, risk-based care planning, risk modification, risk management monitoring, quality-of-care management, and administrative and technical coordination of services and plans. • Public health management: projects aimed at modifying the probability that the population loses the right to health. These projects include management actions, financial sustainability, guarantee of assurance, inspection, collective interventions and mobilization of other sectors of society, territories and citizenship. To define the activities in the health system, there are general laws that are clustered through national mandates called decrees. It is in this respect that the Integrated Health Care Policy is established by Resolution 429 of 2016 as well as the health care model described in Resolution 3202 of 2016. Both decrees constitute a series of mandatory guidelines for the health sector and other related sectors, defining the activities to be developed by each of the institutions that make up the health system in Colombia. This health model includes quality standards and check points at the health services, which will be carried out through comprehensive care routes. From a clinical perspective, the best standards in services should also look at administrative features. These comprehensive care routes also review and regulate payment mechanisms for health services; develop information systems based on digital clinical charts, train human talent in health, and create incentive plans for achieving goals in different entities of the health sector in Colombia. 25 CASE STUDY FROM COLOMBIA Public Health Management Model and Public Health Plan for Collective Interventions Resolution 0518 of 2015 makes provisions related to public health management and guidelines for the implementation, monitoring and evaluation of the Public Health Plan for Collective Interventions (PIC). The PIC is a benefit plan of the SGSSS, which comprises a set of collective interventions and individual actions of high externality that have general collective benefit and social impact. This is done through the execution of collective or individual interventions developed over the life-course, within the framework of the right to health and defined in the Ten-year Public Health Plan – PDSP. Principles 1. Government: the PIC is directed and administered by the government. Departments, districts and municipalities are in charge of formulating, executing, monitoring and evaluating the PIC. 2. Gratuitousness: collective interventions of the PIC are free and directed to the entire population, regardless of the state of insurance. The population is not subject to affiliation processes, minimum contribution periods, co-payments, moderate fees or recovery fees. 3. Territoriality: the PIC is governed by the processes of autonomy and local power. Collective interventions are defined by each territorial entity. Collective intervention characteristics 1. Accessibility: no barriers 2. Opportunity 3. Security 4. Relevance 5. Continuity 6. Integrality 7. Adaptability. Responsibilities 1. Carry out collective interventions. 2. Formulate, evaluate and implement processes. 3. Meet with departmental and territorial entities for the implementation of projects, strategies and collective interventions for promotion of health and prevention of disease. 4. Guarantee the Expanded Programme on Immunization (vaccines) – PAI. 5. Monitor, evaluate, manage and control public health plans. Resolution 0518 establishes that the Ministry of Health and Social Protection will be the one to define guidelines for formulating, implementing and evaluating the PIC, together with the entities involved. Periodic health benefits plan (individual actions) For health services provision, the National Government establishes that the insurance entities must form networks of services or care. These networks must demonstrate the existence of all health services, at different levels of complexity, understanding that they must be guaranteed services in the municipality of residence of the affiliate, i.e. services of low complexity in the same municipality of residence, those of medium complexity in the same department, and those of high complexity in the geographical area and the nearest access (32). For mobility between different EPS providers, different modalities have been established. If it is a hospital service, the EPS is in charge of locating the providing institution and assuring transport between the two. On the contrary, at the ambulatory level, the EPS authorizes the network institution where the service must be provided, and the user is in charge of requesting the appointment, according to their own needs. The Health Benefits Plan (PBS), structured in accordance with Resolution 2003 of 2014 (33), which 26 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) regulates the unique qualification system according to levels of complexity, establishes the necessary conditions for a health institution and services to function. It is important to emphasize that this standard not only includes regulation of service provision in buildings destined for this purpose, but also health care transportation and home care services. This standard determines the administrative, financial, technical and scientific conditions that institutions must meet in order to provide health services. It is important to note that, in Colombia, health services cannot be provided if the control entity has not verified compliance with these standards. From a scientific and technical point of view, and considering that for the provision of health services institutions must guarantee a series of minimum components, Resolution 2003 of 2014 establishes seven groups of standards with which compliance by providers is mandatory. These groups of standards are as follows: 1. Human talent standards: determines the minimum profiles in terms of training and experience that people working in each of the services should have. 2. Infrastructure standards: establishes the conditions of the building, waste management, emergency plans and environmental conditions for service provision. In the case of health care transportation, it includes vehicle conditions and communication systems. 3. Endowment: refers to the equipment and other minimum health devices that each of the health services must have, including maintenance. 4. Medicines, medical devices and supplies: refers to the existence of management processes for medicines, homeopathic and phytotherapeutic drugs, biological products, medical devices (including those for measurement), in vitro diagnostic reagents, X-ray and equipment for dental use, as well as other care supplies used by the institution. Other supplies include those in the lender’s warehouses, whose conditions of selection, acquisition, transportation, reception, storage, conservation, expiration control dates, cold chain control, distribution, dispensing, use, return, follow up of use and final disposal directly affect risks in service provision. 5. Priority processes: these refer to the existence, dissemination and compliance of health care processes that directly condition delivery of health services with quality and with the lowest possible risk. They include procedures, patient safety policies, implementation of clinical practice guidelines, and management of referral and counter-referral processes among health service institutions. 6. Clinical history and records: establish the technical conditions of handling, layout and safety of clinical records. 7. Interdependence of services: the existence or availability of services or products, own or contracted care, or administrative support necessary to provide services in a timely, safe and comprehensive manner. These standards are grouped by levels of complexity and by mode of care, where the complexity determines the technological and professional capacity for service provision and modality refers to the way in which it is provided, such as outpatient, hospital, mobile unit, domiciliary, among others. Once the IPS is enabled, i.e. it meets the criteria and demonstrates this to the departmental territorial entity; it can make contracts for the provision of health services with the EPS. 5.4 Regulatory process Colombia is one of the countries with the largest number of health systems regulations. This does not make it stronger, but on the contrary, it creates gaps when something is not explicitly regulated. There are legal gaps in provision, administration and surveillance, and control in delivering health services in Colombia. 27 CASE STUDY FROM COLOMBIA Within the normative apparatus of the State at present, the Ministry of Health and Social Protection is the entity in charge, and acts as the main reference and governing body of the system. It establishes the operating rules that include the definition of benefit plans in health and the determination of responsibilities for each of the members of the system. In this sense, decree 4107 of 2012 establishes the objectives, functions and areas that make up the Ministry, as well as the functions of each of the areas. In view of the above, the Ministry of Health and Social Protection has the power to regulate access to technologies, organize health services delivery, and is responsible for the EPS. It is also responsible for structuring the health care model, operating integral routes of health care, formulating guidelines related to the management of financial resources in health, delimiting the competencies of professionals, technicians and the auxiliary health system, as well as the regulations that these must comply with to be recognized and maintain their ability to provide services. In accordance with the provisions of the above- mentioned decree, the functions of the Ministry of Health and Social Protection, in relationship to primary health care are as follows: 1. Formulate policy; direct, guide, adopt and evaluate plans, programmes and projects in the field of health and social protection. 2. Formulate policy; direct, guide, adopt and evaluate the execution of plans, programmes and projects of the National Government in matters of health, public health, occupational risks and control of risks arising from common, environmental, health and psychosocial factors that affect individuals, groups, families or communities. 3. Formulate, adopt, coordinate, implement and evaluate strategies to promote health and quality of life. Prevent and control communicable and noncommunicable diseases. Direct and guide the public health surveillance system. 4. Formulate, adopt and coordinate actions of the National Government in matters of health in situations of emergency or natural disasters. 5. Promote and impart guidelines aimed at strengthening research, investigation, achievement, dissemination and application of national and international advances in subjects such as care, promotion, protection, health development, quality of life and prevention of diseases. 6. Formulate and evaluate policies, plans, programmes and projects in the areas of user protection, promotion of health and prevention of illness, health and occupational risk assurance, service delivery and primary care, financing and information systems, as well as the other components of the SGSSS. 7. Formulate, adopt and evaluate pharmaceutical policy, drugs, devices, inputs and biomedical technology. Establish and develop mechanisms and strategies aimed at optimizing their use. 8. Establish mechanisms to advance price negotiations on medicines, supplies and medical devices. 9. Formulate and evaluate the policy for human talent in health, in coordination with the competent entities, to guide training, exercise, and management of health professions and occupations. 10. Regulate provision of public and private health services, organize service delivery networks, and establish standards for service provision and guarantee their quality, in accordance with the law. 11. Participate in formulation and evaluation of policy for the definition of affiliate systems, protection to the user, insurance and pension information systems. 12. Formulate and evaluate policy for the definition of guarantee of health services provision and information systems related to occupational risks. 28 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 13. Conduct studies and analysis of the feasibility, stability and financial balance of resources allocated to health and social promotion by the Ministry. 14. Define and regulate information systems of the Social Protection System, which includes affiliation to the health care system, collection and parafiscal contributions. The administration of health information systems will be done in coordination with the Ministry of Finance and Public Credit. 15. Promote actions for the recognition and enjoyment of people’s rights to health, social promotion, and care, protection and improvement of quality of life. 16. Promote solidarity in accordance with Constitutional principles, such as participation of community organizations, nongovernmental entities, associations, mutual associations and other participants in developing health actions. 17. Promote articulation of actions of the State, society, family, individual and others responsible for the execution of health-related activities. 18. Provide technical assistance in matters of health and social promotion to entities or organizations that are territorially decentralized. 19. Ensure health and social promotion in health norms, government regulations and health insurance regarding professional risks. 20. Administer funds, accounts and resources for special administration of social protection under the charge of the Ministry. In this sense, the National Government has the capacity to delimit the scope and conditions in which the health system in Colombia operates. However, programmes for the training of health professionals are regulated through the Ministry of National Education, which determines the criteria that health education programmes should have based on the standards and delimitations defined in the human talent policies issued by the Ministry of Health and Social Protection. This element makes it difficult to regulate the functioning of the education system, the quality of training, and the institutions that have professionals, as they are guided by other rules that do not allow full control of the Ministry of Health and Social Protection, making training policies slower than expected. 5.5 Monitoring and information systems Since the creation of the new health system in Colombia in 1993, the government has developed structures that allow knowledge of the activities that are established in Colombia. These include, first, setting up measurement parameters for each of the system components and creating reporting structures that allow transparency of coverage, provision of services that are of good quality and adequate in quantity, price systems and the main indicators, among others. Colombia must submit an initial memorandum setting out its position on 250 legal instruments of the Organisation for Economic Co-operation and Development (OECD) to be allowed to be part of the Organisation and to show the sustainability of the Colombian health system. Some of these 250 legal instruments relate: (i) to having representative statistical information systems for the country to model future trends among countries; and (ii) to establish international standards in relation to indicators that analyse performance of health systems and measurement of health policy outcomes in six priority areas established by the OECD. These are measurement of health system results, quality of health care, effectiveness/efficiency in health expenditure (value for money), economics of disease prevention, financing of the health system and human talent in health (34). Thus, as the Ministry of Health and Social Protection must contribute to this road map and process of adherence to the OECD, it must establish a system to monitor progress and compliance with health policies and interventions in the country, in order to guarantee policies that improve the economic 29 CASE STUDY FROM COLOMBIA and social well-being of the population, favour the exchange of evidence in analysis and data comparisons to predict trends. Similarly, Colombia has organized and structured registries, observatories, monitoring systems and situation rooms – ROSS-MSPS, prioritized by the Ministry of Health and Social Protection: • to provide comparable data on and indicators of health outcomes (morbidity, mortality, risk factors), and use of health services (quality and access) among the Colombian population; • to monitor the performance of the Colombian health system by monitoring the strategic indicators in the six priority areas of the OECD; • to manage knowledge to guide policy formulation and action, in order to ensure effective implementation of health policies and practices, while providing evidence. Registries, observatories, monitoring systems and situation rooms (ROSS-MSPS) According to Law 715 of 2001, it is the responsibility of the Ministry of Health and Social Protection to define, design, regulate, implement and administer the comprehensive health information system, as well as the public health surveillance system, with participation of territorial entities. Specifically, in the area of observatories, in 2014 Resolution number 01281 was established, which aims to consolidate the guidelines that allow the integration of health information generated by the ROSS with the National Health Observatory (ONS- INS), linking them with SISPRO. To control these activities, a reporting model called the services provision registration system was designed. This mechanism allowed knowledge of the number of procedures, appointments, medicines and other services that were provided to the population. However, this isolated mechanism did not allow correlation of all variables, which could include other characteristics of the health systems. For this reason, five years ago, work was done on a platform that integrates all these related features; the platform is called SISPRO (www.sispro.gov.co). It allows review of the results in health indicators, characteristics of each of the territories, number of services rendered, quality indicators and integration with elements of human talent, and following up the Colombian population’s affiliation to the health system. Its design is based on a data warehouse in which the necessary information for the construction of indicators and reports is concentrated. The data come to the Ministry from internal and external information sources. SISPRO consolidates and provides information through the following components: single affiliate registration (RUAF), individual registry of health services delivery (RIPS), integrated contribution settlement form (PILA), hospital comprehensive system (SIHO), data management system (SGD), drug price information system (SISMED), among others. In Colombia, the ROSS prioritized by the Ministry of Health and Social Protection have been identified, as a whole, to fulfil well-defined roles, strategies and competencies in terms of knowledge management (35).The ROSS model has been applied for the purpose of reporting the formulation of policies and interventions in health, as follows: • providing information, data and managing knowledge about the health situation of the Colombian population; • leading the monitoring of health behaviour inequalities, and changes between those inequalities within specific groups; • managing knowledge to guide formulation of policies in health and ensure, in this way, effective implementation of interventions and strategies. The Ministry of Health and Social Protection Department of Epidemiology and Demography (DED), fulfilling the competences and obligations for monitoring, evaluation and knowledge management established for the health sector, has prioritized, grouped and concentrated on a set of ROSS that generates information supported by SISPRO, manages knowledge and disseminates information. 30 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) These are grouped according to their nature and are monitored in four categories (35): • Observatories ‚ ONV Colombia – National Violence Observatory ‚ ONVIH – National Observatory on Program Management for STDs, HIV/AIDS ‚ ONSM – Mental Health National Observatory ‚ Colombia’s Maternal Health National Observatory ‚ ONIEA – National and Intersectoral Teenage Pregnancy Observatory ‚ OEV Colombia – Ageing National Observatory ‚ OSAN Colombia – Food and Nutrition Security Observatory ‚ Drugs and Health Technologies Observatory ‚ ERCCAV – Chronic Renal Disease and Cardiovascular Health Observatory ‚ Health Economics Andean Observatory ‚ Colombia’s Ethnic Groups Health Observatory ‚ National Zoonoses Observatory ‚ Colombia Disability Observatory ‚ ONC Colombia – National Cancer Observatory ‚ ONCASASS Colombia – Observatory of Quality and Follow up to Actors of the Health System ‚ Human Talent in Health Observatory • Tracking systems ‚ System to Follow up on Health Care for Victims of the Armed Conflict in Colombia ‚ SSIVE – Monitoring for Voluntary Interruption of Pregnancy ‚ National System to Follow up Children and Adolescents in Colombia ‚ System for Monitoring Mandatory Health Notification Events ‚ Monitoring System for Achievement of Millennium Development Goals – MDG HEALTH Colombia ‚ SAPS – Monitoring System for the Primary Health Care Strategy ‚ Colombia’s Basic Indicators in Health Standard System ‚ Indicator System for Monitoring OECD Indicators ‚ National System of Monitoring and Evaluation of the Ten-year Public Health Plan 2012–2021 • Records ‚ Orphan and Rare Diseases Record ‚ Preventive Health Activities Record • Situational rooms ‚ PAI – Expanded Programme on Immunization The sources of information of the Ministry of Health and Social Protection include more than 30 administrative records that are currently in different stages of integration with SISPRO, including RIPS, Public Health National Surveillance System (SIVIGILA), Vital Statistics, Disability Registry Chronic Kidney Disease Registry HIV Registry, and many others. One of the most important administrative records about health information is SIVIGILA, which is a technical and operative guide that standardizes the criteria, procedures and activities that allow systematization of activities for epidemiological surveillance of events of public health interest. This has been functioning since 1998. It has been created to provide systematic and timely information on the dynamics of events that affect or may affect the health of the Colombian population in order to guide policies and planning in public health, make decisions for the prevention and control of diseases and risk factors in health, optimize monitoring and evaluation of interventions, and rationalize and optimize available resources to achieve the effectiveness of actions in health, aiming to protect individual and collective health. SIVIGILA has a series of mandatory compliance protocols issued by the National Health Institution (INS), which guide individual and collective interventions as well as the flow of information according to each case. SIVIGILA also has a network software that is under development; at present, its purpose is to manage information online and in the near future, it will administer the same information in real time. 31 CASE STUDY FROM COLOMBIA In Colombia, mandatory notification is required for 47 diseases. These diseases have different forms and frequency of notification: immediate notification, daily notification and observable reporting cases. Those responsible for notification are physicians and those who work in health care establishments, whether public or private. To carry out a proper and useful reporting process, it is necessary to make the report in a timely manner and complete the records for these matters. Sheet records are standardized by the Ministry of Health and all the fields must be completely filled. The physician or establishment must notify the regional health secretary who in turn must notify the Ministry of Health (36). Public Health Ten-year Plan (PDSP) 2012–2021 The sources of information of the Ministry of Health and Social Protection are complemented by more than a dozen population surveys, including the National Health Survey, National Mental Health Survey, National Nutrition Situation Survey, National Demographic and Health Survey, among others. Dozens of research related to the implementation and evaluation of different public policies developed in the past 5 years will also be used as sources with the support of the Ministry. These studies have been structured in the 10-year research plan that is being implemented in parallel with the support of the PDSP. Other sources of information being used for the monitoring of the PDSP include the use of records and research generated by other institutions, such as administrative records generated from the education, agriculture and environment sectors, or research carried out and published by DANE, such as the Quality of Life National Survey. Sources derived from national, departmental, district, municipal and international institutions are also used, completing the extensive map of sources of information required for the monitoring and evaluation of the PDSP (30). Seven priority dimensions have been defined in the PDSP. For their implementation, different objectives have been established; for these to be achieved, a series of actions must be incorporated, as established by Law 1438 of 2011. All of these ultimately aim to improve the health of each person, in a differential and equitable manner. Therefore, monitoring and evaluation of the PDSP must generate evidence of progress both in the execution of actions and progress in improving conditions that affect or endanger the health of people, families and population groups, towards the goals that demonstrate the achievement of the proposed objectives (30). Tracking indicators for various dimensions are distributed as shown in Table 11. Table 11. Dimensions and their tracking indicators in PDSP DIMENSION NUMBER OF INDICATORS Social coexistence and mental health 13 Sexual rights and sexuality 13 Enviromental health 13 Emergencies and disasters in public health 7 Food and nutritional security 9 Healthy life free of communicable diseases 11 Healthy lifestyle and noncommunicable conditions 15 TOTAL 81 Source: Ministerio de Salud y Protección Social. Plan Decenal de Salud Pública, PDSP, 2012–2021 32 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 6. The way forward and policy considerations In Colombia, it is important to strengthen the following areas: • Finalize regulation of the current care model. In parallel, strengthen the competencies of regional actors to implement the model. • Define the profiles of local officials responsible for the leadership of primary health care actions, and strengthen the capacity and technological infrastructure necessary for deployment of this system. • Define payment mechanisms for health actions, in such a way that it encourages the achievement of goals established at the national level. • Strengthen follow-up actions on human talent health policies in Colombia. • Strengthen the technological infrastructure of different system members in order to obtain more immediate data and lower adjustment rates. • Strengthen training of human talent: nursing, physician and family medicine programmes. • Regulate, pilot and implement the health model, taking into account the three differential elements (model for the population of large cities, high rurality and dispersed population). • Implement and monitor the health services networks model, based on primary providers (low complexity) and complementary providers (medium and high complexity). This factor is important because the Colombian population must recognize health professionals as legitimate and suitable for health decision-making. • Changes have been made in the list of health services offered under the health benefit plan of 2017, where all health services will be covered with the financial resources of the system. All health technologies would be able to be prescribed by health personnel, except those that are considered luxurious, experimental and cosmetic, and those that lack evidence of effectiveness and safety. It is very important that the National Government and health professionals regulate and become aware of the importance of making rational use of technologies, and having information mechanisms to avoid inappropriate use that can generate unnecessary expectation in the Colombian population. • Promulgation of the Development Plan Law 2014–2018 establishes a change in the regulation of health technologies at entry to the Colombian market. This element is of particular importance, as it must find a balance between the need for and generation of technologies that are innovative and have a greater impact on health, such as cell therapy, genetics, and high technology for illnesses such as cancer or diabetes, among others. It is also relevant to work within commercial markets and Colombia’s trade agreements with other countries. 33 CASE STUDY FROM COLOMBIA References 1. [National Administrative Department of Statistics – DANE. Postcensus studies, National and Departmental Population Projections 2005–2020]. DANE, Bogotá, Colombia: DANE; 2010 (in Spanish) (https://www.dane.gov.co/files/investigaciones/ poblacion/proyepobla06_20/7Proyecciones_poblacion.pdf, accessed 30 September 2017). 2. [Presidency of the Republic of Colombia. Decree 4107 of 2011, by means of which the objectives and structure of the Ministry of Health are issued]. 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World Health Organization Avenue Appia 20 CH-1211 Genève 27 Switzerland alliancehpsr@who.int http://www.who.int/alliance-hpsr This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries.