Evaluation of a primary health care strategy implemented in a market-oriented health system : the case of Bogota, Colombia

Sammanfattning: Introduction: Despite Colombia having adopted a health system based on an insurance market, Bogota in 2004, as part of a left-wing government (elected for first time in the city), decided to implement a Primary Health Care (PHC) strategy to improve quality of life, level of population health and reduce health inequities. The PHC strategy has been implemented through the HomeHealth program by three consecutive governments over the last eight years in the context of continuous political tension stemming from differences between national and district health policies.This thesis is an attempt to provide a better understanding of the overall experience of implementing a PHC strategy in the context of a market-oriented health care system. The research aimed to evaluate results of the PHC strategy through the intervention of the Home Health program and to identify factors that have enabled or limited the on-going PHC implementation process in Bogota.Methods: This study used a combination of quantitative and qualitative methods. A descriptive analysis was performed to assess direct results of the PHC strategy in terms of progress in the Home Health program coverage and increases in health personnel ratios reaching out to poor and vulnerable groups in Bogota. A cross sectional analysis was carried out to evaluate qualities of the delivery of PHC services through the attainment of PHC essential dimensions in the network of first-level public health care facilities. An ecological analysis was performed to estimate the contribution of the PHC strategy, through the Home Health program, to improve child health outcomes and to reduce health inequalities. A qualitative multiple case study was conducted to identify contextual factors that have enabled or limited the on-going PHC implementation process in Bogota.Results: The descriptive analysis showed a notable initial increase and rapid expansion in the development of the PHC strategy between 2004 and 2007, followed by a period of slower growth and stagnation between 2007 and 2010. The cross-sectional analysis suggested that the Home Health program could be helping to improve the performance of first-level public health care facilities. Ratings assigned to PHC dimensions by different participants pointed out the need to strengthen family focus, community orientation, financial resources distribution, and accessibility. The ecological analysis showed that localities with high PHC coverage had a lower risk of under-five mortality, infant mortality and acute malnutrition as well as a higher probability of being vaccinated than low PHC coverage localities. The belonging to a high-coverage locality was significantly associated with risk reductions of under-five mortality (13.8%) and infant mortality by pneumonia (37.5%) as well as increases in the probability of being vaccinated for DPT (4.9%). Concentration curves and concentration indices indicated inequality reductions in all child indicators betwen 2003 and 2007. In 2007 (period after implementation), the PHC strategy was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-five mortality (24%), infant mortality rate (19%), acute malnutrition (7%) and DPT vaccination coverage (20%). The main facilitators of the results achieved so far by the PHC strategy were all related to the commitment and good will of actors at different levels. Longterm political commitment, support by local mayors and hospital managers, organized communities historically active in the process of social participation, as well as extramural work carried out by community health workers and health care teams were highly valued. Barriers to the implementation included the structure of the national health system itself, lack of a stable funding source, unsatisfactory working conditions, lack of competencies among health workers regarding family focus and community orientation, and limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation.Conclusion: Despite adverse contextual conditions and limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has helped to improve the performance of first-level public health care facilities in the essential dimensions of PHC and has also contributed to improvement of child health outcomes and reduction of health inequalities associated with socioeconomic and living conditions. Significant efforts are required to overcome the market approach of the national health system. Structural changes to social policies at the national and district level are needed if the PHC strategy is expected to achieve its full potential. Specific interventions must be designed to have well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.