The Politics of Health: Priorities, Institutions, and Public Policy
During colonial times and the first century following independence, health care in Colombia consisted of services provided by traditional healers and private physicians trained first in Europe and later in national medical schools. The physicians served the elite and practiced curative medicine exclusively. Health care of the indigent, orphans, and the mentally ill was at first the domain of charity institutions, largely run by the Roman Catholic Church. As the population increased, orphanages, shelters, and municipal and community hospitals, usually staffed by religious orders, emerged throughout the country. Political pressures and local initiative, rather than assessment of regional needs, determined the size and kind of health facilities built and operated. Therefore, the distribution of hospital beds and services in the country was haphazard. With the advent of modern high-cost technology, this approach led to wasteful duplication of services and a major escalation in investment and operating costs.
The government initiated official action in the health field in 1913. The Ministry of Public Health, largely as it exists today, was established in 1953. Government programs were initially small, geared exclusively to the control of communicable diseases by reducing environmental hazards, providing water and sewerage facilities, and controlling garbage disposal. Vaccination campaigns were attempted, as was the isolation of patients with contagious diseases. At first, there was no relationship between these government activities and hospital care. Rural health care was virtually nonexistent, and reliance on traditional practitioners was almost universal until the 1950s.
In 1945 the National Provident Fund (Caja Nacional de Provisión--Cajanal) was created to provide prepaid health services and other benefits to government employees. In 1946 the Institute for Social Insurance (Instituto para Seguros Sociales--ISS) was organized under the Ministry of Labor to provide life and disability insurance, a pension plan, and a health program for employees in the modern private subsector. The ISS health system grew rapidly and independently of both municipal hospitals and the Ministry of Public Health. Subsequently, many smaller prepaid health programs were organized for railroad and telecommunications workers, the police, the armed forces, and other employees either not protected by the ISS or Cajanal or dissatisfied with the services. In the late 1980s, about 200 of these social security and family welfare funds existed.
The health sector was divided into three main subsectors: the government--consisting of the Ministry of Public Health, its five autonomous specialized agencies, and the Department of Health Services (Servicio Seccional de Salud--SSS); the social security subsector--comprising the ISS for private employees, Cajanal for public employees, and the smaller funds for specific population groups; and the private sector. Lacking coordination, these subsectors evolved along divergent paths.
Beginning in the late 1960s, the ministry's programs focused on extending coverage to persons not protected by organized health services. Priority was given to rural areas, poor marginal urban populations, and maternal and child health care. Primary health care, largely provided by paramedical personnel, was the principal instrument for achieving this objective.
A major review of the health sector by the government in 1974 led to the development of the National Health System, designed to provide adequate health care to all Colombians. Health was also viewed as a major component in integrated development efforts in the 1970s and early 1980s. These efforts, which received substantial support from the World Bank and other international agencies operating in Colombia, attempted to enhance productivity, income, and living standards of "viable" and "stable" peasant communities with small- and medium-sized farms. Good results and continued multilateral financing guaranteed its survival for more than a decade.
The 1979-82 National Integration Plan (Plan de Integración Nacional--PIN), as the national government's development plan was called, continued to emphasize expanding health coverage to the most vulnerable groups (mothers and children under five) and areas (rural and urban squatter settlements), recognizing the disparities in health status among regions and population subgroups. The National Health System was viewed as the major instrument to achieve the goal, and increased coordination among the Ministry of Public Health, the ISS, the social security funds, and family welfare funds was emphasized. Specific coverage targets were identified, including immunization of 80 percent of infants and 100 percent of children under five years; piped water and sewerage to 78 percent of the urban population and 79 percent of the nondispersed rural population; and a 15 percent increase in prenatal care. The ultimate goals were to reduce infant mortality by 15 percent, child mortality by 25 percent, and various kinds of morbidity by given percentages.
In 1981 the government established the Plan to Accelerate Health Development, based on grouping the SSS into six nuclei led by the six most developed departments. These departments would help their less-well-favored neighboring departments and national territories with technical assistance, coordination, data processing and monitoring services, supervision, and evaluation of programs. The central nucleus in Bogotá was to oversee and to develop the norms of the system.
In the late 1980s, the Barco administration implemented two other major social programs with both a direct and an indirect impact on health care for the poorest groups in society. The programs were the National Rehabilitation Plan, actually initiated by the Belisario Betancur Cuartas administration (1982-86) to shift public expenditures to the most remote and least-developed rural zones of the country, where guerrilla groups maintained strongholds, and the National Plan for the Eradication of Extreme Poverty, which focused on reducing urban poverty by 80 percent among those persons below the level of extreme poverty. Like the programs of the 1970s and early 1980s, these two new programs consisted of food subsidies, primary health care, communal education, locally constructed small public works projects for transportation, schools, and health care centers. In contrast with the earlier effort, however, Barco hoped for improved delivery of services through better coordination of different government agencies.
The private sector also acquired some paragovernmental functions in relation to health care. The Family Compensation Funds, or Cajas, were governmentally mandated, private sector institutions that held a percentage of the total salary paid by a firm to its workers and used it to provide cash subsidies and different types of services to affiliated workers. Some of the largest Cajas developed hospitals, pharmacies, dental units, general medical consultation services, and outpatient health care centers for children and nonworking spouses. Cajas were legally barred from duplicating the work of other governmental institutions, such as the ISS. This unorthodox model could be considered a private component of the urban social security system, managed jointly by unions or workers, firm owners, and the government.
Another key paragovernmental private health care provider was the National Federation of Colombian Coffee Growers (Federación Nacional de Cafeteros de Colombia--Fedecafe). Fedecafe collected and managed the taxes originating from coffee exports, using the money both to stabilize and protect the coffee industry and to improve living conditions in the coffee regions of the country. In the central Andean region--the core of the coffee economy--Fedecafe was a major provider of basic health care, sanitation, access to clean water, nutritional education, immunization, and dental services.
Except for extensive support by the international system, the provision of health care was a relatively low priority for the Colombian political establishment in the 1970s and 1980s. In political electoral terms, there was no clear constituency for national health care. Those sectors lacking health care and risk protection were usually the poorest groups in society, the least organized, and the weakest in political influence. In addition, other groups, including public employees, transportation workers, oil workers, private employees, and middle-class professionals, struggled independently and autonomously to develop some form of health care and risk protection.
The health sector was perceived implicitly by politicians as a legitimate part of the "spoils" of office (botín burocrático) because of its relatively high employment capacity for political appointees. Traditionally, with some significant exceptions, the Ministry of Public Health and its regional division were "assigned" to politicians; that is, they were effectively outside the control of national planning officials and programs. Indeed, the financial sources that supported departmental health services--the lottery and state taxes on alcoholic beverages--were periodically shaken by revelations of political corruption and reckless management.
Compared with other ministries and given the magnitude of its task, the Ministry of Public Health was woefully underfunded. The ministry's expenditures as a share of the national product had decreased since the late 1960s, and by the mid-1980s they were at approximately 0.6 percent of the gross domestic product (GDP). Since the late 1960s, with the exception of the period of the Alfonso López Michelsen administration (1974-78), the share of the health sector in total central government expenditures had declined. In fact, the fiscal adjustments in late 1984 and 1985-- necessitated by the global recession and Colombia's ensuing trade and national account deficits--cut heavily into social expenditures, especially health and education. Between 10 percent and 20 percent of public health care beds were not operating in 1985 because of inadequate funding. Another symptom of the low priority given to health care services was its relative share of foreign earnings. Total foreign currency commitments for the health sector in Colombia in the 1973- 82 period amounted only to US$402 million.
Considerable institutional overlap and bureaucratic inefficiency and uncertainty characterized the ministry's specialized institutions. Both the National Institute of Health and the National Institute of Municipal Development supported local investments in water and sewerage systems in small- and medium- sized towns. In 1988 the latter institute was being dismantled and its functions transferred to the Central Mortgage Bank, the Malaria Eradication Service, and the Cancer Institute. In addition, ministry units were autonomous. Although some coordination at the operational level occurred, each institution generally developed its own policies and programs.
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