Malaria control reinvented: health sector reform and strategy development in Colombia

Abstract

SummaryThe consequences of health sector reforms on control of malaria were analysed using Colombia as an example. One of the most complex health sector reform programmes in Latin America took place in the 1990s; it included transferring the vertical vector-borne disease control (VBDC) programme into health systems at state and district levels. A series of studies was undertaken in 1998-2000 at the national level (Ministry of Health Study), at the state level (Departamento Study) and at the health district level (District Study) using formal and informal interviews among control staff and document analysis as data collection tools. A government-financed national training programme for VBDC staff -which included direct observation of control operations -was also used to analyse health workers' performance in the postreform period (longitudinal study). The results showed that some shortcomings of the old vertical system, such as the negative aspects of trade union activity, have not been overcome while some positive aspects of the old system, such as capacity building, operational planning and supervision have been lost. This has contributed to a decrease in control activity which, in turn, has been associated with more malaria cases. Malaria control had to be reinvented at a much larger scale than anticipated by the reformers caused by a whole series of problems: complex financing of public health interventions in the new system, massive staff reductions, the difficulty of gaining access to district and state budgets, redefining entire organizations and -in addition to the reforms -introducing alternative strategies based on insecticide-treated materials and the growth of areas of general insecurity in many parts of Colombia itself. However, positive signs in the transformed system include: the strengthening of central control staff (albeit insufficient in numbers) when transferred from the Ministry of Health to the National Institute of Health, the opportunities offered by the Basic Health Plan (PAB) for new planning initiatives and intersectoral co-operation and the integration of malaria diagnosis and treatment into the general health services (associated with a decrease of malaria mortality). The potentials of the new system have not yet been fully exploited: capacity building, communication and management skills need to be improved and it require guidance from the national level.

Malaria complicada en el Chocó: hallazgos clínicos y comparación de datos con el sistema de vigilancia

“…Varios estudios en el país muestran que no se han producido mayores avances en materia de acceso, equidad, eficiencia y calidad en los servicios de salud (4); y se documenta un deterioro en el control del evento con debilitamiento progresivo de la responsabilidad del Estado, la fragmentación de las acciones de control y cambios negativos en los indicadores de mortalidad y morbilidad (11), y se señala la urgente necesidad de la reinvención del control de la malaria (12,13).…”

Assessing options for an innovative malaria control program on the basis of experience with the new Colombian Health Social Security System

“…When a method or activity whose efficacy has been proved does not give the expected results, then the difficulties are attributed to isolated factors of control programme organisation and operation (administration, financing, personnel, etc.) or incontrollable processes within the context (5,33,76,77).…”

“…The same thing happened again with VBD programmes put together during the process of decentralisation and reform, which weakened public health. In this sense, findings from two recent studies (5,33) suggest that there is limited access to diagnosis and treatment, the disassociation of qualified personnel has left responsibility for the programme in the hands of untrained personnel and broken up the public network. Likewise, if decentralisation's long-term scheme for transferring resources has contributed towards improving equity in regional allocation (87), the same has not happened with allocating subsidies to the regions according tot their Unsatisfied Basic Needs (UBN), whose distribution is widely inequitative (14)(15)(16)88).…”

Between Intent and Achievement in Sector-Wide Approaches: Staking a Claim for Reproductive Health

“…Their caveat on integration in reproductive health programmes is the potential loss of that strength of focus needed to secure improvements in maternity care. Similar concerns of loss of technical expertise, declining treatment and logistics systems, and rigor in supervision and management are common to most vertical programmes faced with the prospect of integration at district level [31][32][33]. Sustaining change in the critical hospital-based elements of this strategy also proves problematic in resource poor societies [34], or where professional attitudes to the delivery of obstetric care are poor [27].…”