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Colombia 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)
(see Interest Groups
, ch. 4). 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--see Glossary).
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
(see Balance of Payments
, ch. 3). 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.
Data as of December 1988
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