Transformation of ministries of health in the era of health reform: the case of Colombia

Towards universal health coverage: governance and organisational change in ministries of health

Countries have implemented a range of reforms in health financing and provision to advance towards universal health coverage (UHC). These reforms often change the role of a ministry of health (MOH) in traditionally unitary national health service systems. An exploratory comparative case study of four upper middle-income and high-income countries provides insights into how these reforms in pursuit of UHC are likely to affect health governance and the organisational functioning of an MOH accustomed to controlling the financing and delivery of healthcare. These reforms often do not result in simple transfers of responsibility from MOH to other actors in the health system. The resulting configuration of responsibilities and organisational changes within a health system is specific to the capacities within the health system and the sociopolitical context. Formal prescriptions that accompany reform proposals often do not fully represent what actually takes place. An MOH may retain considerable influence in financing and delivery even when reforms appear to formally shift those powers to other organisational units. MOHs have limited ability to independently achieve fundamental system restructuring in health systems that are strongly subject to public sector rules and policies. Our comparative study shows that within these constraints, MOHs can drive organisational change through four mechanisms: establishing a high-level interministerial team to provide political commitment and reduce institutional barriers; establishing an MOH ‘change team’ to lead implementation of organisational change; securing key components of systemic change through legislation; and leveraging emerging political change windows of opportunity for the introduction of health reforms.

How does managed competition affect hospital prices in a social health insurance system? The Colombian case

This paper studies the effect on hospital service prices of a health system reform that allows managed selective contracting and regulation as a means for efficiency and price competition. Cross-sectional data about prices and market structure were analysed from a pool of 20 markets which includes 15 million Colombians. A multilevel regression method comparing three different market settings was performed. The analysis evaluates the effects of insurer choice, hospital quality and market characteristics using a nationwide health services transactional database. A Hirshmann-Herfindahl index was applied to evaluate the markets concentration. Among the results, bilateral monopolies were made evident, both in insurance and hospital markets. Insurer selective contracting policy has the greatest impact on pricing with hospital monopoly heavy effect on health service prices. Colombian government has a challenge in regulating managed competition in order to maintain competition and access to healthcare. Health reforms using market competition as a mechanism for efficiency should follow closely health services market evolution in order to introduce effective regulatory policies.

Colombia: In vivo Test of Health Sector Privatization in the Developing World

The reform of the Colombian health sector in 1993 was founded on the internationally advocated paradigm of privatization of health care delivery. Taking into account the lack of empirical evidence for the applicability of this concept to developing countries and the documented experience of failures in other countries, Colombia tried to overcome these problems by a theoretically sound, although complicated, model. Some ten years after the implementation of “Law 100,” a review of the literature shows that the proposed goals of universal coverage and equitable access to high-quality care have not been reached. Despite an explosion in costs and a considerable increase in public and private health expenditure, more than 40 percent of the population is still not covered by health insurance, and access to health care proves uncreasingly difficult. Furthermore, key health indicators and disease control programs have deteriorated. These findings confirm the results in other middle- and low-income countries. The authors suggest the explanation lies in the inefficiency of contracting-out, the weak economic, technical, and political capacity of the Colombian government for regulation and control, and the absence of real participation of the poor in decision-making on (health) policies.

Where there is no policy: governing the posting and transfer of primary health care workers in Nigeria

The posting and transfer of health workers and managers receives little policy and research attention in global health. In Nigeria, there is no national policy on posting and transfer in the health sector. We sought to examine how the posting and transfer of frontline primary health care (PHC) workers is conducted in four states (Lagos, Benue, Nasarawa and Kaduna) across Nigeria, where public sector PHC facilities are usually the only form of formal health care service providers available in many communities. We conducted in‐depth interviews with PHC workers and managers, and group discussions with community health committee members. The results revealed three mechanisms by which PHC managers conduct posting and transfer: (1) periodically moving PHC workers around as a routine exercise aimed at enhancing their professional experience and preventing them from being corrupted; (2) as a tool for improving health service delivery by assigning high‐performing PHC workers to PHC facilities perceived to be in need, or posting PHC workers nearer their place of residence; and (3) as a response to requests for punishment or favour from PHC workers, political office holders, global health agencies and community health committees. Given that posting and transfer is conducted by discretion, with multiple influences and sometimes competing interests, we identified practices that may lead to unfair treatment and inequities in the distribution of PHC workers. The posting and transfer of PHC workers therefore requires policy measures to codify what is right about existing informal practices and to avert their negative potential. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd

Redesigning a Ministry of Health's organizational structure: exploring implementation challenges through Botswana's experiences

INTRODUCTION

The Botswana's Ministry of Health redesigned and adopted a new organizational structure in 2005, which was poorly implemented. This article explores factors that influenced the implementation of this organizational structure.

METHODS

This article draws from data collected through in-depth interviews with 54 purposively selected key informants comprising policy makers, senior managers and staff of the Ministry of Health (N = 40) and senior officers from various stakeholder organizations (N = 14).

FINDINGS

Participants generally felt that the review of the Ministry of Health organizational structure was important. The previous structure was considered obsolete with fragmented functions that limited the overall performance of the health system. The new organizational structure was viewed to be aligned to current national priorities with potential to positively influence performance. Some key weaknesses identified included lack of consultation and information sharing with workers during the restructuring process, which affected the understanding of their new roles, failure to mobilize key resources to support implementation of the new structure and inadequate monitoring of the implementation process.

CONCLUSION

Redesigning an organizational structure is a major change. There is a need for effective and sustained leadership to plan, direct, coordinate, monitor and evaluate the implementation phase of the reform. Copyright © 2014 John Wiley & Sons, Ltd.

Reviewing HIV-Related Research in Emerging Economies: The Role of Government Reviewing Agencies

Little research has explored the possible effects of government institutions in emerging economies on ethical reviews of multinational research. We conducted semi-structured, in-depth telephone interviews with 15 researchers, Research Ethics Committees (RECs) personnel, and a government agency member involved in multinational HIV Prevention Trials Network (HPTN) research in emerging economies. Ministries of Health (MOH) or other government agencies often play pivotal roles as facilitators or barriers in the research ethics approval process. Government agency RECs reviewing protocols may face particular challenges, as they can lack resources, be poorly organized, have inconsistent review processes and limited expertise, and use differing definitions of national interests, including upholding national reputation and avoiding potential exploitation and stigma of the country's population. The MOH/governmental review body may be affected by power dynamics and politics in study reviews; may consider issues both related and unrelated to research ethics as understood elsewhere; and may prioritize particular diseases, treatments, or interventions over other topics/types of research. Poor communication and deeply-rooted tensions may exist between sponsor and host countries, impeding optimal interactions and reviews. Investigators must understand and plan for the potential effects of governmental agencies on multinational collaborative research, including preserving adequate time for agency review, and contacting these agencies beforehand to address issues that may arise. Better understanding of these issues can aid and advance appropriate global scientific collaboration.

Health care privatization in Latin America: comparing divergent privatization approaches in Chile, Colombia, and Mexico

The public-private mix in Chile, Colombia, and Mexico was very similar until the early 1980s when Chile undertook health care privatization as part of comprehensive health care reform. Since then, health care privatization policies have diverged in these countries. In this study we characterize health care privatization in Latin America and identify the main factors that promoted and hindered privatization by comparing the experiences of these countries. We argue that policy elites took advantage of specific policy environments and the diffusion of privatization policies to promote health care privatization while political mobilization against privatization, competing policy priorities, weak market and government institutions, and efforts to reach universal health insurance hindered privatization. The privatization approaches of Chile and Colombia were classified as "big-bang," since these countries implemented health care privatization more rapidly and with a wider scope compared with the case of Mexico, which was classified as gradualist, since the privatization path followed by this country adopted a slower pace and became more limited and focalized over time. We conclude that the emphasis on policy-driven privatization diminished in the 1990s and 2000s because of increased public health care financing and a shift in health care reform priorities. Health care privatization in the region, however, continued as a consequence of demand-driven privatization.

Unmasking the open secret of posting and transfer practices in the health sector

This article focuses on processes of granting posts and transfers to health care workers and administrators that can be described as 'mission inconsistent (MI)', meaning that they are not conducted in a way that maximizes health outcomes or that respects the norms of health care worker professionalism. We synthesize relevant literature from several different disciplinary perspectives to describe what is known about the problem of MI posting and transfer in the health sector, to critically engage and interrogate these literatures, and to briefly discuss efforts that have been made to maximize mission consistency. The article concludes by suggesting principles for future research that would foster a more complete understanding of posting and transfer practices.

Reformas de saúde em perspectiva comparada: uma questão sem fim .... ou uma busca improvável

Considerando a natureza problemática das tentativas de reformar os sistemas nacionais de prestação de serviços em saúde, este documento aborda o contexto e a lógica das reformas do setor. Após um retrospecto das abordagens do aumento de capacitação em três gerações de reformas do setor público, o documento examina as reformas aplicadas ao financiamento, organização e prestação dos serviços de saúde, e sugere estratégias para reformas que levem a capacidade em consideração.

The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe

This paper reports on comparative analysis of health planning and its relationship with health care reform in three countries, Eritrea, Mozambique and Zimbabwe. The research examined strategic planning in each country focusing in particular on its role in developing health sector reforms. The paper analyses the processes for strategic planning, the values that underpin the planning systems, and issues related to resources for planning processes. The resultant content of strategic plans is assessed and not seen to have driven the development of reforms; whilst each country had adopted strategic planning systems, in all three countries a more complex interplay of forces, including influences outside both the health sector and the country, had been critical forces behind the sectoral changes experienced over the previous decade. The key roles of different actors in developing the plans and reforms are also assessed. The paper concludes that a number of different conceptions of strategic planning exist and will depend on the particular context within which the health system is placed. Whilst similarities were discovered between strategic planning systems in the three countries, there are also key differences in terms of formality, timeframes, structures and degrees of inclusiveness. No clear leadership role for strategic planning in terms of health sector reforms was discovered. Planning appears in the three countries to be more operational than strategic.

Good governance and sustainability: a case study from Pakistan

OBJECTIVE

On the basis of a case study in Pakistan, the paper argues that good governance, characterized by transparency, accountability and meaningful community participation, plays a critical role in the sustainability of donor-funded health systems projects in the public health sector.

METHODS

The Family Health Project (FHP) (1992-1999), funded by the World Bank, has been used as a case study. Critical analysis of secondary data mainly obtained from the Department of Health (DoH) in the province of Sindh in Pakistan is the major tool used for the study. Data from other sources including the World Bank have also been used.

RESULTS

The analysis reveals that the existing health care system could not fully absorb and sustain major "sociopolitical" thrusts of the project, meaningful community participation and "democratic" decision-making processes being the most important ones. The hierarchical structure and management process made it difficult to produce a sense of ownership of the project among all managers and the rank and file staff. The Provincial Health Development Center (PHDC) and District Health Development Centers (DHDCs) established by the FHP did not receive adequate financial and political support from DoH and the Ministry of Health to have much control of the project at the local level. Consequently, these Centers largely failed to institutionalize a continuing training program for district level health officials/professionals. Due to lack of political support, the District Health Management Teams (DHMTs) could not be institutionalized. Community participation in the DHMTs was symbolic rather than forceful. Improved coordination among all stakeholders, more stable and competent leadership, more meaningful community participation, greater devolution of project management to the district level, and better management of resources would have resulted in more effective and efficient implementation of the project. Based on these findings, the paper introduces a Sustainable Management Approach (SMA) as a tool that can be used to ensure the sustainability of health systems projects, particularly those funded by international organizations in developing countries.

CONCLUSIONS

Good governance and a conducive organizational culture are important prerequisites for incorporating any new project within an existing system. This includes prior consensus building among all stakeholders, a meaningful and inclusive participatory planning, implementation and evaluation process involving communities, political commitment, and the identification and use of appropriate leadership for project management.

Colombia and Cuba, contrasting models in Latin America's health sector reform

Latin American national health systems were drastically overhauled by the health sector reforms the 1990s. Governments were urged by donors and by the international financial institutions to make major institutional changes, including the separation of purchaser and provider functions and privatization. This article first analyses a striking paradox of the far-reaching reform measures: contrary to what is imposed on public health services, after privatization purchaser and provider functions are reunited. Then we compare two contrasting examples: Colombia, which is internationally promoted as a successful--and radical--example of 'market-oriented' health care reform, and Cuba, which followed a highly 'conservative' path to adapt its public system to the new conditions since the 1990s, going against the model of the international institutions. The Colombian reform has not been able to materialize its promises of universality, improved equity, efficiency and better quality, while Cuban health care remains free, accessible for everybody and of good quality. Finally, we argue that the basic premises of the ongoing health sector reforms in Latin America are not based on the people's needs, but are strongly influenced by the needs of foreign--especially North American--corporations. However, an alternative model of health sector reform, such as the Cuban one, can probably not be pursued without fundamental changes in the economic and political foundations of Latin American societies.

Health care costs and financial consequences of epidemiological changes in chronic diseases in Latin America: evidence from Mexico

OBJECTIVE

To determine the costs of health services and the financial consequences of changes in the epidemiological profile of chronic diseases in Latin America.

STUDY DESIGN

We conducted longitudinal analyses of costs and of the economic impact of the epidemiological transition in healthcare services for diabetes and hypertension in the Mexican health system. The study population included both the insured and uninsured populations.

METHODS

The cost-evaluation method was based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2004-2006, six models were constructed according to the Box-Jenkins technique, using confidence intervals of 95% and the Box-Pierce test.

FINDINGS

Costs ranged from US$613 to US$887 for diabetes, and from US$485 to US$622 for hypertension. Regarding epidemiological changes for 2004 compared with 2006, an increase is expected in both cases, although results predict a greater increase for diabetes, 10-15% in all three institutions (P<0.05). Comparing the financial consequences of health services required by insured and uninsured populations, the greater increase (17%) will be for the insured population (P<0.05). The financial requirements for both diseases will amount to 9.5% of the total budget for the uninsured population and 13.5% for the insured population.

CONCLUSIONS

If the risk factors and the different healthcare models remain as they are at present, the economic impact of expected epidemiological changes on the social security system will be particularly strong. Another relevant financial factor is the appearance of internal competition in the use and allocation of financial resources among the main providers in the health services; this factor becomes even more complicated within each provider. In effect, within each institution, hypertension and diabetes programmes must compete for resources with other programmes for chronic and infectious diseases.

Tuberculosis control and managed competition in Colombia

Law 100 introduced the Health Sector Reform in Colombia, a model of managed competition. This article addresses the effects of this model in terms of output and outcomes of TB control. Trends in main TB control indicators were analysed using secondary data sources, and 25 interviews were done with key informants from public and private insurers and provider institutions, and from the health directorate level. We found a deterioration in the performance of TB control: a decreasing number of BCG vaccine doses applied, a reduction in case finding and contacts identification, low cure rates and an increasing loss of follow up, which mainly affects poor people. Fragmentation occurred as the atomization and discontinuity of the technical processes took place, there was a lack of coordination, as well as a breakdown between individual and collective interventions, and the health information system began to disintegrate. The introduction of the Managed Competition (MC) in Colombia appeared to have adverse effects on TB control due to the dominance of the economic rationality in the health system and the weak state stewardship. Our recommendations are to restructure the reform's public health component, strengthen the technical capacity in public health of the state, mainly at the local and departmental levels, and to improve the health information system by reorienting its objectives to public health goals.

Universal health care for Colombians 10 years after Law 100: challenges and opportunities

Colombia's 1991 Constitution reformed the country's public health care system. Per constitutional mandate: (subsequently developed by Law 60/1993 and Law 100/1993), (1) health is a right of all citizens, (2) the Social Security System must coordinate, provide and control an effective, universal and collective public health service, (3) health services management and delivery are decentralized to strengthen the role of departments and municipalities, (4) the private sector is incorporated within the insurance and health services delivery functions, and (5) basic health services are free and compulsory. After summarizing some of the most relevant Colombia's health system features, this article addresses four central aspects of the country's health care reform, namely: (1) the Unit of Payment by Capitation (UPC) as a provider payment mechanism, (2) asymmetries of information among the different agents of the General System of Social Security in Health (SGSSS), (3) the delegation by the Fund of Solidarity and Assurance (FOSyGA) of collection and control functions to Health Promotion Entities (EPS), and (4) the attempt to achieve universal health insurance as defined by Law 100. The article concludes with a description of various measures and political decisions necessary to ameliorate the financial crisis of the SGSSS and overcome difficulties in reform implementation.

The relationship between disease control strategies and health system development: the case of TB

This paper focuses on the lack of dialogue and policy consonance between those taking the lead in health systems change and those developing specific disease control strategies. In the first part, the origins and characteristics of this situation are explained using, as an example, TB control. Attention is then paid to the development of disease control friendly health systems. Four aspects of policy development are analysed paying particular attention to TB control: analysis of policy context, mechanisms for collaboration between policy actors; agreement on decision-making processes; development of common aims and objectives. Although the focus is on TB control, the principles illustrated carry some relevance for other disease control programmes.

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

The 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.