Assessing options for an innovative malaria control program on the basis of experience with the new Colombian Health Social Security System
Evaluación de opciones para un programa innovador de control de la malaria, con base en la experiencia del Sistema de Seguridad Social en Salud de Colombia
Carlos A. Agudelo C.I; Augusto Corredor A.II; María Victoria ValeroIII
IMédico. M. Sc. Salud Pública. M. Sc. Ciencias. Instituto de Salud Pública, Facultad de Medicina, Universidad Nacional de Colombia. E-mail: email@example.com
IIMédico. Especialista en Medicina Tropical. Instituto de Salud Pública Facultad de Medicina, Universidad Nacional de Colombia. Bogotá, DC. Tel 3165405
IIIBacterióloga. M. Sc. Epidemiología. Investigadora independiente. E-mail: firstname.lastname@example.org
OBJECTIVES: Designing and proposing alternative models for municipal and Departmental malaria control programmes based on evidence obtained concerning the process of malaria on the Colombian Pacific Coast and regarding key problems in the malaria control programme before and following health system reform in 1993.
METHODS: An evaluative study was carried out, comparing the situation before and following the 1993 reform; model design was also compared. Control programme is understood as being the institution, the human group and administration in charge of control activities. The study was carried out in 2002 and 2003, in the Departments along the Colombian Pacific Coast; the four departmental capitals, 28 malarial and 5 control municipalities were included primary and secondary information was obtained by means of surveys and semi-structured interviews, community meetings and reviewing documentation in the secretariats of health, the Vector-borne disease control programme-VBDC, the Expanded Immunisation Programme-EIP, Health Promoting Entities-HPE, Subsidised Regime Administrators-SRA and Service-Providing Entities-SPE.
RESULTS: The following results were obtained: 1. Illustrating and analysing malarial tendencies in the country and on the Pacific Coast, and the corresponding institutional transformations in the programme; 2. Characterising the control programme which existed before 1993; 3. Characterising departmental modes of decentralising the programme; 4. Identifying the effects of reforming the system and characterising control programme problems; 5. Comparing the programme with the Expanded Immunisation Programme (EIP); 6. Comparative analysis of the programme and identifying current gaps in management capability; 7. Actors' perceptions regarding the control programme; 8. Values and challenges for an innovative control programme; and 9. Designing a model for up-dating/adapting the control programme.
DISCUSSION: Malaria control programmes' problems and weaknesses are frequently and inarticulately attributed to the lack of knowledge and management skill of personnel working in such programmes, the lack of an information and communication system or weaknesses in the municipalities or personnel. These factors may well have had an effect; however, a global and institutional approach leads to locating the programmes within a social, political and cultural context. This allows interpreting control programmes' current problems, amidst decentralisation and reform processes, and linking this interpretation to modelling and opening a space for innovation in such programmes. The study's main limitations spring from particularities regarding Pacific Coast control programmes and weakness in health information systems.
Key Words: Malaria, control programme, models, decentralisation, healthcare system, Colombia (source: MeSH, NLM).
OBJETIVOS: Diseñar y proponer modelos alternativos para los programas municipales y Departamentales de control de la malaria, con base en evidencias obtenidas sobre el proceso de la malaria en la Costa Pacífica de Colombia y sobre las problemáticas claves del programa de control de la malaria antes y después de la reforma del sistema de salud de 1993.
MÉTODOS: Se realizó un estudio evaluativo, de comparación antes y después de la reforma de 1993, y de diseño de modelos. Por programa de control se entendió la institución, el grupo humano y la administración que están a cargo de las actividades de control. El estudio se llevó a cabo durante el año 2002 y 2003, en los Departamentos de la Costa Pacífica colombiana. Se incluyeron las cuatro capitales departamentales, 28 municipios maláricos y 5 de control. Se obtuvo información primaria y secundaria, por medio de encuestas y entrevistas semiestructuradas, reuniones comunitarias y revisión documental en secretarías de salud, programa de Enfermedades Transmitidas por Vectores-ETV, Programa Ampliado de Inmunizaciones-PAI, Empresas Promotoras de Salud-EPS, Administradoras del Régimen Subsidiado-ARS e Instituciones Prestadoras de Servicios-IPS.
RESULTADOS: Se obtuvieron los siguientes resultados: 1. Ilustración y análisis de las tendencias de la malaria en el país y la Costa Pacífica, y las correspondientes transformaciones institucionales del programa. 2. Caracterización del programa de control antes de 1993. 3. Modalidades departamentales de la descentralización del programa. 4. Identificación de los efectos de la reforma del sistema y caracterización de las problemáticas del programa de control. 5. Comparación con el programa PAI6. Análisis comparado del programa e identificación de brechas actuales en la capacidad de manejo. 7. Percepción de los actores sobre el programa de control. 8. Valores y retos de un programa de control innovador. 9. Diseño de un modelo para adecuación del programa de control.
DISCUSIÓN: Las problemáticas y debilidades de los programas de control de la malaria se atribuyen con frecuencia, y de manera desarticulada, a la falta de conocimiento y habilidades gerenciales del personal que labora en el programa, a la carencia de un sistema de información y comunicación, a la debilidad de los municipios o del personal. Si bien estos factores han incidido, una aproximación más global e institucional permite ubicar los programas en un contexto social, político y cultural. De esta manera es posible interpretar las problemáticas actuales de los programas de control, en medio de los procesos de descentralización y reforma, y enlazar esta interpretación a un ejercicio de modelamiento que abra espacio a la innovación en tales programas. Las principales limitaciones del estudio se desprenden de las particularidades de los programas de control de la Costa Pacífica y de la debilidad de los sistemas de información en salud.
Palabras Claves: Malaria, programa de control, modelo, descentralización, sistema de salud, Colombia (fuente: DeCS, BIREME).
A round 85 % of Colombian territory is endemic for malaria (1-4). More than 250 000 confirmed cases were registered in 1998. In 2000, 129 municipalities (12 % of the total) and 3 million inhabitants (7,5 % of the total) presented an Annual Parasite Index (API) greater than 10 per thousand inhabitants and constant transmission. The incidence of urban malaria has increased during the last decade, affecting more than 20 municipalities (5). The areas having the greatest risk of transmitting the disease are the Pacific Coast, Urabá, the lower river Cauca, the upper river Sinú and the territories of Orinoquía and Amazonía (6). On the other hand, 1,7 million people (4.1% of the total) live in territories having controlled transmission and around 13.4 millions people inhabit areas having sporadic transmission.
A sequence of changes having a great effect occurred in Colombia during the 1990s, corresponding to the process of globalisation and international politics regarding liberalising economies and restructuring countries (7). The cepalin (Comisión Económica para América Latina - CEPAL) model for development employed during the previous fifty years was abandoned and a development model centred on structural adjustment and reducing fiscal deficit programmes became adopted. At the same time, the National Health System (NHS) was abandoned and Law 100, 1993, created the General Social Security in Health System (GSSHS). This dealt with a system of regulated competition, a mixed public/private model (8,9) based on public contracts (10), which has also been called structured pluralism (11).
The Ministry of Health, the National Council for Social Security in Health and Sectional and Local Health Offices represent the GSSHS management and control organisms. The system has two affiliation regimes; there is the contributory system receiving 12 % of a person's wage (4 % from the employee and 8 % from the employer) and the subsidised system for the poor population, representing people who cannot afford to make a contribution. 52,3 % (12,13) of the total population were affiliated in 2000, 30,5 % in the contributory regime and 25, 2 % in the subsidised regime. The public and private entities insuring the system are the Health Promoting Entities (Empresas Promotoras de Salud - EPS) and the Subsidised Regime Administrators (Administradoras del Régimen Subsidiado - ARS). The former receive contributions, transferring that surplus value relating to each affiliated family called Unit of Payment per Capitation (UPC) to the Solidarity and Guarantee Fund (Fondo de Solidaridad y Garantía - Fosyga). The latter receive resources from general taxes, via Fosyga and the Seccional and Local Health Offices. The Service-Providing Institutions (SPI) are both public and private.
The set of services for people is called the Compulsory Health Plan - CHP (Plan Obligatorio de Salud - POS), which is more extensive in the contributory than in the subsidised regime. Public health activities were grouped into a Basic Attention Plan BAP (Plan de Atención Básica PAB), in the hands of departmental and municipal authorities. A large part of those prevention, monitoring, diagnosis and treatment activities relating to a set of diseases including malaria, leishmaniasis and dengue is financed by CHP and BAP resources; these are managed by the Vector-borne disease (Enfermedades Transmitidas por Vectores ETV) control programme.
55 % of Colombia's population remained below the poverty line from 1995 to 2002 (14-25). Health insurance coverage and spending has grown, but inequality in access to and use of services remains. Departments and municipalities have progressively assumed management of public health activities and transmittable disease control programmes, without achieving a suitable transition towards decentralisation and a model of regulated competition (5,26-32). Very little research has been done regarding the last aspect to ensure that results regarding difficulties concerning decentralisation and reform processes can be understood. Some of them (5,33) suggest problems regarding management capacity, financing, organisation, personnel, allocating funds, monitoring and intersectorial coordination.
A research project was thus designed and carried out for advancing understanding these complex phenomena; it proposed an alternative model for up-dating/adapting municipal and Departmental malaria control programmes, based on evidence obtained from the process of malaria on the Colombian Pacific Coast and key problems arising from the malaria control programme before and following health system reform in 1993. This included identifying gaps in the ability for local management of the control programme generated after the 1993 reform.
An evaluative study compared the situation before and following reform in 1993, as well as the design of models. The control programme was interpreted as being that institution governing or entrusted with control activities by means of a human group and administration. Models were interpreted as being formal or systemic representations of some hypotheses contributing towards obtaining a command of observations and experiences (34,35). The design of an institutional model corresponds to a coordinated organisation, administration and operation programme.
Population and Methods
The study was carried out in the Departments bordering the Colombian Pacific Coast: Chocó, Valle del Cauca, Cauca and Nariño. These Departments' four capital cities (Quibdó, Cali, Popayán and Pasto, respectively), 28 other municipalities and 5 controls were included for a total of 37. The study group's municipalities presented endemic malaria and epidemic outbreaks and 89,3 % of them corresponded to municipal categories 5 and 6 (the poorest levels). Control group municipalities did not present malaria during the study, but did have the VBD programme on hand. Twenty-two municipalities (59,5 %) were decentralised, 18 corresponding to the study group (64,3 % of the group).
Primary and secondary information concerning the malaria control programme (before and after 1993) was obtained from the following:
102 Institutional surveys carried out with Departmental and municipalities' Vector-born disease control programmes (VBD), Health Promoting Entities (EPS), Subsidised Regime Administrators (ARS) and Service-Providing Institutions (IPS);
65 semi-structured in-depth interviews carried out with departmental and municipal Health Secretariat functionaries, members of community organisations, key informants and NGOs;
6 unstructured interviews were carried out with functionaries from the former MES (Malaria Eradication Service), now involved with the current control programme;
20 meetings and workshops were held with institutional and community groups so that the situation regarding malaria and the control programme could be evaluated;
19 municipal, Secretariat of Health and Ministry of Health-National Health Institute documents pertaining to information systems, data-bases and malaria monitoring were inspected; and
32 national and international documents, books, reports and studies regarding control programmes in the country were consulted.
Information about the Extended Immunisation Programme (EIP) was obtained by means of semi-structured surveys. Survey and interview forms were tested and adjusted accordingly. People carrying out the surveys and interviews were similarly trained and submitted to a test of their consistency. Fieldwork was carried out between September 2002 and January 2003.
Suitable software (Stata, SAS, Epiinfo and NUD*IST) was used for analysing the quantitative and qualitative information (36,37), using parametric and non-parametric tests, such as variance analysis, Fisher, Student t, Kruskas-Wallis and multiple correspondence tests.
Applying the following criteria did before-after comparison of the malaria control programmes: malarial trends, programme structure and organisation, functions or responsibilities, efficacy and gaps (planning, allocation of resources, personnel, training, monitoring of the disease and intersector coordination).
Comparison with other VBD programmes and the EIP was only done for the period after 1993. The modelling exercise was done from those results obtained from the previous methods, including principles, approaches, objectives, criteria, viability, scope, parameters and components.
1. Control programmes: before-after comparison
Two marked tendencies have characterised malaria in Colombia during the last forty years: decreased mortality and progressive increase in morbidity (Figure 1). In spite of cases being under-registered, representing between 15 % and 25 % according to region, an annual average of 160 thousand cases has been reached during the last few years, with frequent epidemic outbreaks and urban malaria occurring (38-43). P. vivax malaria predominates in Colombia.
The Pacific Coast area has represented a significant part of the problem regarding malaria in Colombia. Between 1960 and 1997, 10 % to 46 % of the total number of positive samples from the country corresponded to this region. However, P. falciparum malaria predominates on the Pacific Coast. On the other hand, the Pacific Coast has an appreciable list of municipalities presenting urban malaria: Quibdó, Istmina, Condoto, Tado, Atrato, Bagadó, Sipí and Lloró in the Chocó Department; Buenaventura in the Valle del Cauca Department; El Charco and Tumaco in the Nariño Department; and Guapi in the Cauca Department (44-54).
The control programme before 1993
The Malariology Campaign (Campaña Malariología) was created in 1943 as a Section of the Interamerican Cooperative Public Health Service and a dependency of the Ministry of Work, Hygiene and Social Security. The Campaign became the Malariology Division in 1947; MES was created in 1956 as a dependency of the Ministry of Health Public, replacing the Malariology Division, putting into practice WHO recommendations for advancing centrally financed and controlled eradication programmes (55-61).
The MES consisted of a Central Office located in Bogotá, housing the Management and a laboratory. This had sections for engineering and operations with insecticides, epidemiology and chemotherapy, entomology, education and training and administration. It had technical and administrative autonomy and jurisdiction throughout the whole country (62). Control campaigns initially included a single annual DDT spraying cycle, protecting at least 50 % of the population living in malarial areas, but covering just 14,3 % of them.
The first eradication campaign began in August 1957 and was extended to October 1958; it was expected that this would achieve its purpose by interrupting the parasite's transmission cycle. Total coverage of malarial areas was maintained from 1959 to 1961. At the end of 1962 it finished its spraying operations and continued with monitoring and prevention activities. The Eradication Campaign was mainly based on intra-domiciliary DDT spraying and the mass, free distribution of medicine to patients suffering fever.
The MES functioned as a vertical programme centred on organising campaigns, being formally dependant on the Ministry of Health, but functionally autonomous respecting the latter. The eradication strategy was abandoned towards the end of the 1970s, but it was suggested that its methodologies should continue to be used (63). The control programme assumed the functions of active-passive detection of cases, diagnosis, treatment and vector control in 1969. Problems became identified throughout this whole period, such as the lack of continuity and official resources and weakness in epidemiological monitoring, as well as poor civil society participation. The Eradication Campaign did manage to reduce Colombia's malarial area from 92 % to 85 % of the country's territory and contributed towards decreasing mortality.
The Special Direct Campaign Administrative UnitSDCAU (Unidad Administrativa Especial de Campañas Directas-UAECD) was created in 1976 (64), one year after the creation of the National Health System. The Malaria Eradication Service's functions were assigned to this unit (65), its organic structure consisting of personnel distributed amongst 18 Regional Offices.
The Direct Campaign Division's control activities, carried out through regional programmes helped by central level, consisted of:
- Spraying with DDT and phenitrotion, where resistance was detected;
- UVL spatial applications;
- Attending people with fever symptoms at 6 500 information posts; and
- Making diagnoses by 440 microscopes used by volunteers or Health functionaries.
The spraying, entomology, epidemiology, medication and case searching operations were undertaken throughout the whole country by 646 operators.
The process of decentralisation by which those functions regarding tropical disease control became progressively transferred to the Departments and municipalities began in 1986. The XV Heads of Region meeting in 1988 proposed methodologies in line with the decentralisation being experienced in the country, as well as monitoring and prevention strategies within the context of primary health attention (66) and a less vertical structure allowing the participation of the community and Sectional Health Services. This approach was also being promoted within the international setting, implying a change towards control programmes administratively structured for dealing with risks in geographical areas whose basic problems were demographic, social and cultural ones (67). This approach led the Seccional Health Services in Colombia to assume some functions in the control programme, but the main centralised and vertical parameters were conserved, since the Direct Campaign division closely followed the MES model.
Malarial tendencies and the control programme
Analysing the data relating to the 42 years presented in Figure 1 indicates that this series has great variability and strong self-correlation, preventing it from being valid for use in regression methodologies. On smoothing the series of data, the progressive increase in morbidity can be observed and three ascending cycles identified (ten years each). The long-term process of the malaria control programme has been divided into two periods for comparison purposes, bearing their transformations and health system characteristics in mind as follows:
1960-1991: the Malaria Eradication Service (MES) during the time of the National Health System; and 1992-2001: the Vector-born Disease Control programme (VBD) during the time of the GSSHS.
In turn, some sub-periods can be identified during the first period:
1977- 1986: SDCAU
1987-1991: SDCAU and decentralisation.
Significant differences were found on regrouping the first two sub-periods and obtaining the average Annual Parasite Incidence (API), as indicated below:
API averages illustrate the increase in morbidity, even taking into account those limitations introduced by the variability of the data. Between the first and last API average there is a 143,5 % increase. The API for the third period represents a 23,1 % increase on the second period, whilst the API rose by 98,1 % during the last period respecting the first.
Figure 2 shows that malarial tendencies are related to transformations in the control programme and the processes of decentralisation and health system reform.
Two clear types of achievement were obtained during the period corresponding to MES and SDCAU; an appreciable contribution was made towards the decrease of mortality due to malaria and a methodology for effective operation, centred on spraying and medicament distribution campaigns. However, this MES model and methodology became superseded by new, powerful social, cultural and political conditions in which the problem of malaria which unfolded during the 1980s. Morbidity increased rapidly from 1986 onwards. In the period following 1993, morbidity continued to increase and began to become expressed in a set of connected problems: repeated epidemic outbreaks, the parasite and vectors' resistance, urban malaria and other similar problems. Even though it is not a good idea to simply attribute current complex problems regarding malaria in Colombia to decentralisation and health system reform, the evidence presented here suggests that the new health system and its VBD Programme has not managed to confront prior tendencies in a suitable way, nor prevent them becoming worse.
Current programmes' characteristics and problems
The results in terms of those variables considered are presented next. It should be pointed out that when significant differences were found between the study group and the control group, these have been specifically indicated.
Service Providers. The Secretariat of Health directly carried out VBD and malaria action in 86,5 % of those municipalities studied. Proportions per groups are shown in Figure 3. Private entities were only found offering services in 3 (8,1 %) out of the 37 municipalities. However, in 16 (43,2 %) out of the 37 municipalities, the Secretariats of Health were using some form of contracting with municipal public entities, especially with SPEs, for totally or partially executing the VBD programme, especially activities regarding diagnosis, treatment and handling severe malaria.
Ownership. Control of malaria was part of the VBD programme in 30 (81,1 %) out of the 37 municipalities surveyed. It was thus not differentiated in terms of jobs, personnel or administration (Figure 3).
Planning. Annual operational plans (at Departmental and municipal levels) were frequently thrown off balance, not up-dated or out-of-date respecting malarial areas' specific needs and were submitted to multiple political influences.
Organisational structure. 51,4 % of the total had a structure including a management level, coordination/administration and execution levels, and at least one horizontal work division in the last two levels. The proportion of this structure increased on passing from the study group to the control group and the capital cities, as shown in Figure 3. Overlapping of dependency and job functions was frequently found within the framework of this structure. The VBD programmes were exceptional in that they had a shared mission or organisational goals. Management personnel recognised that they lacked participation and flexibility in allocating work and in decision-making regarding organisation. At the same time they did not have stable relationships with training institutions or with properly equipped physical settings/entities.
Control and supervision. 86,5 % of the municipalities studied had inspection, monitoring and control mechanisms, but 51,4 % of these mechanisms belonged to the municipal or Departmental Secretariat of Health. 70,3 % of the municipalities reported that there was quality control regarding programme activities and 67,6 % of them were running supervision activities (Figure 3).
Financing. All the Departments and municipalities were operating financing schemes prior to Law 715, 2001 being passed. Those resources applied to the VBD programme formed part of the municipal health budget, whose main sources in 2001 were as follows: transfers of current income from the State (ingresos corrientes de la Nación ICN), the fiscal allocation and resources from the Solidarity and Insurance Fund (Fosyga). These resources represented a little over 60 % of the total health budget. Another 30 % came from Departmental contributions and the sale of Level I Hospital services1. Some of the resources were partially managed by the Departments in close to half of the municipalities from the two groups.
Most Departments and municipalities considered that the aforementioned resources were insufficient and that payments were made late. They frequently found that there was not enough clarity in allocating and managing those resources destined for the VBD programme. Not one of the municipalities had any sort of system of public accountability.
Personnel. Heads of VBD programmes in the Departments had a professional qualification and 75 % of them had some type of postgraduate degree. VBD programme heads (or those in charge assuming the management of other programmes) in medium-sized and some cities had had professional training, but only 25 % to 30 % of them had managed to study for a postgraduate degree. 26 out of the 28 municipalities in the study group had one or more professionals in management posts; a third of them had up to two years' seniority and another third had 20 years or more seniority. Technicians participated in management posts in 10 out of the 28 municipalities (35,7 %), especially in the smallest ones, most of them having up to five years' seniority.
15 out of the 28 municipalities (53,6 %) had at least one professional in the post of programme coordination; in 10 of the municipalities (35,7 %) they had up to 1 year's seniority. They had 5 or more years' seniority in just 4 municipalities (14,3 %).
Most interviews highlighted the following aspects: personnel in charge of the programmes did not have sufficient technical, administrative and analytical abilities for planning and managing based on objectives and for performing as managers. Salaries were not appropriate and there were no financial and/or non-financial incentive systems. Personnel administration was thus not professional but rather authoritarian, promotions were not made based on merit and/or performance and they frequently became political ingredients. Corruption in contracting and recruiting personnel was common.
Training. Training activities were only carried out in 9 out of the 28 municipalities (32,1 %) in the study group and 2 out of the 5 municipalities (40 %) in the control group during 2001-2002. There was a lack of shared training processes for VBD programme personnel or any having a common/heterogeneous purpose.
Operational personnel base and activities. 97,2 % of the operational personnel stayed in the main towns, operating according to a programme of visits or as a response to emergency situations. On the other hand, 21,6 % of such personnel were carrying out activities different to just that of malaria, but within the framework of the VBD programme.
Consumer items. Providing medicine, insecticides and mosquito netting was generally late and insufficient.
Networks. It was found that the microscope network was relatively well developed in the municipalities in the study group, since 85,7 % of them had it (Figure 4). The same thing did not happen with other networks required for managing malaria, especially in entomology.
Monitoring and information system. In spite of it being considered that capturing cases of malaria was deficient, more than 80% of the municipalities had an epidemiological monitoring system and it was considered that the information was reliable (Figure 4). At the same time, everyone had received support for training; however, only 35,1 % considered that this had been a good opportunity and that feedback from the information had been useful. The information system lacked integration and had very little technological development. It also lacked systematic information regarding the efficacy of chemical and biological control activities. At the same time, an important discrepancy became presented between the information regarding cases managed in the municipalities and that used by the Ministry of Health.
Social participation. A precarious level of social participation was observed, this being one of the malaria control programmes' notable weaknesses. Regarding this aspect, differences between study and control groups became significant. Only 32 % of study group municipalities had some type of participation social, whilst the control group had 100 % (Figure 4).
Interaction and coordination. It was generally found that there were no political frameworks allowing goals for coordinated action to become defined amongst the municipalities. Vertical and horizontal interaction amongst VBD programmes, like the public sector, was consequently weak. Intersector coordination with other programmes reached 54,1 % in all municipalities, indicating that this tool is not used properly, giving little opportunity for making other sectors become aware (Figure 4).
Programme dynamics. The perception predominated that the VBD programme had become weakened from 1997 to 2001, except in the capital cities (Figure 5). Difficulties were recognised in both the study and control groups, especially regarding financing, organisation, personnel, logistics and technical capacity (Table 1).
VBD coverage. 50 % or more of municipalities from the three groups stated that programme coverage had diminished during 1995-2001 (Figure 5).
Adapting the VBD-malaria programme to the scheme laid down in Law 100 and decentralisation. It was found that 56,7 % of the total had adapted their approach very little or not at all to those schemes laid down in Law 100 and decentralisation (Figure 5). This suggests that if important transformations had been made to the VBD programme, these had still not been adequately adopted to the scheme of organisation and operation laid down in Law 100.
Relationship between variables. Bivariable analysis (variable to variable, Kruskas-Wallis test) indicated the existence of some associations (p<0.002), as shown below. Two types of grouping were systematically made; on the one hand, the lack of adapting to Law 100, the weakening of the programme and declining coverage were related to the programme's lack of differentiation and also to supervision of activities, the existence of a monitoring system and the absence of social participation. On the other hand, greater adapting to Law 100 was associated with decentralisation and greater capacity for providing coverage. The former suggests that it is possible to find VBD programmes where epidemiological monitoring and supervision activities are being undertaken, in spite of weaknesses and lack of coverage.
Multivariable analysis (multiple correspondence) showed that it was possible to coordinate and simplify the system of relationships, giving new significance to those, which had previously been identified in bivariable analysis. Taking municipal development as a parameter, four areas of results were identified in terms of those variables-categories with which each one was most associated.
Study group municipalities were associated with adapting to Law 100 (little or acceptable), apl-p and apl-a, decentralisation (dm-s), as well as having increased the programme (ep-in) and having the capacity to provide acceptable coverage (cpc-a), but were independent respecting organisational structure and programme differentiation. Another delimited area corresponded to those municipalities which had not adapted to Law 100 (apl-n), with intermediate or more complex organisational structure (eo-2, eo-3), in which the programme had stayed the same or had become weakened (ep-ig; ep-hd), were undifferentiated (gd-nd) but had supervision of activities (sa-s) and were independent of decentralisation. Category 2 municipalities (cat-2) were most associated in this area (i.e. capital and intermediate cities).
Control and capital groups (g-cr; g-cap) tended to be associated with some study group municipalities (cat-4), in terms of social participation (ps-s). A set of them had no social participation (ps-n), the programme had become weakened (ep-hd) and did not have supervision of activities.
Insuring entities SRAs and HPEs (Administradoras del Regime Subsidizado - ARS, Empresas Promotoras de Salud - EPS). 15 surveys were carried out, 13 (86,7 %) with SRAs and 2 (13,3 %) with con HPEs. Out of the total 5 were public and 10 private. The main variables' frequencies are given below.
- Payment for activities regarding managing complicated malaria: 12 (80 %) totally paid and 1 (6,7 %) partially paid;
- Specific resources for diagnosing and treating the involved population: 10 (66,7 %) had no resources; only 2 (13,3 %) showed that they had them;
- Reports regarding malaria: 10 (66,7 %) had not presented a report or had not supplied information; 5 (33,7 %) presented two or more reports during the year to Departmental or local Secretariats of Health; and
- Participation: only 6 insuring entities (40 %) participated in some aspect of designing the local Basic Attention Plan, especially in diagnosis and monitoring (26,7 %).
Service-providing entities - SPEs (Prestadores de Servicios IPS). 20 surveys were carried out with service-providing institutions: 16 (80 %) in the study group, 2 (10 %) in the control group and 2 in the capitals. Out of the total, 11 (55 %) were hospitals or clinics; 16 (80 %) were public and 4 private.
The main frequencies indicated that:
- Levels: 13 (68,4 %) from level I, 5 (25 %) from level II and 1 (5 %) from level III;
- Users Association: these were found in 10 (50 %) IPS;
- Resources for individual promotion and prevention: 7 (35 %) had such a resource;
- Reports: 10 (50 %) IPS presented 12 reports or more per year about malaria, most were sent to the Departmental Secretariat of health;
- Medicine: 5 (25 %) manifest that the supply of medicine was appropriate. Out of the total of those IPS receiving medicine, 17 (85 %) received from the Ministry of Health, via the Department or municipality; and
- Only 10 (50 %) IPS participated in drawing up the BAP, especially in diagnosing and designing it.
Extended immunisation programme - EIP vs. VBD Programme. Secretariat of Health SPEs carried out vaccination in 22 out of the 28 study group municipalities; at least 11 of the 28 municipalities had carried out vaccination campaigns during 2002-2003. Likewise, the municipalities, except for supplying the vaccines, mostly did those activities forming part of the vaccination programme. The latter and more than 85 % of the EIP programmes depended on financing from the Ministry of Health, but also used Departmental resources.
The same as in the case of the VBD programme, the perception that this had became weakened predominated in the EIP programme too (Table 2), being even more accentuate in the study group. The main difficulties were related to aspects regarding financing, decentralisation, logistics, technical capacity and personnel.
More than 80 % of the municipalities in both groups estimated that coverage had diminished or stayed the same during 1995-2001. On the other hand, no less than 75 % of the EIP programmes had managed to become adapted to the scheme laid down in Law 100 and current capacity for providing an acceptable or total response was high, except in the logistics.
The Student t test was used for comparing the replies obtained in the VBD and EIP surveys, applied to summing the proportions from the study groups and the capitals in each type of survey (gl=62). Significant differences were found in the EIP programme (p<0.02), mainly regarding the "weakening of the programme" and the "acceptable and total capacity for providing coverage" options; the VBD programme presented the greatest proportion of significant difference in the "programme has become increased" option.
Comparison and balance
As has been stated, both the control programme prior to 1993, at least in its final phase, and the programme following 1993 presented low efficacy respecting growing tendencies and new problems regarding malaria.
The information obtained, complemented by secondary information (69-72,75-80), led to key malaria control programme characteristics being identified, as shown in Table 3.
The balance between the two programmes puts those aspects conserved from the prior programme and gains from the VBD programme into relief:
- Aspects persisting from the prior programme, in the new conditions pertaining to the relationship between the Ministry of Health and Departmental and municipal Health Services: providing consumer goods, especially medicine. Likewise, providing consumer goods continues to be insufficient and hardly opportune.
- Aspects relating to gains from the control programme post 1993: resources have increased but they are perceived to be less even applied due to their dispersion throughout many Departments and municipalities having relative autonomy; there has been a rapid deterioration of conditions which have led to increased morbidity; the diversity of actors, but these having little commitment to the programmes; the concurrence of many sources of financing for the programmes; budgetary control by Departments and municipalities.
Gaps in the current programme. The following are considered to be gaps in the programme prior to 1993.
Positive aspects of that programme which have not been incorporated into the VBD programme:
- Normative dimension: its own specific normative frameworks;
- Planning: ecological coordination according to a regional overview, the experience and capacity for formulating regional and Departmental plans;
- Personnel: the volume and stability of personnel according to perceived needs; motivation of and incentives for personnel;
- Managerial capacity: countrywide or regional management capacity and global evaluation; control of resources; the system of information regarding malaria, within the framework of the National Health System information system;
- Training: elaborating partial plans;
- Strong institutional structures; and
- Systematic community interventions.
Potential gains from the new programme which have not been implemented:
- Planning and supervising activities and analysing achievements;
- Continuity in the planning process;
- Capacity for providing the programmes with Technical Assistance;
- Flexible and integral management of new strategies and activities;
- Prepared personnel having sufficient training in managerial and administrative aspects;
- Sufficient and continuous training of personnel, with appropriate remuneration;
- Managing personnel based on merit and transparent management;
- Using the BAP as a tool for activities, research and coordination;
- Appropriate and continuous control of resources;
- Positive transformation of the effects of how policy is made; and
- Appropriate availability of entomologists; continuous control efforts being made.
2. Decentralisation, territorial models and health system reform
Decentralisation has been a show, constant, long-term process in Colombia since 1986, modelled by Law 12 in 1986, 60 in 1993 and 715 in 2001. The last two established and improved the system of transferring resources between the Nation, Departments and municipalities, serving as the basis for decentralisation. Law 10, 1990 felt the way forward for decentralisation in the health sector and introduced some institutional changes in it. Law 100 in 1993 fully reformed the health system and created the GSSHS.
Political and administrative decentralisation of the municipalities is still far from being finished. Only 522 municipalities (49 % of the total) had managed to obtain the necessary certification for them to become decentralised in 2001; the degree to which these municipalities have fulfilled the requirements for obtaining such certification has not been homogeneous (68). Decentralisation and reform thus represent the two general and political frameworks having an effect on all health programmes, including VBD control (69-71). Pacific Coast Department and municipal experience constitutes a special and specific case, since VBD control programmes have followed their own route towards decentralisation.
In the Departments dealt with in this study, the Institute of Health in the Nariño Department, based in Pasto, has a VBD Control Unit in Tumaco, its second city, managing the programme for 10 endemic municipalities. The Department is decentralised, as are some municipalities but in that related to the VBD programme they depend on the Tumaco Unit.
The Cauca Department is decentralised but a good part of the municipalities are not; the VBD programme is centralised at Departmental level, operating like this with the malarial municipalities.
Former MES personnel in the Valle del Cauca were appointed to a Decentralised Departmental Institute assuming responsibility for the VBD programme in 42 municipalities. This Institute has the same hierarchical level as that of the Secretariat of Health, but this is an operational unit which in turn centralises the VBD programme in an appreciable number of municipalities, in spite of some of them being already decentralised.
The Chocó Department is decentralised but the municipalities are not and the VBD programme is centralised at Departmental level, operating like this with its malarial municipalities.
This type of incomplete but stable decentralisation, in the midst of general processes related to administrative political decentralisation, has provided space for relationships leading to advantages for some actors; from the technical point of view it allows more centred managing of those critical problems which municipalities are not able to confront on their own. But the problems inherent in this decentralisation scheme are son evident; the regional or departmental unit assumes responsibility for the control programme and the municipalities do not carry out activities or assign resources. From a political point of view, this is a scheme allowing dominant political parties' lines of clientelist action to use the State's departmental and municipal apparatus, as well as its public institutions.
The achievements and problems of the GSSHS have an effect on all of the system's dimensions, including the VBD programme. Amongst the former, it is worth mentioning the increase in insurance and spending on health, the consolidation of contributions and fiscal resources as sources of financing, the vertical, horizontal and regional solidarity, the increase of subsidies to the poor and the broad package of services. On the other hand, some problems can be highlighted: the insufficient level of affiliation (72), the inefficacy in spending, the increase in expenses, inappropriate flows of resources, inadequate and insufficient identification and affiliation of poor people, segmentation of the population and weak stewardship/management.
3. Actors' perceptions
Other dimensions of VBD programme characteristics and problems have to do with each actor's perceptions of themselves and the other others actors, within the framework of the health system. Their perceptions are given below (Table 4).
4. Control model
A large part of the fundamental elements of the model for malaria control that we are proposing have already been presented (structural basis and malarial tendencies, the programme's current problems, etc.). Likewise, those challenges and values found in the National Malaria Control Plan (Plan Nacional de Control de la Malaria - PNCM) were considered when designing the model in terms of objectives, goals and strategies (eliminating transmission, diminishing morbidity, avoiding mortality and complications and preventing the appearance of outbreaks of malaria). Similarly, the transformation of the political and institutional context leading to having an effect on programme control should be pointed out; the Ministry of Health was recently merged with the Ministry of Work and social Security, forming the Ministry of Social Protection, generating extensive reorganisation and relocation of functions and dependencies.
The modelling exercise required the following aspects of the model for the control of malaria to be taken into account:
- Principles underlying the new control model programme: a set of key capacities must be included having a significant effect on programmes having different degrees and level of development;
- Approach: comprehensive, seeking to compensate or equilibrate coverage and quality; and
- Purposes and objectives: for contributing towards reducing and preventing mortality and morbidity, controlling transmission and avoiding epidemic outbreaks, the model has the following objectives:
- Augmenting malaria programme control management capacity (building management capacity) at municipal and Departmental level;
- Improving control activity quality and scope (prevention, treatment and monitoring) in the municipalities and Departments;
- Criteria and viability: these have been conceived as being a realizable challenge, between the optimal and the desirable, in a complex institutional and social setting within the current normative framework, without which processes should be undertaken for modifying or producing Laws and Decrees. Simpler normative transformations could be necessary (i.e. Ministry Resolutions or Assembly and Council decisions);
- Scope: applicable at departmental and municipal level; and
- Parameters: the model's parameters are strengthening human talent, institutional adjustment and normative development (organisation, planning, infrastructure, supplies, etc.).
The control model's components are synthetically shown in Table 5, in terms of those capacities and aspects of normative adjustment and institutional development that should be acquired.
The predominating approach of managing malaria as a public health problem is centred on activities (diagnosis, treatment, insecticides, mosquito nettings, education, etc.). This approach has contributed much knowledge regarding malaria, as well as some recent successes (73-75). 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).
Health system reform and decentralisation processes and the growing negative effects of terminating the former National Health System weakened public health programmes in Colombia (69-71). Taken together, they suggest that it is not enough to have good methods for confronting malaria or controlling its effects on the population, but rather others requiring examining the organisation entrusted with such methods.
This study was focused on the institution entrusted with the malaria control programme; this institution is part of a health system (a set of interacting elements), operating as a service (generating products for a population). Its dynamics and problems can be considered from several theoretical approaches: systemic development (78), agency roles and stewardship (79-82). The agency is orientated towards control programmes regarding service users. Stewardship provides a normative framework guided by ethics; such approach allows proposing a broader methodology for approaching malaria control programmes, from which the context and activities can be observed.
Some studies have been carried out at international level concerning adapting malaria control programmes to local conditions, from the Garki project's pioneering studies (83), especially as case studies (84). Most studies in Colombia have been concentrated on the characteristics of the malaria problem and transmission and programmes and activities (38-55). Some of them have occupied themselves with factors regarding the social, economic, political and cultural structures which have had deeply effected malarial tendencies in our country. Less interest has been provoked by evaluating the effects of transformations in agrarian production systems, spontaneous and forced migrations, colonisation (85), growing coca crops and the political confrontation, corruption and clientelism which have provided greater or lesser impetus than decentralisation and State reform.
The tendencies and the situation of malaria in the population thus depend on the complex interaction of factors conditioning the intensity of transmission, the frequency of the disease, its forms of manifestation and its epidemiological characteristics. Reconstructing malaria's long-term tendencies led to finding that there was an early increase in morbidity in the 1980s (86). New social, political and cultural processes became combined during this period that then became added to decentralisation and even later on to reform. The MES and SDCAU effectively contributed towards reducing mortality for more than 20 years, but then they became exceeded by structural efforts and processes governing malaria. 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 (14-16,88). Other Concurring problems are affecting the health system: insufficient affiliation, many stages and delays in designing resources as subsidies, insuring entities' inappropriate management, inequalities in contracting and the absence of monitoring and control mechanisms from dominating positions and little social participation (88). VBD programmes thus found themselves amidst multiple pressures originating from economic, socio-political, decentralisation and health system reform processes. In this respect, some studies have indicated that those processes affecting the context of public institutions also have an effect on their organisation, administration, human resources and financial management (89-93).
Characterising the current malaria control programme's characteristics and problems has led to identifying its profile. This type of programme is mainly public in Colombia: SPE managed, financed and curative services. They have little degree of administrative development and lack training plans; many personnel have a low degree of scholastic preparation and have recently become involved with such programmes, lacking incentives and remuneration is low. There are insufficient consumer products and these are late in being delivered. The programmes operate mainly through visits to municipalities. There is little social participation and other social, institutional and civil sectors are not coordinated. Insuring entities are mainly private but apart from the Secretariats of Health (respecting the VBD) and they have no affect on drawing up the BAPs.
Comparing the VBD programme with the EIP suggests that they have experienced similar effects in decentralisation and reform; however, the processes have been different. The VBD programme tries (without success to date) to ensure that insures and providers appropriately comply with their roles and apply the CHP. Vaccination campaigns were progressively abandoned by the Secretariats of Health after 1997 in the EIP and the programme became assumed by the HPE-SRA insuring entities and the SPEs, leading to a rapid fall in vaccination and the level of effective protection. The later return to the scheme of campaigns, in conditions of more advanced decentralisation, retained the SPEs as vaccination agents and recovering the role of the Secretariats of Health, improving the level infant vaccination.
In view of the above, the exercise of VBD malaria programme institutional modelling was carried out with sufficient foundation, dealing with those gaps identified and aiming at the objectives proposed in national malaria control policy. The model is centred on capacities, normative adjustments and institutional development. This model allows the organisation, planning methodologies, resource allocation and managing personnel having multiple abilities to become progressively transformed (94). It likewise leads to institutions outside the health sector and the private sector to become involved in malaria control activities (95,96). Just like the institutions, malaria control programmes must become up-dated and adapted, acquiring the capacity to operate in adverse conditions.
The study had a set of limitations. In terms of control programmes, it represents the territorial (Department) centralised or partially decentralised scheme. It does not have a VBD programme corresponding to a completely decentralised territorial scheme. On the other hand, it is based on the malarial, ecological and epidemiological type, predominating on the Pacific Coast, meaning that as other regions share it then it is not the only one in the country. The weakness of Departmental and municipal health information systems restricts any reliable information that can be used
Acknowledgements. This paper was made possible through support provided by the Alliance for Health Policy and Systems Research (AHPSR) and the World Health Organisation. We would like to thank Miguel González-Block and Indra Pathmanathan (AHPSR Manager and consultant) for their methodological help. We would also like to thank Carolina Suárez, Adrián Muñoz and Diony Pulido for their direct help with the field-work and the innumerable functionaries from the Departmental and municipal Mayors' offices and Secretariats of Health, from the SPEs (IPS), SRAs (ARS) and HPEs (EPS), from the community and from NGOs for their collaboration which made it possible to obtain all the information used in this study.
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Recibido 14 Noviembre 2003/Enviado para Modificación 21 Enero 2004/Aceptado 28 Junio 2004