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).
RESUMEN
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
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).
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.
RESULTS
1.
Control programmes: before-after comparison
Malarial tendencies
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 Unit–SDCAU
(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:
-
1960-76: MES
-
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:
|
Period
|
Average API
|
SD
|
|
1960-1986
|
2.696
|
1.146
|
|
1987-1991
|
5.333
|
1.366
|
|
1992-2001
|
6.556
|
1.236
|
K-W test:
24.912 gl:2 p: 0.000004
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.
MES SDCAU VBDC
GMCS IAM
NMCP
|
|
MES: Malaria Eradication Service;
SDCAU: Special Direct Campaign Administrative Unit; VBDC: Vector-born Disease
Control Programme; GMCS: Global Malaria Control Strategy; IAM: Initiative
against malaria; NMCP: National Malaria Control Plan.
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 services.
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.
Table 1. Difficulties regarding the programme
