Health Care system in Colombia

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INTRODUCTION Since 1978, WHO has emphasized the importance of primary health care (PHC) for promoting and protecting population health. [1] PHC is highlighted as the mechanism through which countries can provide better health to persons, families and communities, with greater equity and lower costs,[1,2] because it “brings promo- tion and prevention, cure and care together in a safe, effective and socially-productive way at the interface between the population and the health system.”[2]

Colombi a is a culturally and ethnically diverse country with a highly varied demographic and epidemiologic profi le, and an increased burden of chronic non-communicable diseases in the past decade without yet having eradicated infectious diseases. [3–5] Until recently, Colombia’s health system favored develop- ment of a hospital-based, curative health care model, oriented toward highly specialized care (the system revolving around spe- cialists) under a free-market model (with users seen as consum- ers and with a variety of public and private insurers and service providers) that generates inequities in fi nancing and limits ac- cess to health care, patient-centered care and community-based health improvements.[6]

In 2011, Law 1438 modifi ed Colombia’s health system, putting PHC legally at the center of the system to address the country’s health priorities, emphasizing: • public health actions such as health promotion and disease pre-

vention; • coordination of intersectoral actions; • a culture of self-care; • comprehensive health care involving individuals, families and

communities; and • active community participation and local approaches to attaining

long-term, continuous and intercultural attributes of care.[7–9]

This article describes an intervention based on PHC and commu- nity-oriented primary care (COPC) principles,[10] aimed at building

capacity for community participation to change population health status in Colombian communities.

INTERVENTION Purpose, rationale and participants The Citizenship for Healthy Environments (CxES), a qualitative participatory action research (PAR) project to build community capacity to infl uence health, was carried out from January 2012 through June 2014 (30 months) with organizations in Bogotá and Cundinamarca, Colombia. In al- liance with several institutions (Corona Foundation, Universidad de La Sabana, Organization for Excellence in Health, Community Development Consortium and Social Foundation) the authors in- vited several community organizations to become part of a joint project.

The rationale for CxES was that implementation of PHC initiatives aimed at solving priority health needs requires the integration of multiple actors (decision makers, health institutions, academia, hu- man resources in health, and communities),[11,12] with the com- munity playing a major role in successfully leading and managing this type of initiative and adapting it to local conditions.[13,14] COPC is a n approach that places the community at the center of PHC; it enables concerted, community-based identifi cation of the population’s problems and needs and their solutions, transforming health services and improving local capacity to bring about behav- ioral changes in the population.[15–17] In Colombia, however, the population and local health department and hospital offi cials are barely aware of PHC and COPC concepts or the practical applica- tion of PHC-based initiatives.[13,18]

PAR was selected because it is a methodology oriented toward generating change in persons using collective experience as a starting point (beginning with an assessment of community needs and problems) through an intersectoral approach and planning and implementation of actions for health improvement. Both quantita- tive and qualitative methods can be used for PAR, which serves as the foundation of COPC because it contributes to community

Building Community Capacity in Leadership for Primary Health Care in Colombia Erwin H. Hernández-Rincón MD MS PhD, Francisco Lamus-Lemus MD MS MPH, Concepción Carratalá-Munuera MS DrPH, Domingo Orozco-Beltrán MD PhD, Carmen L. Jaramillo-Hoyos, Gloria Robles-Hernández

ABSTRACT Primary health care looks beyond clinical services to health promotion and primary prevention at the population level. In 2011, Colombia adopted a normative approach to primary health care, to advance efforts to set health priorities and transcend a curative, hospital-based system. An intervention was carried out in eight communities in Bogotá and Cundinamarca, Colombia to build community capacity to infl uence health. Activities included training community leaders to design and implement health improvement initiatives aimed at the most important health problems identifi ed by their organizations. Twenty-eight leaders completed the training. They designed and implemented eight health improvement plans to address the most important health problems in their respective communities: protecting public spaces for children’s physical activities, improving family practices in child nutrition, organizing a health insurance benefi ciaries’ health promotion network, organizing a

service delivery network for homeless persons, connecting people with cognitive disabilities to treatment services, combatting violence against women, working against child abuse, and integrating health education into school curricula. Lessons were learned about capacity-building in primary care, approaches to strengthening intra- and interinstitutional conditions, and managing processes for community ownership. The intervention enabled development of initiatives for solving various problems by different types of organizations, highlighted participants’ understanding of their role as health agents, and promoted community participation and intersectoral action.

KEYWORDS Primary health care, qualitative research, community health agents, community health planning, health education, community-based participatory research, Colombia

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contextualization, health assessment, prioritization, program imple- mentation, and ongoing evaluation and improvement.[16,19]

PAR is carried out in complex sociopolitical contexts where dia- logue and negotiation about objectives and means are integral to researchers building relationships with participating communities. In building such relationships, PAR encourages deepening local knowledge and stimulates interest in becoming part of research to better understand the community’s health. PAR increases the community’s understanding of its health status and empowers lo- cal actors to take committed action.[20] Its results are not limited to description but rather focus on action to improve public health practice, complementing common epidemiologic approaches and promoting capacity to conduct research at the local level.[21,22]

Participating organizations Organizations were recruited that were involved in various community actions addressing diverse health problems and vulnerabilities (children, people with disabilities, preg- nant women, older adults or victims of armed confl ict in Colombia). [5] Organizations were selected based on the following criteria: or- ganizational life (people in the organization work collectively toward a common goal and distribute responsibilities accordingly; develop- ment of actions oriented toward a specifi c goal and in a particular community); prioritization of collective over individual interests; and infl uence in the surrounding area—the organization’s territorial lo- cation.[23] The eight participating organizations included public, private, religious or charitable, and community-based groups: two grassroots women’s organizations in Soacha (Families f or Progress and the We Are Women, We are Families Association), one school in Sopó (Paul VI State School), four institutions providing services to vulnerable communities in Bogotá (Center for Stimulation and Devel- opment, Royal Friends Foundation, Child Welfare Association, and Medalla Milagrosa Ambulatory Care Center), and one institution with links to the rest (the Archdiocese Food Bank).

Activities Training community leaders for health initiative manage- ment Leadership trainers were eight professors from Universidad de La Sabana (three physicians and two nurses, all community health professors with master’s degrees and at least eight years’ experience in their respective professions) and the Community Development Consortium (a psychologist, a lawyer and a social worker, all with experience in social development in grassroots community organizations). Thirty leaders enrolled in the training, three or four selected by each organization based on the following criteria: current membership, responsibility for developing actions related to health or its determinants, length of time in the organiza- tion, interest, and time commitment. Training was based primarily on COPC principles[15] and Universidad de La Sabana’s com- munity health experience. A modular, cyclical training process was designed to give leaders an opportunity to refl ect on their under- standing of PHC and COPC concepts, and to identify problems and needs in their communities.[10,17,24−26] The training lasted a total of 20 weeks over six months in weekly fi ve-hour sessions using a variety of pedagogical techniques including master classes, prac- tical demonstrations, debates, case studies and problem-based learning, supported by an online learning platform for complemen- tary asynchronous refl ection and discussion outside meetings.

Development and implementation of organizational improvement plans As part of the training, each organization developed and sub- mitted a proposal for an improvement plan to address one priority problem. Once each proposal was formulated, it was implemented

based on the principles covered in the training (16 months) (Table 1). Four tutors or facilitators supervised and participated (known as accompaniment) in practical implementation of the plans until the end of the project. Tutors were professors of community health at Universidad de La Sabana (three public health physicians and one public health nurse, all with master’s degrees), who were selected for having at least fi ve years’ experience in community health actions.

Systematization of experiences and extraction of lessons learned Systematization was carried out simultaneously with the other two activities and throughout the process (a progress and adjustment report refl ecting achievements and challenges midway through the process, and a fi nal report on achievements, challenges and commit- ments). Content analysis was carried out on all reports, as well as photographic records, meeting notes, fi eld journals and recordings of each plan’s activities. This activity involved analytical refl ection and reconstruction, leading to knowledge generation from and for practice, through extraction and comprehension of lessons learned.[27,28]

An external team from the Community Development Consor- tium (an economist and a psychologist with experience in social development and qualitative research who were not part of the training and planning team) conducted systematization. They held semistructured interviews, triangulated data from all sources, obtained lessons learned from the pedagogical process, and re- viewed and performed content analysis on documents generated by the organizations (community description and needs assess- ment, improvement plan, progress and adjustment reports, partial results, and fi nal reports). The four tutors and one representative of each organization were interviewed based on an open-ended question: What factors enable or limit citizen capacity-building, generating a sense of ownership in the community and the terri-

Table 1: Training modules, content and topics

Preparation (weeks 1–5) Introduction to basic concepts and CxES approach (PHC, COPC, PAR, health promotion, disease prevention, community leadership, health legislation in Colombia) Building trust and community (weeks 6–7) Building trust to develop community work (trust, knowledge of the community, knowledge of family and community health) Situational assessment (weeks 8–12) Determining problems, needs and priorities of each community (health situation assessment, health planning, health needs, community health diagnosis, epidemiology, demography and population, priority setting, problem rationales, problem analysis) Preparing the work (weeks 13–15) Development of proposed so- lutions or interventions for problems identifi ed (project management, educational and intervention techniques, information gathering, inter- sectoral action, design of health improvement plans) Field work (week 16) Strategies to deal with situations arising after implementation (teamwork, negotiation and confl ict resolution) and specifi c themes (disease groups, life cycle) Evaluation and adjustment (week 17) Assessment of work so far (social and community participation, data collection and analysis) Work sharing (weeks 18–19) Strategies for dissemination and com- munication of processes and community intervention results, health communication, research dissemination, report writing) Sustaining and improving the work (weeks 19–20) Factors that en- sure initiatives’ continuity and sustainability (proposals for continuity, sharing of improvement plans)

COPC: community-oriented primary care CxES: Citizenship for Healthy Environments PAR: participatory action research PHC: primary health care

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tory for building a healthy environment? Three analytical categories were defi ned: (1) citizen capacity-building for PHC (individual and collective competencies to be developed in grassroots PHC com- munity managers); (2) intra- and interinstitutional conditions—or- ganizational and community factors needed for creation of healthy environments; and (3) sense of ownership—elements that foster behaviors contributing to healthy environments.

Data were organized and validated by two people from the systematization team, two tutors and two members of participating organizations, who identifi ed lessons learned in each category. This activity was ongoing throughout the process but most intensively in the six months following implementation.

Ethics All organizations gave written informed consent to par- ticipate, by means of a voluntary agreement setting out their un- derstanding that the project originated in the community, whose participants and organizations were the owners and active subjects of the process.[29]

RESULTS AND LESSONS LEARNED Training of community leaders Of the 30 leaders who initiated train- ing, 28 completed it (93.3%). Training objectives were met, including comprehension and explanation of their reality based on assessments of their communities’ principal needs and problems (Table 2). The train- ing phase included their designing improvement plans and leaders expressly committing to lead their organizations in implementing them.

Organizational improvement plans Once each organization had defi ned their problems and needs, they designed an improvement

plan related to one problem, defi ned by type of social response, vulnerability addressed and organizational characteristics. In all eight improvement plans, interventions were based on promoting healthy lifestyles, improving living conditions and fi nding opportuni- ties for participation. The main results were evaluated per objec- tives, achievements and indicators set forth in the planning stage, using quantitative and qualitative instruments according to each organization and topic (Table 3).

Systematization In the citizen capacity-building for PHC category, organized actions regarding PHC were understood in direct relation to participants’ empowerment as central actors in health promotion, disease prevention and a culture of self-care. The aforementioned empowerment results were facilitated by having taken on a community health initiative based on organizations’ protagonism in identifying their own PHC needs and strategies for action, by breaking with the dynamic usually found in non– community-oriented interventions. Changes were observed in perception of health as a collective matter, in which the subjects are protagonists in generating healthy community environments, helping overcome a hospital-centric vision. Throughout the training process and during plan implementation, it was observed that, as part of the PAR process, organizations made a clear conceptual and practical differentiation between disease prevention and health promotion, the latter understood as a collective matter and not the exclusive purview of the health system.

In the intra- and interinstitutional conditions category, it was em- phasized that sustainability of building healthy environments with community participation requires a regional approach and not only

training of people and organizations to act as replicators in their surroundings. This was because improvement plans were limited by organizational characteristics and did not in- volve all sectors in their context, health institu- tions among them. Given the heterogeneity of organizational contexts, these were expected to have only modest infl uence in their terri- tory. At the same time, such heterogeneity was useful for comparing different experiences to generate lessons learned for creation of a PHC model with community participation.

Intersectoral work in PHC may be oriented to- ward infl uencing policies as well as broadening and improving the quality of interest groups’ ac- tion strategies. Throughout the training and ac- companiment process, participants displayed an interest in connecting with other actors they had not initially considered infl uential for achieving healthy life styles; this interest en- abled leaders to facilitate opening new spaces for participation by other community members. Initiatives for creating alliances and seek- ing opportunities for greater infl uence in their surroundings varied by type of organization, organizational structure, fl exibility for change and ownership of PHC’s conceptual framework (Table 3).

In the sense of ownership category, commu- nity leaders expressed and refl ected in the im-

Table 2: Community leader training results

Aspect Indicators and results (8 organizations, 30 leaders, 20 sessions) Face-to-face activities

Satisfactory participation and performance in 95% of sessions (fulfi lling theme objectives and following training process thread), 93.3% (28/30)

Online activities Participation and completion of followup and support activities, 86.7% (26/30)

Main lessons learned (at conclusion of process)

Health: understanding that health is not limited to physical health but involves interaction among >3 components (physical, mental, social, cultural, spiritual), 93.3% (28/30) PHC: understanding overall concept from perspective of Alma-Ata and as fundamental to maintaining population health, 93.3% (28/30) Health promotion: understanding that health promotion is not about disease and highlighting importance of self-care, 100% Community health: need to solve community problems together recog- nized, 93.3% (28/30) Healthy environments: environment’s importance for health empha- sized, 93.3% (28/30)

Completion and approval

28 community leaders

Products

Each organization satisfactorily submitted three requested products. Context report: description of context, community characteristics and possibilities for coalitions Situational assessment: community needs assessment based on literature review, local and national regulations, review of documented socioeconomic, epidemiologic and demographic factors, and other sources of information, depending on the organization List of needs and problems obtained, from which one was selected by agreement among organization members Improvement plan: selected problem validated and examined more deeply; intervention objectives and actions defi ned and scheduled based on a logic model

PHC: primary health care

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Table 3: Community improvement plans by issue, reach and main results Community (description) Issue or problem Reach Results

Royal Friends Foundation (child nutrition, Usaquén, Bogotá)

Diffi culty accessing public space (parks) because of lack of safety and maintenance (a limitation for physical activity for different age groups)

Direct: 689 children and families in various Foundation programs Indirect: Usaquén population 475,000 (target population 114,000 reproductive-age women and 58,000 children aged <9 years)

• Mutual knowledge and support by allied social actors • More physical activity in local parks • Creation of institutional networks for recovery of public

spaces for physical activity • Raised community awareness of self-care in adoption of

healthy behaviors and environmental transformation • Opening of public spaces for citizen participation to combat

gang violence • Increased children’s knowledge of importance of recycling

and care of the environment

Child Welfare Association (daycare center for vulnerable children, Suba, Bogotá)

Poor nutritional practices in families of children in daycare center

Direct: 217 children and 355 parents

• More parental interest in good nutrition for their children • More family participation in growth and development of

children. Greater family awareness of good nutritional practices

• Parents provided with tools on healthy eating habits • Improved children’s quality of life

Archdiocese Food Bank (food bank, Bogotá)

Lack of coordination of service network for specifi c needs of client population

Direct: 801 organizations Indirect: 113,742 persons (73,657 children, 14,209 families)

• Strengthened healthy experiences in clients on themes of healthy eating and behaviors, physical activity and self- care

• Intervention in benefi ciary organizations: organizational strengthening, health and nutrition, accompaniment

• Comprehensive approach to food security

Medalla Milagrosa Ambulatory Care Center (services for homeless persons, Los Mártires, Bogotá)

Need for interinstitution- al networks supporting quality of services

Direct: citizens living on the streets (approximately 100, variable), persons with addic- tions, immediate families, and the Center’s interdisciplinary team

• Updated Center vision, mission and objectives with PHC focus

• Participation in district-level task forces with Health Depart- ment, Social Integration Department, Volunteer Committee

• Strengthened healthy behaviors in homeless persons • Strengthened interinstitutional networks • Clients empowered by recognition of their social capacities

and capabilities

Stimulation and Development Center (services for persons with cognitive disabilities, Teusaquillo, Bogotá)

Need for favorable settings for families; students and teachers to conduct therapeutic in- terventions that develop potential of persons with cognitive disabilities

Direct: families, teachers and students linked to the Center in Bogotá and Cundinamarca

Indirect: external community (potential clients, persons and institutions interested in cogni- tive disabilities)

• Improved quality of organizational services for greater con- sistency with institutional vision and mission

• Greater interest and participation by families, caregivers and academics in intervention and management processes with clients

• Increased requests from academic institutions for training practicums in disabilities at the Center

• Intervention on social and family aspects of antenatal care and early childhood care for disease prevention, especially cognitive disability

• Greater interest by Center clients, families and employees in development of behaviors to improve quality of life

Families for Progress (women working with families affected by violence, Soacha, Cundinamarca)

Gender-based violence

Direct: 38 women leaders, Comuna 1, Soacha

Indirect: 114 relatives of wom- en (husbands and children)

• Strengthened self-esteem and awareness of tools for pre- venting violence (Law 1257) reported by all women

• Able to respond and reinforce lessons learned reported by 31.6% (12/38) of women

• Organizational strengthening: revised statutes, structure, internal policies, in keeping with mission

• 6 community-wide workshops, 2 on self-esteem and 4 on Law 1257

Paul VI State School (school for children aged 4–18 years, Sopó, Cundinamarca)

Diffi culty of developing life skill and health pre- vention habits in family and school settings

Direct: 955 pre-school and primary school children (urban and rural) and 31 teachers.

Indirect: 1750 students, 66 teachers and administrators, students’ families and munici- pal administrators

• Improved basic knowledge of ARD and prevention mea- sures, 75.2% (718/955) of children

• Teachers’ recognition of importance of knowledge of ARD prevention; some know when to seek medical help

• Improved knowledge of healthy behaviors, healthy eating, physical activity, hygiene and their benefi ts for children, 80.6% (25/31) of preschool and primary teachers

• Integration of health themes into curricula (initiated) • Connections made with municipal health and education

departments for development and replication of initiative throughout municipality

We Are Women, We Are Families Association (women organized for protection of women and families, Soacha, Cundinamarca)

Child abuse and its implications

Direct: 51 participants from Comuna 1 in Soacha.

Indirect: neighborhood commu- nities, especially participants’ families

• Increased members’ knowledge of child abuse • Increased mothers’ awareness of protection and care,

childrearing guidelines • Application of new knowledge within members’ families • Creation of discussion forum with mothers and families

about recognizing types of child abuse and importance of infant attachment

• Establishment of child abuse documentation center ARD: acute respiratory disease PHC: primary health care

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provement plans that family and nutrition are two central elements in community ownership of healthy lifestyles and environments. Nutrition was not given special emphasis during the training pro- cess or in drafting improvement plans, but organizations made it a central focus of their initiatives. This may suggest that nutrition is a fundamental fi rst step in developing community ownership of healthy lifestyles. Organizations certainly considered nutrition a main driver and promoter of healthy behavior within families.

One of the main factors infl uencing the sense of ownership of healthy lifestyles and environments is related to organizations’ communication mechanisms and strategies. The experience dem- onstrated the effects of organizations’ participation in local discus- sion forums and community radio to present ideas, challenges and strategies promoting the concept of health as a social construct requiring broad participation.

General lessons This project demonstrates the potential impor- tance of community participation in developing health programs and confi rms the utility of working with preexisting social capital to foster community empowerment.[30,31] PAR methodology fa- vored development of PHC action in organizations, guaranteeing the initiatives’ continuity and adjustment to the COPC conceptual framework,[10,17,19] as well as enabling community members to claim ownership of the research. The intervention showed that developing community-based health initiatives is possible and can generate greater sustainability and sense of ownership.

Experiences in Colombia have traditionally focused primarily on top-down or institutional PHC initiatives rather than on integrating the community at the grassroots level.[13,18] It is therefore im- portant to involve all the actors in order to strengthen PHC initia-

tives and meet the population’s health needs.[11,15] A community participation approach to building healthy environments requires overcoming an excessive focus on health care services, which can encourage people to depend on treating specifi c ailments rather than addressing their fundamental vulnerabilities and improving their health (bearing in mind the importance of including the hos- pital sector to achieve more comprehensive plans). Linking orga- nizations with PHC training and action processes does not in itself guarantee that the process will include all social actors present in a community, nor that it will bring about tangible changes in health status, but needs to be matched with changes to social determi- nants and generation of community leadership and empowerment.

CxES contributes important lessons for implementing Colombia’s new, legislatively mandated,[7] comprehensive health care mod- el,[32] which includes prevention, promotion, diagnosis, treatment and palliative care, all under a local approach in which the com- munity plays a key role. It facilitated and evaluated development of primary care initiatives in different types of organizations to ad- dress a variety of problems. In all cases, participants demonstrated comprehension of their role as health agents, promoting commu- nity participation and intersectoral action. Forming alliances among community actors, health services and academic institutions that train human resources is equally important for achieving knowledge transfer to all necessary social actors, thus ensuring sustainability of PHC-based health systems.

ACKNOWLEDGMENTS The authors thank participating communities and their leaders and organizations, as well as the tutors and facilitators who accompa- nied the CxES process.

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THE AUTHORS Erwin H. Hernández-Rincón (Correspond- ing author: [email protected]; amsic [email protected]), public health physician with master’s degrees in health system governance and management and in primary care research, and a doctorate in clinical research. Center for Studies in Community Health (CESCUS), Uni- versidad de la Sabana School of Medicine, Chía, Colombia.

Francisco Lamus-Lemus, pediatrician with master’s degrees in public health and applied de- velopment, CESCUS, Universidad de La Sabana School of Medicine, Chía, Colombia.

Concepción Carratalá-Munuera, nurse with a master’s degree in nursing and doctorate in public health, Department of Clinical Medicine, Miguel Hernández University Division of Medi- cine, Alicante, Spain.

Domingo Orozco-Beltrán, physician special- izing in family and community medicine, with a

doctorate in medical sciences, Department of Clinical Medicine, Miguel Hernández University Division of Medicine, Alicante, Spain.

Carmen L. Jaramillo-Hoyos, psychologist spe- cializing in knowledge management, Community Development Consortium, Bogotá, Colombia.

Gloria Robles-Hernández, economist special- izing in regional development and in economics, plan ning, systematization of experiences, fol- lowup and evaluation, Community Development Consortium, Bogotá, Colombia.

Submitted: December 1, 2016 Approved for publication: June 9, 2017 Disclosures: Citizenship for Healthy Environ- ments was a Joint Project of Colombia’s Corona Foundation, Universidad de La Sabana, Organi- zation for Excellence in Health, Consortium for Community Development and Social Founda- tion from 2012 through 2014. Preparation and submission of this article is part of a research project, Comprehensive Primary Health Care in Colombia: A Regional Focus to Address Chronic Non-Communicable Diseases, funded by an internal call for proposals of Universidad de La Sabana (MED-187-2014).

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