Health Care system in Colombia

Nursing Inquiry. 2018;25:e12242. wileyonlinelibrary.com/journal/nin  |  1 of 8 https://doi.org/10.1111/nin.12242

© 2018 John Wiley & Sons Ltd

The result is that people come to feel quite happy in their oppression like the prisoner who after 10 years in jail de- cides it is not such a bad place, with its warm bed and three meals a day (David Smith, 1999)

1  | INTRODUC TION

Sometimes, as with the prisoner, we just give up trying to know what is beyond the bars. Why? Perhaps we are satisfied with the way we are living or we encounter an overwhelming sense of not knowing what we would do if we were free. We then become like the prisoner who considers after 10 years that he only needs a

warm bed and three meals a day. Is this the easy way to feel safe in the world? How is it possible to feel fulfillment when our world is limited by others?

Living in the world is a unique experience for all. What do we do, however, when the experience involves marginalization, alien- ation, or oppression? Judgments must be made, and actions must be taken to bring about positive change in those situations. In the current era of globalization, political power has changed its task to that of administering life as the machinery of production, and human beings, as the centerpiece of globalization, must adjust to the exigencies of the individualized, competitive, and consumer- ist market to survive (Bourdieu, 1998). In addition, economic de- velopment as a result of privatization of services has had serious effects on the quality, accountability, distribution, access, and

Accepted: 11 March 2018

DOI: 10.1111/nin.12242

F E A T U R E

Understanding the space of nursing practice in Colombia: A critical reflection on the effects of health system reform

Pilar Camargo Plazas

School of Nursing, Queen’s University, Kingston, ON, Canada

Correspondence Pilar Camargo Plazas, School of Nursing, Queen’s University, Kingston, ON, Canada. Email: [email protected]

Worldwide, healthcare has been touched by neoliberal policies to the extent that it has some of its characteristics, such as being asymmetrical, competitive, dehuman- ized, and profit driven. In Colombia, Law 100/93 was created as an ambitious reform aimed at integrating the social security and public sectors of healthcare in order to create universal access, and at the same time to generate market competence with the objective of improving effectiveness and responsiveness. Instead, however, Colombian health reform has served to generate competition which has aggravated inequalities among people. Within this context, we practice nursing. As nurses, our responsibility is to advocate for our patients. We cannot ignore what is happening worldwide in hospitals and community health settings because our responsibility is to promote health, prevent disease, and care for human beings. So, today, when the world pushes for economical profit and competence on one hand, and, on the other, for moral compromises to care, respect, and advocacy for all human beings, being a nurse in the Colombian health system represents a challenge for us. This challenge is especially significant because harm and benefit, justice and injustice, respect and disrespect are separated by a fine line that is easy to transgress.

K E Y W O R D S

globalization, health inequities, health reform, neoliberalism, nursing practice

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equity of health and social systems around the world (Rotarou & Sakellariou, 2017). As such, the implementation of neoliberal reg- ulations in the area of health and the deterioration of the welfare state has led us to forget that health is considered a human right (Vargas Bustamante & Mendez, 2014). Healthcare has been seri- ously altered by globalization and neoliberal policies and has gained negative characteristics, such as being asymmetrical, competitive, dehumanized, and profit- seeking. Health, as a part of the economic, social, and political forces, benefits development and plays a key role in achieving development. However, the unequal distribution of healthcare resources affects the lives of people and their free- dom. If health and life are considered human rights, why are human beings worldwide exposed to disparities that affect their rights to health, life, and well- being?

Most healthcare systems worldwide promote universality; under this principle, all citizens are provided with preventive and curative care (Camargo Plazas & Cameron, 2015; Camargo Plazas, Cameron, & Smith, 2012; Rotarou & Sakellariou, 2017). Universality is an ad- mirable principle; however, in reality, many people have to face re- strictions and sometimes lack access to healthcare. The Colombian health system promotes universality and access to healthcare; under these healthcare principles, citizens should be provided with pre- ventive and curative care. Colombia’s health system was changed as a part of wider state reforms and as a consequence of external pressures; its programs and interventions address external priorities at the expense of integrated approaches that incorporate internal realities such as the social determinants of health (Camargo Plazas et al., 2012). Clearly, healthcare should be addressed for more than economic purposes. Furthermore, healthcare systems need to build a more symmetrical and humane system that gives equality and ac- tual commitment based on the universal principles they promote. This commercialization changes the scale of human values; compas- sion, respect, and equality are low priorities, because they do not produce economic rewards (Camargo Plazas et al., 2012). Thus, de- spite the ethical issues, healthcare is a victim of global disparities and economic progress.

Within this context, we practice nursing. Over the last 20 years, our nursing practice has been influenced by the changes imposed by neoliberal policies in the healthcare system (Malvarez & Castrillon Agudelo, 2005). In nursing, we claim that care is the opposite to in- difference. Indeed, care expresses itself as something natural, nei- ther imposed nor contrived; it just appears, connecting two people in a unique moment that emerges from empathy, creating bonds and connections in a singular way. Through our actions, we can give the best of our practice. The idea of our attention is to bridge the gap between health professionals and patients. Are our actions congru- ent with our essence? Should nurses adapt their practice to the pri- orities of consumerism, competitiveness, and profit- driven policies established by health reform? As (Smith, 1994) says, “the idea is to get people in touch with precisely those parts of their experience which lie beyond, behind, underneath, and above the superficial pleasures of merely getting by” (p. 148). Through this paper, my idea is to get in touch with all aspects and dimensions of the practice of

nursing in Colombia. To do so, I first describe the definitions of glo- balization and neoliberal policies. Then, I continue with a description of the Colombian health reform, discussing the nursing practice in Colombia and conclusion. I have tried to understand the space of our practice. Etymologically, the word space comes from the Latin word spatium, meaning place in respect of distance or extent. I discuss the extent of the space in which nursing practice in Colombia exists and moves.

2  | GLOBALIZ ATION AND NEOLIBER ALISM

Globalization describes the process of greater expansion and mutual integration of markets across political boundaries of nation- states (Labonte et al., 2015; Martens, Akin, Maud, & Mohsin, 2010). The interdependence of world economies is the result of the increased flow of goods, services, capital, and the rapid and expansive spread of technologies (Labonte et al., 2015; Martens et al., 2010). Since the 1970s, globalization has challenged the political, economic, and technological landscapes and has transformed the social, cultural, and environmental spheres of many societies around the world (Labonte et al., 2015; Soleymani, 2010). Because of various perspec- tives, globalization is always at the center of overlapping debates. One debate is oriented toward exploring the potential effects, either positive or negative, of the global integration of finance and produc- tion (Labonte et al., 2015). This debate is framed by a broader issue that questions whether or not the interconnectedness of globaliza- tion has benefited most individuals and communities in the world (Bloom, Henson, & Peters, 2014; Brown & Labonte, 2011; Labonte et al., 2015). A different debate explores the effects of integrating markets in the healthcare sector (Labonte et al., 2015). Evidence shows that economic integration has generated profound changes that have redefined how international health agencies, financial in- stitutions, states, government agencies, transnational corporations, non- governmental organizations, public and private healthcare sectors, healthcare professionals, and other affinity- based organi- zations, communities, households, and individuals operate and in- teract with each other (Bloom et al., 2014; Brown & Labonte, 2011; Labonte et al., 2015). Economic globalization is regulated by neolib- eralism, which is defined as an economic theory favoring free trade, privatization, minimal government intervention, and reduced public expenditure on social services (Harvey, 2005; Navarro, 2009; Smith, 2010).

The assumption in neoliberalism is that economic growth and unhindered welfare are the result of free markets, privatization of companies, and services with limited government intervention (Bell & Green, 2016; Bockman, 2013). This gives primacy to the in- teractions between individuals and markets. Neoliberal economic theory espouses the welfare- maximizing consequences of market exchange. Under neoliberalism, a role of governments, local authori- ties, and institutions is the development of guidelines and regulatory frameworks that allow global markets to successfully function (Bell

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& Green, 2016; Rotarou & Sakellariou, 2017). Then, government is deemed as less able and effective than private institutions at de- livering social services, including health and education. This results in the slashing of welfare spending of governments, increasing pov- erty and inequality. Liberalism stems from the work of Adam Smith’s The Wealth of Nations, where he encourages minimal government intervention in the economy so that trade can flourish (Rotarou & Sakellariou, 2017). This liberal view of economy dominated for the following 150 years until it was replaced in the 1930s by Keynesian economics. Keynesian economics endorsed a mixed economy in which the private sector could function with an interventionist role of the government, especially during recessions (Rotarou & Sakellariou, 2017). This economic model was the standard followed by high- income nations from the later part of the Great Depression until the oil crisis in the 1970s. At this point, neoliberalism emerged in the economic and political debate with the introduction of neolib- eral economic theories by Friedrich Hayek and Milton Friedman, and neoliberalism then spread after the elections of Margaret Thatcher in the United Kingdom and Ronald Regan in the United States (Bell & Green, 2016; Rotarou & Sakellariou, 2017).

In the 1990s, under the guidance of international institutions such as the International Monetary Fund (IMF) and the World Bank, middle- income and low- income governments were forced to limit their interventionist role; instead, they proceeded to reduce capital controls and massive and unregulated privatization of state enter- prises and to limit social welfare. Both institutions introduced the Washington Consensus, a set of economic policy prescriptions for middle- income and low- income countries. These economic prescrip- tions imposed by the IMF and the World Bank opened the econ- omy of the world to neoliberalism (Mukhopadhyay, 2013; Rotarou & Sakellariou, 2017; Vargas Bustamante & Mendez, 2014). Confidence in neoliberal policies as the only way to invigorate the economy faded away in the 1990s when the Washington Consensus received negative results, as there was no indication that neoliberal policies had indeed produced economic growth (Hartmann, 2016; Rotarou & Sakellariou, 2017). As such, neoliberalism has been pinpointed as the main culprit behind the increases in socioeconomic disparities, high rates of poverty, unemployment, and violence, worsened work- ing conditions, and reduced social security (Rotarou & Sakellariou, 2017).

Scholars have considered health a productive asset that affects the economic growth of any nation (Hartmann, 2016; Mukhopadhyay, 2013), and the market- based dominance of healthcare is a relatively recent phenomenon in many countries throughout the world. Before the imposition of neoliberalism in the mid- 1970s, health was con- sidered a public good and responsibility of governments (Hartmann, 2016; Rotarou & Sakellariou, 2017). In Latin America, health and so- cial security reforms promote the development of basic benefit pack- ages, target basic care to the poorest, and stimulate the involvement of private companies in the provision of healthcare insurance and services (Vargas Bustamante & Mendez, 2014). However, the pro- vision of care by private conglomerates has had serious effects on the quality, accountability, cost, access, and equity of health systems

around the globe. Private companies focus on increasing profits and not on providing affordable and good- quality care, leading to dete- riorated health systems, increased urban- rural divide, and increased inequalities of access to healthcare services (Mooney, 2012; Rotarou & Sakellariou, 2017; Vargas Bustamante & Mendez, 2014). The regu- lation of health systems and the welfare state by neoliberal policies makes it difficult to define health as a basic human right (Rotarou & Sakellariou, 2017). Yet, neoliberalism perceives healthcare sys- tems as commodities where productivity and economic growth are the sources of potential revenue. In neoliberalism, health systems cannot be public and social goods. Institutions such as the IMF and World Bank promote healthcare systems with a market- oriented concept in which reductions in public sectors and the introduction of user fees and other costs reduce access to healthcare for the poor (Mooney, 2012; Rotarou & Sakellariou, 2017). As such, neoliberalism has brought devastating consequences, including the widening so- cial disparities and the concentration of income and wealth among a few (Navarro, 2009).

3  | THE COLOMBIAN HE ALTH REFORM

In 1993, the Colombian government introduced its market- oriented healthcare reform (Arroyave, Cardona, Burdorf, & Avendano, 2013; Bernal, Forero, & Forde, 2012; Bernal & Zamora, 2014). The main goal of the health reform addressed the funding crisis in the pub- lic social security institute through increased healthcare spending while increasing coverage by encouraging the participation of pub- lic and private service with regulated competition (Arroyave et al., 2013; Bernal & Zamora, 2014; Londono & Molano, 2015; Vargas Bustamante & Mendez, 2014). The Colombian healthcare system is financed through a combination of payroll contributions and general taxation. The comprehensive national insurance scheme includes a contributory regime for those able to pay and a subsidized scheme for low- income individuals. Users enroll with public or private insur- ers, have legal rights to an explicit package of health benefits, and receive care from a mix of public and private providers. Furthermore, Colombian citizens who are employed and independent workers earning more than a predetermined minimum income must enroll in the contributory health insurance regime. Low- income individuals are identified through a proxy means test (Bernal & Zamora, 2014). Benefits from the health reform included increased coverage, de- creased individual spending, and better insurance equity (Arroyave et al., 2013; Bernal & Zamora, 2014; Cucunuba et al., 2017).

Despite these benefits, the health reform has received some criticism. The reform has increased the complexity of the healthcare system, potentially leading to delays in access to health services and reduced spending in prevention and public health (Arroyave et al., 2013). The system has also been threatened by the increased af- filiation of citizens in the subsidized scheme or those who do not contribute to the system. Thus, even though the benefit plan is equal, the value per capita paid by the general system of health to each insurance company is not equal, decreasing the leadership and

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legitimacy by the Ministry of Health (Bernal & Zamora, 2014; Bernal et al., 2012). The health system lacks preparation for the social re- ality of Colombia, which experiences typical changes of transitional societies such as an aging population, decreasing fertility, rapid ur- banization, and the persistence of infectious diseases with concomi- tant increasing of chronic conditions (Wesbter, 2012).

The health reform in Colombia shifted the financing and pro- vision boundary between public and private services following im- posed neoliberal policies. Although the health reform was an attempt to guarantee the fundamental right to health for all Colombians (Londono & Molano, 2015), there is still much to do and improve. The practical application of the health reform has shown signifi- cant disconnectedness between the public health approach and the market- driven vision of the government (Londono & Molano, 2015; Vargas Bustamante & Mendez, 2014). Currently, the healthcare sys- tem requires a structural reform that is independent from the private sector. As such, swapping the goal of the health system from being profit driven to providing health benefits makes health not merely a legal statement (Londono & Molano, 2015).

4  | NURSING IN COLOMBIA

Nursing started in Colombia as a vocation practiced by Catholic nuns and monks. The first course for midwives was started on 22 September 1867 in the National University in Bogota. At the end of the 19th cen- tury and the beginning of the 20th century, the art of nursing was taught by physicians, nuns, and philanthropic women from prestigious families of Colombia (Velandia Mora, 1995). The first school for nurs- ing started in 1924 in Cartagena at the Santa Clara Hospital, and that course was initiated by two physicians, Drs. Jose Caballero and Rafael Calvo. Dr. Calvo had been to France and, impressed with how nursing was organized there, decided to establish the same method of training. As with others around the world, the initial school was established in the style of Florence Nightingale’s school (Velandia Mora, 1995).

Meanwhile, in Bogota, the same kind of patron system of nursing schools was developed. Women from wealthy families were the first students at those schools and, from 1929 to 1932, the government addressed the organization of nursing schools that were part of the faculties of medicine. Those schools were characterized by their discipline, uniform, and rules that were reminiscent of the convents (Velandia Mora, 1995). Another important fact concerns how schools were divided with respect to specialties. For example, in Bogota, the school was hospital based, while the Cartagena school focused on public health. In 1937, the National University of Colombia in Bogota was reorganized to improve the course of nursing and transferred the program from the San Juan de Dios Hospital to the new San Jose Hospital. Two types of education were developed: One type was for nurses who visited patients at home (the origin of the social worker in Colombia), and the other type was for hospital- based nurses.

At this time, nursing acquired the status of a profession in Colombia (Velandia Mora, 1995). Colombia had always looked for ad- vice in nursing from other countries from 1935 to 1954, but in 1935,

Helena Samper, a Colombian nurse trained in the USA, returned to Colombia and became the director of the faculty of nursing. The fac- ulty started to become autonomous, but in 1939, Samper died and the faculty was again directed by a physician. Although the faculty was part of the university, the entity in charge of the faculty was the Ministry of Health (Velandia Mora, 1995). In 1942, PAHO sent to two nurses Bogota, the Canadian Helen Howitt and the American Johanna Schwarte, to advise the faculty of nursing in the National University. In 1945, the faculty left the Ministry of Health and started to be part of the university, and Helen Howitt served as dean of the faculty of nursing until 1957 (Malvarez & Castrillon Agudelo, 2005).

In 1946, the government determined the modalities of schools in nursing education as follows: The first group included general nurse and clinical nurse as 3- year programs and specialist nurse as a 4- year pro- gram; the second group included auxiliary nurse, clinical auxiliary nurse, auxiliary midwife nurse, and helpers as 1- year programs (Velandia Mora, 1995). In 1961, a 4- year professional study program was created at the National University. This degree focused on establishing nursing teach- ers by having nurses in a 3- year program take an extra course. Nursing education continued to focus on public health and hospital- based nurs- ing through the 1960s. This trend of 4- year programs for professionals and 12 months for auxiliaries has continued over time (Velandia Mora, 1995), although today, undergraduate programs are all 5- year programs.

In terms of education, in Colombia the Asociación Colombiana de Facultades de Enfermería (ACOFAEN) [Colombian Association of Faculties of Nursing] oversees accrediting nursing programmes. In 1980, there were 13 universities with nursing programs; in 2004, the number of universities increased to 30. To date, 50 nursing pro- grams have been created but only 47 fulfill the regulations of quality established by ACOFAEN. Colombia also has a long- standing tradi- tion of graduate education. Master’s degrees and specialization de- grees have been available for over 30 years (Malvarez & Castrillon Agudelo, 2005; Velandia Mora, 1995). The doctoral program was also developed in the 2000s. Law 266/1996 and Law 911/2004 are the legislative frameworks established to regulate the practice of nursing in Colombia. Law 266 constituted the National Council of Nursing and established the Tribunal for Nursing Ethics. It defined the aims and principles of professional practice, competencies, re- sponsibilities, quality of care, and the nature and scope of the prac- tice. It also established the unique national license for professionals. Before this law, registration was regulated and handled by the gov- ernment. In addition, Law 911 defined the ethical and disciplinary re- sponsibility of nursing professional practice. However, these laws do not regulate nursing salaries, working hours, and the range of duties for professionals; thus, employment conditions continue to be reg- ulated and controlled by national legislation that also includes other health workers (Malvarez & Castrillon Agudelo, 2005).

5  | NURSING PR AC TICE IN COLOMBIA

Nursing is a profession centered in human beings. To watch and learn about the individual, we need to understand the life of a patient as a

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whole, and by understanding the life of a patient, nurses can address their efforts toward specific necessities. In nursing, we go beyond what is affecting that unique human being, because it is not possible to generalize the situation of a person; for example, not all diabetics suffer the same symptoms. We cannot observe the disease to under- stand the person; in nursing, it is necessary to see the person to take care of the disease. As nurses, we open our eyes to the experience of the other. In nursing, caring for the other is a moment of mutual accomplishment between nurse and patient. It is a moment when care is the bridge between two worlds. In addition, it is a moment with one goal—the recognition of the other through the vicarious experience of illness. Through these interactions, we get to know what it is like to experience health and illness (Camargo Plazas & Cameron, 2015; Camargo Plazas et al., 2012). As human beings, we need one another to survive, and our actions toward others need to be based on understanding the perspectives and vulnerabilities of others (Cameron, Carmargo Plazas, Salas, Bourque- Bearskin, & Hungler, 2014). Consequently, the interaction implies being a part of the world of other people, and the interchange experience is always under parameters of mutual respect and recognition.

Are our actions always congruent with our essence? To answer this question, I present a particular nursing situation that occurred in an emergency setting in Colombia. This story evolved from a critical hermeneutic phenomenological study investigating the experience of living with a chronic illness in the age of globalization in Colombia and Canada (Camargo Plazas, 2011). Hermeneutic phenomenology explores the various dimensions of human experience in human situ- ations such as embodiment, spatiality, relationality, and temporality. Critical pedagogy as a theoretical perspective invoking the work of Paulo Freire and Enrique Dussel was used to examine emerging find- ings in the context of globalization and its resulting global inequities. Hannah was the youngest participant of the study, and she was 26 when we met. She had been living with chronic illness for 10 years of her life. Despite her young age, Hannah has gone through many difficulties. In particular, many bad experiences with healthcare pro- fessionals, friends, and some relatives have shaped her experience with the illness. She became a nurse to fight the indifference she suffered for a long period in the healthcare system. The following story portrays Hannah’s perception of what nursing care is when she is a patient and her reflection of what a nurse should be.

They were running from one side to the other, moving patients from one side to another, all except me. It was complete chaos. I understand they were busy, but I was ill and I just needed at least one stretcher to rest my pain- ful body. I kept trying to call them, but nothing resulted. After 2 hr of being in pain, I called my mom, who was outside in the waiting room, just to see a friendly face. My mom, on her way in, talked to the nurse and told her, “My daughter is your colleague. She is a nurse too and she is suffering. She is in pain. She cannot wait any lon- ger in a wheelchair. Please help her”. The nurse answered back with indifference, “Sorry, it’s not my problem. Her

problem is the doctor’s problem.” I know it was not her problem, because it was not her body, the one in pain. It was my body, the one in pain. I was the one in pain. I was just asking for a little compassion. It is sad to see how we are prepared for one thing, but in practice, we do a dif- ferent one. As a patient, in my moments of vulnerability I like to see that there are friendly faces for me. When you are ill you always need a friendly hand helping you to go through the moment of crisis. During the moments of illness, what someone needs is support, a friendly hand that lets you know everything is going to be all right. When you are a patient, you need a shoulder to rely on, someone that makes you laugh, and someone that rec- ognizes you as a human being. There is something else besides the painkiller or the nursing procedures, and it is the presence and understanding of another human being (Hannah)

Sadly, Hannah’s story is lived every day and everywhere by many people living with chronic illness in Colombia. Despite their nursing mandate to care for human beings, Colombian nurses have been com- pelled to work under the precepts of competence, consumerism, and individualism of the healthcare system (Camargo Plazas & Cameron, 2015). In this story, Hannah is asking for solidarity and compassion from the nurses, but on the pathway to recovery and control of her ill- ness, she found indifference and dehumanizing care. She experienced abandonment from the nurses who did not appreciate the constraints placed by her chronic condition. The nurses that cared for Hannah were indifferent, and she was merely a spectator of their actions. They worked over her ill body as if she were a car or another object in need of repair. Furthermore, they acted over her mechanically without con- sidering her well- being. There was little compassion in the attention she received. However, she claimed respect.

What makes these nurses act in that way? Perhaps the way the health system is organized kills the humaneness of healthcare pro- fessionals. Stories such as Hannah’s are a dramatic example of how the expansion of private insurance services in Colombia has not im- proved health services for vulnerable populations. The corporate push toward extreme efficiency, calculability, predictability, and control by the health reform has changed the relationship between healthcare professionals and patients (Camargo Plazas et al., 2012). As (Austin, 2011) stated,

We find that the growing inflexibility of interactions demanded by the customer service model glosses over the mutual vulnerability inherent in the nurse- patient relationship and reduces the capacity for the nurse’s self- reflection and- enactment in order to maximize his or her “productive activity” in a competitive service environ- ment (p. 161)

In Colombia, under health reform, the relationship between patient and nurse has become primarily instrumental. Nursing care is then

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replaced by the fulfillment of predictable tasks serving expectant con- sumers, as described in Hannah’s story. Hannah’s experience shows how people with chronic illness live under the pressure of corporate agendas and rigid neoliberal structures that serve to dehumanize their condition (Camargo Plazas et al., 2012). Regardless of the effects of the health reform on health status, much of nursing work has been focussed toward the management of pathologies—indeed, it remains highly medicalized (Camargo Plazas et al., 2012). Health systems orga- nize themselves around the idea of disease care, rather than healthcare (Austin, 2011; Eliason, 2015; Rotarou & Sakellariou, 2017).

Since the 1990s, neoliberalism has been the primary ideology driving the Colombian government, economy, and healthcare de- livery (Camargo Plazas et al., 2012). Neoliberal policies encourage the loss of government regulation and funding of health and human services by replacing government intervention with a private market economy. This for- profit orientation has changed healthcare systems around the world from emphasizing patient- centered care and qual- ity to emphasizing cost- savings and efficiency, transforming nurs- ing care into a commodity for sale (Eliason, 2015). Although nursing as a profession has not been the apparent focus of the policy and program alterations promoted and implemented to restructure the delivery of healthcare, neoliberalism has profoundly affected the practice of nursing in Colombia. Restructuring efforts have focused on organizational restructuring with current changes in how health- care funding is allocated and how certain services are delivered. The goal is to provide health services more efficiently and effectively.

The core of nursing is its relationship with the patient, family, and community (Cameron, 2006), and that relationship must be at the center of a patient- oriented healthcare system. However, a profit- oriented healthcare system can neither produce an authentic rela- tionship nor the intimacy of caring (Austin, 2011). As such, in the Colombian health system, quality has been exchanged for quantity, and the eventual result is a healthcare system that is seen as a market with goals that focus on supply, demand, and competition, thereby reducing the patient to a mere consumer. Today, worldwide, we dehumanize and exploit each other for the sake of economic profit and technological advantage. In some sense, there is no place for respectful or ethical values, neither for self nor for the other. Both respect and ethical values are treated with indifference (Camargo Plazas et al., 2012).

In hospital- based car, a set of new responsibilities in service and cost management has been imposed on nurses. This means that nursing work has been relegated to administrative and clerical tasks, and much of the responsibility for nursing care has been delegated to less prepared and less trained personnel (Cogollo- Milanes et al., 2010). In addition, sometimes working in the social enterprises of the state or old public hospitals means having to face institutional shortages in human resources, supplies, and equipment, and this generally creates poor morale and job dissatisfaction (Castillo Avila, Torres Llanos, Ahumada Gomez, Cardenas Tapia, & Licona Castro, 2014; Cogollo Milanes & Gomez Bustamante, 2010). Due to the re- duction in costs, nurses have been forced to undertake more work with fewer auxiliary staff members. In addition, work in hospital

settings is recognized as both physically and mentally demanding. Staff shortages only increase the exposure of nurses to emotional stress and fatigue. Nurses also perceive that the social value of the profession is less appreciated and recognized by society, a situation that has caused many nurses to resign (Castillo Avila et al., 2014; Cogollo- Milanes et al., 2010). In Colombia, nurses continue to go to work and are expected to provide excellent nursing care. But how?

6  | WHERE DO WE GO FROM HERE?

Clearly, market- driven reorganization of the healthcare system goes against the essence of nursing that is to care for human beings. Is it possible to find harmony between the two opposites? The panorama of nursing practice in Colombia seems dark, but to use the words of Freire (2002), “the future is problematic and not already decided, fatalistically” (pp. 13–14). Then, the course of our lives is not pre- determined and there is opportunity for change (Freire, 2004). To achieve this social change, it is necessary to question the system and to create new systems and structures (Dussel, 2006).

Neoliberal policies have negatively impacted the humaneness of healthcare professionals. For instance, most professionals must fight to position themselves as human beings in the healthcare sys- tem. Health must be considered as a matter of social justice, because health and the social determinants of it are issues of human rights; consequently, an equitable distribution of resources is thought to be the best approach for good healthcare (Austin, 2011; Eliason, 2015). Justice in health requires societies to provide individuals with the necessary conditions to reach the goal of health. A world in which human beings suffer and die unnecessarily when it is possible to provide a solution is unfair and unjust (Austin, 2011). To deal with unfairness and injustice, it is necessary to attend to the underlying societal causes of disparities (World Health Organization, 2007).

The aim of governments is not to eliminate all health differences but rather to decrease to the lowest level possible or eliminate those that result from avoidable and unfair factors (Eliason, 2015). In the- ory, this aim is a good one; however, in reality, minorities must face restrictions, and governments are controlled by external forces that make it impossible to control the widening gap. Thus, instead of fo- cusing on providing well- being for all, governments have focused on ensuring market competence, which, when coupled with globaliza- tion, cause direct and indirect effects on health. The direct effects of globalization on health are related to the impact on health sys- tems, health policies, and the exposure to hazards such as tobacco marketing. The indirect effects are related to trade liberalization and the availability of resources for public expenditure on health with its resulting effects on living conditions and household income (Hartmann, 2016; Labonte et al., 2015). Meanwhile, minorities con- tinue to expose themselves to risky behaviors and struggle with a lack of treatment continuity and lack of money to pay for care, consequently living with uncontrolled illnesses and functional lim- itations. The state needs to focus on providing adequate attention on human beings, changing the concept of the creation of wealth as

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equivalent to eliminating inequality, and understanding that health inequities always have moral and ethical dimensions (Austin, 2011; Eliason, 2015; Selberg, 2013). Health systems need to become more humane, exemplifying equality and a real commitment in relation to the universal principles they promote. As nurses and members of the Colombian healthcare system, our responsibility is to be advocates for our patients. However, our advocacy in this world of inequalities must take into consideration that self- determination and freedom are the most significant and priceless human rights (Austin, 2011).

An example of dedication and commitment toward advocating for caregivers of people living with chronic conditions occurred in 2008 when Bill 163 was presented to the Colombian senate. This bill was the result of 14 years of research and leadership of the Chronic Patients and Families Care Support Group associated with the Faculty of Nursing at the National University of Colombia (Barrera, De Camargo, Figueroa, Afanador, & Herrera, 2006). Bill 163 entails the protection of the rights to health, access to healthcare, and to pay for full- time caregivers for people with long- term disabilities. These are rights not contemplated previously in Law 100 (Barrera et al., 2006; Barrera- Ortiz et al., 2005). This group of nurses decided not to remain in the background or be added as an afterthought to the policy arena. They decided to act and, as a result, changed the reality of that abandonment of the caregivers of people with chronic conditions (Barrera et al., 2006).

This bill has been a first step in a long and not always friendly pathway. Through these actions, we have learned that we can have a voice and a vote. We need to recognize the context of our world to be able, through actions, to neutralize the oppressive elements of that reality such as the reality of the lack of access of healthcare for people with chronic illness in Colombia. We cannot remain neutral (Freire, 2004), because a profit- driven health system affects how we practice, educate, research, and develop knowledge in nursing; therefore, the social mandate must look forward and deal with the individual and a more inclusive view of human beings. Thus, in nurs- ing we cannot allow our understanding of and care for human beings to be restricted to market terms or economic profit. We must neither forget nor forgo our purpose to treat each person as a unique human being with diverse needs.

7  | CONCLUSION

As members of the healthcare system and Colombians, we cannot forget that our response toward privatization and market- oriented practice must be centered in leadership and in re- orienting our local and national healthcare systems toward ethics. We cannot close our eyes to what is happening now in hospitals or community settings in our country, because our responsibility is to promote health, prevent disease, and care for human beings. As nurses, we need to develop the compassion to deal with the asymmetrical, un- equal, competitive, and consumerist politics of our health system. In that way, we must try to go beyond the barriers that have built up within the health system—a health system that pretends to espouse

equality and universality, but it does not in many ways. Adhering to our mandate, we must follow the ongoing dialogue about wealth, social position, and health outcomes, because we are there on the front lines of implementing the healthcare policies of society. Also, our goals as nurses must include addressing the welfare and protection of our patients. As such, regarding the policies of com- petence imposed by the Colombian health system, nurses need to continue to be socially and politically active to defend the rights of our patients while considering that the problem does not have an easy answer. The situation requires compromise and concrete solu- tions. Therefore, our priority is to prevent and manage disease, to handle the policies of the health system, and to follow the essence of our profession by trying to provide quality care.

ORCID

Pilar Camargo Plazas http://orcid.org/0000-0002-8349-7723

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How to cite this article: Camargo Plazas P. Understanding the space of nursing practice in Colombia: A critical reflection on the effects of health system reform. Nurs Inq. 2018;25:e12242. https://doi.org/10.1111/nin.12242