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This is the published version of a paper published in International Journal of Health Planning and
Citation for the original published paper (version of record):
Mosquera Mendez, P., Hernández, J., Vega, R., Labonte, R., Sanders, D. et al. (2014)
Challenges of implementing a primary health care strategy in a context of a market-oriented
health care system: the experience of Bogota, Colombia.
International Journal of Health Planning and Management, 29(4): E347-E367
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N.B. When citing this work, cite the original published paper.
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Int J Health Plann Mgmt 2014; 29: e347–e367.
Published online 19 November 2013 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/hpm.2228
Challenges of implementing a primary health
care strategy in a context of a market-oriented
health care system: the experience of Bogota,
Paola A. Mosquera1,2*, Jineth Hernández2, Román Vega2, Ronald Labonte3,
David Sanders4, Kjerstin Dahlblom1 and Miguel San Sebastián1
Department of Public Health and Clinical Medicine, Epidemiology and Global Health,
Umeå University, Umeå, Sweden
Postgraduate programs in Health Administration and Public Health, Pontificia Universidad
Javeriana, Bogota, Colombia
Institute of Population Health, University of Ottawa, Ottawa, Ontario, Canada
School of Public Health, University of the Western Cape, Bellville, South Africa
Background Although Colombia has a health system based on market and neoliberal
principles, in 2004, the government of the capital—Bogota—took the decision to formulate
a health policy that included the implementation of a comprehensive primary health care
(PHC) strategy. This study aims to identify the enablers and barriers to the PHC implementation in Bogota.
Methods The study used a qualitative multiple case study methodology. Seven Bogota’s
localities were included. Eighteen semi-structured interviews with key informants
(decision-makers at each locality and members of the District Health Secretariat) and
fourteen FGDs (one focus group with staff members and one with community members)
were carried out. Data were analysed using a thematic analysis approach.
Results The main enablers found across the district and local levels showed a similar
pattern, all were related to the good will and commitment of actors at different levels.
Barriers included the approach of the national policies and a health system based on
neoliberal principles, the lack of a stable funding source, the confusing and rigid guidelines, the high turnover of human resources, the lack of competencies among health
workers regarding family focus and community orientation, and the limited involvement
of institutions outside the health sector in generating intersectoral responses and promoting community participation.
Conclusion Significant efforts are required to overcome the market approach of the national
health system. Interventions must be designed to include well-trained and motivated human
resources, as well as to establish available and stable financial resources for the PHC strategy.
© 2013 The Authors. International Journal of Health Planning and Management published
by John Wiley & Sons, Ltd.
primary health care; barriers and enablers; qualitative study; Bogota
*Correspondence to: P. A. Mosquera, Department of Public Health and Clinical Medicine, Epidemiology
and Global Health, Umeå University. SE-901 87 Umeå, Sweden. E-mail: [email protected]
© 2013 The Authors. International Journal of Health Planning and Management
published by John Wiley & Sons, Ltd.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercialNoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Primary health care (PHC) is enjoying renewed interest thanks to the fact that its values
and comprehensive approach to health system organisation, as first expressed in the
Alma-Ata declaration, are currently promoted by the World Health Organization
(WHO) (PAHO/WHO, 2008). It is also increasingly accepted that socioeconomic,
political and cultural factors, as well as power relations and political processes, shape
the implementation of health policies, health system reforms and the comprehensiveness
and effectiveness of PHC (Buse et al., 2005; Labonté et al., 2008). The 2008 WHO
report called for further evidence to identify the technical and political obstacles to
PHC advancement and implementation (PAHO/WHO, 2008).
Although Colombia had a health system based on market and neoliberal principles, in 2004, the local government of the capital city—Bogota—made a decision
to formulate a district health policy that included the implementation of a comprehensive PHC strategy (Alcaldía Mayor de Bogota/Secretaria de salud Distrital,
2004; Vega-Romero and Carrillo-Franco, 2006; Vega-Romero et al., 2008, 2012;
Mosquera et al., 2012a, 2012b). The strategy aimed to improve the quality of life,
increase the health status of the population, and to reduce health inequities (Alcaldía
Mayor de Bogota/Secretaria de salud Distrital, 2004).
The PHC strategy has been implemented by three consecutive governments over the
last 8 years. During this time, there has been a continuous political tension stemming
from the differences between national and district policies. Although the national
policies emphasise a profit-based and market-oriented health care system, the Bogota
local government proposed a rights-based approach rooted in community participation, the empowerment of social groups and intersectoral work (Vega-Romero and
Carrillo-Franco, 2006; Vega-Romero et al., 2008, 2012).
Recent studies on the experience of implementing PHC in Bogota indicate that the
strategy has contributed to an improvement of health outcomes and a reduction in
health inequalities, despite the adverse national context (Mosquera et al., 2012a,
2012b). However, research has also shown that the strategy has not achieved some
of the expected goals, and the coverage of the strategy has stagnated in the last
3 years (Mosquera et al., 2012a).
Little attention has been paid to analysing the processes, actors, institutional
context and the exercise of power involved in the development of PHC at local level.
This study aims to identify the barriers and enablers of PHC implementation in
Bogota. This analysis should provide a better understanding of the overall experience and inform future strategies, which seek to improve and scale-up PHC strategy
to the national level.
National health policy in Colombia
In the mid-1980s, Colombia began to implement fiscal, political and institutional decentralisation reforms, which aimed to reassign government functions and responsibilities to
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
the national, departmental/district and municipal/locality levels. The central government’s role concentrated on policy design, regulation and public finance. Departmental/district governments assumed the regional planning, management and financial
responsibilities. Municipal/locality governments took on the implementation of policy
and public service provision (Glassman et al., 2009).
In the early 1990s, the national government developed market-oriented economic,
social and health policies (Giraldo, 2007; Vega-Romero et al., 2009), transforming
in 1993 the old National Health System into the current General System of Social
Security in Health (GSSSH) (Republica de Colombia, 1993), which is financed
through a combination of payroll contributions and general taxation (Glassman
et al., 2009). This reform aimed to make the system more efficient by reducing the
state’s role as health care provider, decentralising health service administration to
local governments, privatising health and increasing labour market flexibility
(Corcho et al., 2000; Laurell, 2010). These changes sought to facilitate market
competition and to increase the profitability of health care enterprises. The process
excluded state actions on the broader determinants of health and dismissed the
original principles of PHC. This resulted in a model that mixed managed care and
health care assistance, promoted a biomedical and selective model of primary care
and focused on the prevention of individual risk (Vega-Romero et al., 2009).
In the GSSSH, individual health care services are the responsibility of insurance
companies, whereas public health activities are the responsibility of the local government health authorities (Corcho et al., 2000). Individual health care services can be
provided through either a contributory regime for those able to pay, where formally
employed and independent workers contribute a proportion of their incomes, or a
subsidised regime, funded by general tax revenue, where poor people do not make
any insurance contribution. People are usually enrolled with public or private
insurers and receive care from a mix of providers. Those still uninsured and
classified as poor only have free access to emergency care (Glassman et al., 2009).
Individuals in both the contributory and subsidised regimes receive a health
benefits package. Public health programmes are provided through a collective intervention plan—‘Plan de intervenciones colectivas’ in Spanish—which complements
health care insurance. Local health authorities provide health promotion and disease
prevention services included in the collective intervention plan through contracts
between health secretariats and public health providers (Glassman et al., 2009).
Figure 1 summarises the GSSSH structure.
Bogota’s health policy
The centre-left government, elected for first time in Bogota in 2004, developed a district
health policy intended to guarantee the right to health and to address the social
determinants of health inequalities. Two of the main strategies put in place in the health
sector were the promotional strategy of health and quality of life (PSHQL) (Estrategia
promocional de calidad de vida y salud in Spanish) and the PHC strategy (Alcaldía
Mayor de Bogota/Secretaria de salud Distrital, 2004; Alcaldía mayor de Bogotá/
Secretara de planeación, 2004, 2008; Vega-Romero et al., 2008, 2009).
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
Figure 1. General System of Social Security in Health structure and operation
The PSHQL was conceived as a public management approach, which aimed to
improve the quality of life of the population through health sector collaborations with
other sectors. The PSHQL strategy organises public health actions into four categories:
(i) activities revolving around daily life (families, neighbourhoods, schools and
workplaces); (ii) interventions through the life course (from childhood to old age);
(iii) activities to address transversalities (gender, equity and diversity); and (iv) projects
to develop community autonomy (Secretaria Distrital de Salud de Bogota, 2010).
The PHC strategy, in turn, was based on a comprehensive approach and was
designed to reorient health care delivery to ensure better access and the use of services
(Alcaldía Mayor de Bogota/Secretaria de salud Distrital, 2004; Secretaria Distrital de
Salud de Bogota, 2010). Operationally, the core of the PHC strategy is the home health
(Salud a su Casa) programme. This programme currently works within the network of
first-level public health care facilities operating under the authority of the Bogota
District Health Secretariat (DHS). It includes basic health care teams, comprised a
physician, a nurse, two community health workers and an environmental technician
who provide either intramural or extramural services (Alcaldía Mayor de Bogota/
Secretaria de salud Distrital 2004; Vega-Romero et al., 2009; Secretaria Distrital de
Salud de Bogota, 2010). Aiming for progressive coverage, the intervention began by
prioritising poor people classified as belonging to social strata1 1 and 2, with the
aim of gradual expansion to other strata in the future. Individuals enrolled in the home
health programme are more easily given appointments in healthcare centres and
hospitals and have easier access to social programmes, such as community kitchens,
Strata is a socioeconomic measure that classifies population by groups from 1 to 6, 1 being the lowest and
6 the highest. As in the rest of Colombia, Bogota’s population is classified by social strata.
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
housing subsidies and education grants for children who have left school. The promotion of and support for social mobilisation and the strengthening of education and
defence of the right to health are additional attributes of the programme.
Actors involved in the implementation of the primary health care strategy
Implementation of the PHC strategy takes place within the structure of the GSSSH
and is monitored by the Ministry of Health, which is responsible for the coordination
of the District health authorities. Decentralisation within the Colombian health
system allows district authorities to design their own policies and strategies, as
influenced and shaped by guidelines from central government. In the case of Bogota
district, the mayor heads the city’s government. The DHS is responsible for designing the operational guidelines for health policies and for planning and executing the
monitoring processes at the local level. At locality level, there is a local mayor
appointed by the district mayor from a list of candidates provided by the administrative boards of each locality, members of which do not necessarily come from the
same political party. Public hospitals are in charge of operationalising public health
interventions. Members of the health care teams are responsible for working
directly with the community to provide services. Institutions working in education,
culture, social welfare and the environment can also collaborate and establish
partnerships with public hospitals to implement intersectoral actions. Communities
play a central role, through community-based organisations, in mobilising
intrasectoral and intersectoral actions. Figure 2 shows a list of actors involved in
the PHC implementation.
The setting
Bogota is the capital of Colombia and has 7 571 345 inhabitants (2012). It is divided
into 20 localities, of which 19 is urban and one is rural, and four networks of health
services (north, south, east central and south western). About 51.2% of the population
is classified as being in strata 1 and 2, the two lowest socioeconomic strata. By 2010,
the home health programme had achieved 40.36% coverage (1 497 750 people) of the
population in these two strata through the establishment of 358 basic health care
teams. The development of the PHC strategy in Bogota showed a notable initial
increase in home health programme coverage between 2004 and 2007, followed by
a period of slower growth between 2007 and 2010 (Mosquera et al., 2012a).
The study design
The study used a qualitative multiple case study methodology. Multiple case studies
are variations of case study methodology allowing researchers to explore phenomena
through the inclusion of various units of observation (Yin, 1994). Given that
Bogota’s PHC strategy is a complex intervention that is context dependent and
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
Figure 2. Actors involved in the implementation of the primary health care strategy
involves several social processes, we determined that a multiple case study approach
was the most appropriate methodology.
Seven localities belonging to the four different geographic health networks were
included in the study. These were chosen as a set of representative cases of the
phenomenon to be analysed (the home health programme), because these localities
showed similar trends to those of Bogota as a whole (a significant increase in the
coverage of the programme during the first 3 years of implementation and subsequent stagnation). Their large and diverse population was a second reason for
selection (approximately four million people—57% of the total population of Bogotá
and 80% of the total population classified as strata 1 and 2 are in these seven
localities). The third reason was because of their role as early adopters of the home
health programme. The study used a purposive sampling strategy to identify key
informants on the basis of their individual roles within the health institutions and
communities. This allowed us to explore a broad range of perspectives on issues
emerging, as we aimed for maximum variation in our sampling.
Data collection and analysis
The data collection was conducted between August 2010 and March 2011 and
included 18 semi-structured interviews with key informants (two decision-makers
at each locality and four members of the DHS staff) and 14 focus group discussions
(FGD) of 7–10 people per group. Two FGDs were undertaken in each of the 7 localities, one with staff members of the home health programme and one with community members. An interview guide was developed for the semi-structured interviews,
and another guide was developed for the FGDs. Both guides included open-ended
questions (e.g. how the PHC strategy was introduced in the locality? what were
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
the main concerns about the PHC operationalization? which stakeholders played an
important role in the process and how such roles influenced the scope and development of the PHC strategy?) that aimed to explore enablers and barriers during the
process of the PHC implementation. A field research team comprised five people
performed the interviews and focus groups. Consistent with qualitative research
methods, interviewers maintained an open stance, probing emerging issues and
asking for further explication or clarification when necessary.
All interviews and FGD were tape-recorded, transcribed and were used as the
key texts for analysis. Transcripts of the original text in Spanish were entered into
open code software (ICT Services and System Development and Division of
Epidemiology and Global Health, 2009) for the coding process. Data collected
were examined by first identifying topics and then grouping similar topics together
to form emergent categories. Analysis of the data was performed for each locality
separately, and then the findings were integrated into the overall emergent categories and themes. Data were analysed using a thematic analysis approach (Fereday
and Muir-Cochrane, 2006).
Two researchers (the first and second authors) carried out the analysis independently, finding no significant discrepancies in the identified categories. As the
objective of this research was to identify barriers and enablers to the PHC implementation, categories were grouped into these two themes. The findings were then
discussed by the entire research team to develop the analytic conclusions further.
Finally, in a post-study workshop, the preliminary findings were presented to study
participants to give feedback and to validate the analysis. Some views held by
stakeholders were discussed and clarified, and the main results of the analysis were
confirmed in this member-check workshop.
The Walt and Gilson policy analysis framework (Walt, 1994; Walt and Gilson,
1994) provided a guide for the data analysis. This framework recognises that the
health policy process involves four interacting elements: context, process, actors
and policy content. The assumption is that actors are influenced (as individuals
or members of groups) by the context in which they live and work. Context is
affected by many factors created by politics, historical experiences and culture,
and the process of policy-making is in turn affected by actors. The content of
policy reflects some or all of the elements mentioned previously (Walt, 1994; Walt
and Gilson, 1994).
Ethical considerations
This study was approved by the Ethics Committee of the Department of Postgraduate
Programmes in Health Administration and Public Health, Pontificia Universidad
Javeriana, Bogotá. The study was presented to the boards of all hospitals involved
and was approved by them before the field work was initiated. Oral informed consent
was sought from all participants after explaining the objectives of the study; they were
assured of their right to withdraw from the interview or the FGDs at any time.
Interviews and FGDs were recorded with the permission of participants, and recordings and transcripts were stored confidentially.
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
Analysis of the interviews and FGDs identified a wide range of factors that
influenced the PHC strategy implementation. For the presentation of the findings,
we have organised these factors into two main themes, enablers and barriers to the
PHC strategy implementation. Within the themes, factors are grouped to reflect the
interaction between the four elements proposed in the Walt and Gilson’s policy
analysis framework.
Enablers of implementation
(i) Long term political continuity
There was consensus among decision makers, staff members of the DHS and
members of the home health programme that the continuity of the same political
party in the district government was important in keeping the PHC strategy high
on the political agenda. This political continuity allowed policy maintenance, which
facilitated the implementation that led to the positive results so far achieved and
which are reported elsewhere (Vega-Romero et al., 2008, 2009; Mosquera et al.,
2012b, 2012a). All of the actors at district and local levels understood the PHC
principles as a political process not tied to a particular government programme.
Members of the DHS also mentioned that the dynamic changes at district level
created the political agency necessary to visualise the PHC strategy at national level,
which successfully kept the strategy on the agenda of priorities. One of the
informants stated:
‘…it has not been an easy process, when the city began to implement the PHC
strategy, everybody strongly criticised the political approach, saying that we were
duplicating efforts, substituting the role of insurers, carrying out a parallel health
system. However the political will and agency by the Mayors as well as by the
District Health Secretariat has been successful. In 2005–2006 the PHC strategy
reached greater visibility in all levels and the approach of the district health policy
was accepted by local mayors, hospitals and even stakeholders at the national
level. Nowadays no one questions the strategy and the national government is
already thinking about scaling up the primary health care principles to a national
level’ (Interview-DHS official)
(ii) Support from local mayors and hospital managers
At the local level, an enabling factor identified by the DHS and hospital staff was
the support from local mayors and hospitals managers for the PHC strategy. In their
opinion, this became very important because of the extent of decentralisation of the
health system in Colombia; thus, although there was a general guideline issued at the
district level, the level of importance given to the PHC strategy and its placement
within the institutional structure was primarily a local decision.
A good example of the commitment from some local mayors was the reallocation of
some local resources to support the strategy (additional resources to those allocated
directly through the CIP). Another example, at the hospital level, was the decision taken
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
by some managers to formally include the principles and values of PHC in their strategic
platforms and models of care management. Some respondents expressed it this way:
[…] to have additional resources from the local mayor helped a lot to
increase the number of teams and the home health coverage, also the support from the heads [referring to managers] who have understood that
PHC goes beyond the home health programme, helped to transform the
organisation of the whole hospital… without the support of the heads it
would be very complicated for us [referring to the staff] to give to the
strategy the level of importance required and would be an organizational
burden that was not worth it. (Focus Group –Hospital Staff).
The home health care members interviewed confirmed that these types of
support helped to improve the connection between actors involved at the local
level, as well as all staff within the hospitals and not only those directly responsible
for the strategy implementation.
(iii) Commitment of health care teams and community health workers
Members of the community recognised that the work, commitment and sense of
belonging of the home health care teams helped to achieve greater visibility for the
health sector and to increase community support for the program. This in turn helped
to sustain local adherence to the PHC strategy, generating further political support.
Informants from the community also perceived an improvement in access to the
health care system as well as positive short term results from intersectoral actions aimed
at meeting community needs. Health care teams were especially valued by PHC users—
especially the work of, and guidance offered by, community health workers. This can be
exemplified by the following quotation from a community member:
This commitment that we saw in the staff of the home health care teams… They
come and get muddy. Meanwhile we saw staff from many other institutions
coming around and just give us a glance without getting out of their cars so they
didn’t have to set a foot on the floor… and community health workers from the
home health programme came to our houses, and asked what happened? Did
you know the son of your neighbour got sick? Come on, you have to be a team,
friends, colleagues… and let me help you, I will teach you how to care for your
children when they are sick, I’ll give you a reference for an appointment at the
health care facility… so all this support motivated us and we agreed to ask the
government to maintain the strategy. (Focus Group – Community member)
(iv) Organised communities
Managers and home health care team members identified the involvement of
organised communities that have been historically committed to the process of social
participation as a key factor that facilitated the implementation of the PHC strategy.
From their point of view, these empowered communities were key to beginning the
process, because they had already identified needs and had some experience about
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
how to generate comprehensive responses and work together with institutions. A
home health care team member said:
[…] and we realize in this locality the community had a huge history in participation, let’s put it in terms of numbers 17 000 people came to the general citizen
meeting [event promoted by Bogota’s mayor] and we thought then this locality
moves people and not only because of the PHC strategy but from before. This
was a historic fact that allowed the mobilisation of the community and they helped
us to identify places within the neighbourhoods to open new community health
care centres, the school found a room and the leader of the Community Action
Board lent us an office… this is an example of a very strong social mobilisation
which made our work easier. (Interview -Home health care team member)
According to the home health care team members, the co-responsibility previously
developed in participatory communities allowed the establishment of interventions
as well as supported the continuity and sustainability of old and new ones.
Barriers to implementation
(i) The fragmentation and segmentation of the GSSSH
Structural factors related to the national health system itself were considered one of
the most important barriers to PHC implementation. According to the perceptions of
DHS staff, the division of functions, the fragmentation of actions as well as the reduction
of the state role (i.e. in financing, stewardship and health services delivery) resulted in a
district health policy that limited its influence to the network of first-level public health
care facilities. One respondent from the DHS expressed this barrier as follows:
Who has control over insurer companies hmmm? … If the stewardship of the
District Health Secretariat is a ‘salute to the flag’, we have serious problems with
the contracts of subsidised insurance companies, because there are no specific
tools with which we monitor and control them. And what to say about the contributive insurance companies where the DHS has no influence… and we have not
support from the national level, no one give us any answers about how to manage,
control and monitor. (Interview - DHS official).
Members of the home health care teams confirmed the structural problems, saying
that the public–private combinations of providers and insurers along with the
regulated competition scheme have meant that both public and private institutions
compete for resources, neglecting community needs. A respondent in a focus group
was concerned as follows:
The PHC strategy does not fit into the system in which it has to work, and this is
related to the way the system is organised, with its rationality… insurers,
providers, hospitals and institutions have to fight to find resources and survive
within the market. Then the implementation of the PHC strategy is tied to selling
services and to gaining resources… we lose sense of direction [referring to the goals
of the implementation process] because we are not working to solve community
needs, but to achieve financial sustainability. (Focus Group – Hospital staff)
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
The segmentation and fragmentation of care originated in the different insurance
schemes with different benefit packages, were identified for some members of the
home health care teams as a strong limitation to achieving some of the essential
dimensions of the PHC strategy:
I believe the health insurance scheme and the segmentation in contracts are critical
issues. What did we start to see with the Home Health care teams? In the same house,
the father was enrolled to one regime and the mother with another, one of them was
not capitated with us, then what could we do with this fragmentation? Well, tell the
mother you have right to get the appointment but you mister cannot come to my
hospital because your insurer doesn’t have any contract with me… another example,
I found a pregnant woman and she came to receive antenatal care but I could not do
the HIV test because the insurer does not include that test in the contract, so the
pregnant woman had to go from here to Simon Bolivar [Hospital 1 hour away] where
the insurer was contracted to do the HIV test. What kind of comprehensive services
could we offer this way? (Focus Group – Hospital staff)
(ii) The lack of stable resources
According to staff at the management level, the PHC strategy was limited by an
important constraint on the financial sustainability of the hospitals. In planning
the strategy, it was assumed that hospitals would finance some of the working
time of professionals within the health care teams, with resources coming from
the sale of services. However, hospitals have been facing a crisis in the last
decade and most of them could not find additional resources to fund that
professional working time.
In 2007, the PHC strategy went from being in a core position in the district health
policy to being relegated to the activities concerned with daily life (families) of the
PSHQL strategy. This move had economic implications, because it led to smaller
budgets each year and also, in some localities, to mayors deciding to stop the
additional funding previously allocated to the home health programme. An example
of this view was expressed in the following quotation:
The budget is a real issue, if a hospital is in crisis, the money goes to the
priorities and the decision would be to fire most of the people working in
public health programmes and minimise the money invested in the PHC
strategy… And unfortunately we have to talk about resources, about money,
and when you have money you can do many things, but when the budget
becomes smaller and the DHS starts to cut resources, we have to cut activities
and fire people. (Interview – Hospital manager)
(iii) Guideline changes divorce theory from practice
The relocation of PHC to the PSHQL strategy was perceived by the home health
care teams as a factor that weakened the process of implementation. Hospitals at the
local level had to readapt their work, and the PHC operationalisation was reduced
from its core position to focussing on the set of activities performed by home health
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
care teams within the family setting. A member of the health care team described this
barrier as follows:
After we had gone to all that effort to implement PHC the DHS changed the
guidelines, and PHC was not the core anymore, so yes again to make changes…
we had to adapt quickly to the PSHQL, then we were wondering what will we
keep from the PHC strategy? Well, just the Home Health programme and what
does that mean? There is not a real PHC strategy, only one programme is not a
true PHC. (Focus Group – Hospital staff)
Another limiting factor highlighted by the home health care team members was the
lack of communication between those who designed the operationalisation guidelines
at the DHS and those responsible for implementing the strategy at the local level. A
conceptual separation was perceived between theory (principles, values and goals of
the PHC) and practice (guidelines for operationalising the strategy). Home health care
team members claimed that guidelines for the operationalisation of the strategy were
often contradictory and overly rigid. The PHC strategy advocated generating comprehensive responses to community needs through the promotion of social participation
and intersectoral actions (long-term goals); however, the guidelines had very tight
schedules and short-term goals, which did not give enough time for hospitals to work
together with communities in the identification of needs and the generation of
responses in a participatory way.
Professionals in home health care teams also claimed that instead of developing
programmes and spending resources to meet community needs, the guidelines
forced resources to be allocated to those programmes and interventions established
by the DHS:
One thing is the policy, and another one is how the policy landed into
operationalization guidelines, and there is a total divorce. The guidelines were
confusing: how could someone sitting at a desk design guidelines without asking
or thinking about how things happen in the field? And the goal within the guidelines is not a favour; you have to meet it, so if you do not do ten visits per day,
man… we cannot pay to you, so kill or do whatever you want, but accomplish
the goal, and when we identify this vulnerable population, we say this process
needs more time, I need to organise meetings with the community, open proper
spaces to listen to people, and communities have their own pace… but under
the guidelines it is impossible to spend more time, otherwise I won’t meet the
goal. (Interview – Home health care team member)
(iv) High turnover of workforce
The lack of stable resources and the constraints imposed by the national policy of
labour market deregulation and flexibility, together with the imperative of financial
sustainability faced by hospitals, have resulted in a high turnover as well as a lack
of adequate on-going training for the health workforce. Health workers faced unsatisfactory working conditions such as temporary contracts without social security
(from semi-dependent to self-employment), poor remuneration and work overload.
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
The people working at different levels often felt mistreated and discouraged. The
following quotes from some respondents illustrate the point:
These forms of contracts have maltreated people and people are not motivated to
work, then they don’t do their best. Sometimes when the contract ends the
hospitals leave people waiting 1, 2 and up to six months to renew a contract. Then
when you find a chance to work in other places, you go away and we have a high
turnover, between 80 to 85% of the people change between January to June each
year… Besides the poor labour conditions, hospitals hire professionals to work on
more than one project, only one person for three and four projects, another example, the hospital gets a contract for a product to be completed in twelve months but
they hired me just for four months, then the overwork creates schizophrenia in
people. (Focus Group –Hospital staff)
To the extent that there is a huge turnover, then PHC processes developed with the
community are lost, because the adhesion of the community to the process
depends on trust, and people recognise the staff but when a new worker comes
each three or six months they have to start the whole process again. (Interview
– Home Health care team member)
According to home health care team members, the high turnover was also an important factor at the managerial and coordination level, disturbing the organisational
climate, stagnating and reversing part of the process of policy advocacy at district
level. One member expressed it this way:
The logic is that the person goes away but the process will continue and it is a lie,
the person goes away and the process dies. Look how important people are, when
the chief of social participation goes away, we have not a head anymore that goes
and talks to other heads. We had opened a doorway through her, we were the crew
and we made the proposals, and she did all the coordination with the heads of the
other sectors because she was a significant figure of connection, she talked to the
director or manager of many institutions, when she went away we lost that power
and our work decreased its scope. (Interview – Home Health care team member)
Training and skills development was initially undertaken by the DHS and hospitals; however, budget constraints gradually reduced the investment in training. Because of the high turnover already mentioned, the well-trained staff moved to
another jobs. A staff member of the DHS expressed the problem in this way:
Universities do not train students to do community work, training has a clinical
and individual approach, and so it is very hard… if they came already trained by
the university then it would be easier for them to work, if universities were
involved with the strategy, the training process would not be only a responsibility of hospitals and the DHS, and what to say about the high turnover of the
health human resources… look, people trained in 2006 with international
teachers who are no longer at hospitals, and the hospitals do not have money
for ongoing training processes, so when new people come to work they just read
these booklets and interpret them on their own and then begin to do what they
can. (Interview - DHS official).
© 2013 The Authors. International Journal of Health
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Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
(v) Coordination problems
From the standpoint of Home Health care team members, the process of coordination with actors from other sectors had made initial advances. At the beginning,
institutions agreed to have a joint periodical meeting among all stakeholders to
identify needs and design collaborative interventions. However, some institutions
did not give enough importance to the need for joint action, showed no interest in
the process or just lacked sufficient staff to attend the meetings promoted and led
by the hospital. This became a constraint, because failing to involve all actors and
institutions at local level resulted in an inability to generate comprehensive
responses to solve community needs. A member of the home health care team
had this to say:
All started with the good will of people, but those people somehow represent
institutions. We started holding some meetings, but were unable to continue them,
because it was infertile ground for achieving what we wanted, some institutions
do not want to be involved so even if people wanted to, they could not because
they depend on institutions and we did not find support from some institutions.
(Interview – Home Health care team member)
(vi) Instrumental community participation
Although some communities were organised and historically active in participation, in many localities, community participation was dominated by the individual
interests of their leaders or influenced by other district institutions and political
parties. According to some home health care team members, communities abandoned collective goals when they realised they could receive private benefits.
We do not need to tell lies, the community leader realises he can get a job for his
son, or a new business for his family, help to build a house for his daughter or just
shirts, jackets or lunch… then some institutions take advantage of this situation
and keep the leader happy and he in turn calms down people at community and
this way the community won’t come to claim their rights. (Interview – Home
Health care team member)
People in the community on the other hand identified the decision-making process
as divided, one space where political parties and institutions discuss problems and
take decisions and another separate space where the community identifies their needs
and discusses possible solutions. This division in meetings made communities feel
undervalued in their role. When community interests coincided with the interests
of politicians, participation served as a way of legitimising the actions; however,
when interests did not converge, particular political interests prevailed. A member
of the community explained it in this way:
We realize there were two tables [Agendas] in the process, in one, sectors and
institutions identified problems and generated responses and in the other community talked about their problems, but where were the decisions taken? And what
could the community do? We did not see results in this process, so we started to
stand aside… We did some analysis, we must not be a genius because is obvious,
© 2013 The Authors. International Journal of Health
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Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
institutions have used us, so, please come and sign to confirm you agree… agree with
what? With what has already been decided? With what is already tied? Then, it is a
thing that discourages the community. (Focus Group – Community member)
This study provides a snapshot of the different facilitators and barriers affecting the
ongoing process of PHC implementation. The findings illustrate the challenges
ahead and the actions or interventions needed to support the implementation process
of PHC.
The main enabling factors found in this study across the district and local levels
showed a similar pattern; all were related to the good will, and the commitment of
actors at different levels of PHC implementation (Bogota mayors, staff at DHS, local
mayors, hospital managers, health care teams and participating communities) to
promotes changes and make a difference, not only to successfully implement the
strategy but also to encourage mobilisation processes that could empower people
and communities.
Despite the difficulties of implementing PHC in a context of health system
fragmentation and segmentation, all actors recognised that the change in the orientation of the district policies and the commitment of the last two mayors generated a
new policy environment. This created room for local governments and public
hospitals to reorient their models towards a framework of values and principles,
which involved a renewed way of working that went beyond the curative health care
approach. This change had a positive impact on the attitudes and vision of the
institutions, staff and communities. Studies have shown how modifications in
legislation and policies adopted by governments and health authorities act as enablers
to generate shared goals, which facilitate collaborative work in PHC (West, 2011).
WHO has also highlighted the importance of policymaker commitment and their role
as facilitators to achieve the goals in PHC reforms (PAHO/WHO, 2007).
An enabler deserving special recognition, and that has facilitated the continuity of
PHC implementation, has been the political and economic support from local
mayors and the management of the hospital managers who obtained additional
financing resources to expand the home health programme coverage in their
localities. The establishment of basic health care teams and the extramural work of
professionals, community health workers and technicians with a high level of
commitment were also identified by the community as key achievements. Community
health workers have been especially recognised worldwide because of their capacity
to make valuable contributions to community development, to improve access to
health services, reduce costs to the health system by providing health education, as
well as undertaking actions that lead to improved health outcomes (WHO/Lehmann
and Sanders, 2007). In our study, managers and professionals within hospitals and
communities especially valued the work of community healthcare workers. Their
work has become more visible in the health sector, and this visibility, in turn, has
contributed to community support for the continuation of the strategy.
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
As highlighted by many informants in our study, one of the most significant
barriers to PHC implementation was the conflict between the national and the district
health policy approaches. The former focused on market logic and the profitability
associated with the sale of health care services, whereas the latter focussed on the
promotion of health as a right. The two competing approaches generated an environment of constant tension where the national approach limited the establishment of
the comprehensive PHC strategy reducing it, to some extent, to a programme
underpinned mainly by activities performed by health care teams and community
health workers (Vega-Romero et al., 2012). The difficulties in implementing and
ensuring PHC sustainability in a fragmented and segmented health system such as
the one in Colombia have been described in a literature review conducted in South
America (Acosta et al., 2011). This review, as well as other studies, showed that
in contexts where the health system has a mixture of public and private sectors
and schemes of social insurance, as in Argentina, Chile, Peru and Ecuador, PHC is
reduced in its application to vertical intervention programmes or isolated strategies
with a transient nature (Vega-Romero et al., 2009; Ruiz-Rodríguez et al., 2011).
The lack of a stable source of funding was also identified as an important barrier in
our study. The importance of ensuring adequate resources to meet desired PHC goals
and to support health care teams has been noted in various studies as requiring
special attention if the implementation and sustainability of PHC reforms and the
development of collaborative intersectoral work are to succeed (Deber and Bauman,
2005; PAHO/WHO, 2007; WHO, 2010; Professional Collaboration/Pharmacy Guild
of Australia, 2012). The PHC strategy in Bogota did not include in its planning full
funding for the health care teams. To fill this gap, it was proposed that the hospitals
should look for additional resources even when they were facing a situation of
financial crisis. In addition, the imperative of financial profitability that is embedded
in the planning process of all public institutions worsens the situation; public
hospitals need to be financially sustainable, and in consequence, they tend to orient
their activities to the selling of individual services rather than delivering public
health interventions such as PHC, because those do not represent financial profits.
In addition to the funding problem, there is a lack of competencies regarding
family focus and community orientation in many health workers. This is partly
explained by the biomedical approach that prevails in the curricula of universities
and technical health training programmes (Vega-Romero et al., 2009). Although
the DHS and the hospitals attempted to overcome this barrier through a major initial
investment in capacity building, the impact was limited because of the cuts in
budgets and high turnover of human resources. Both the need to establish a permanent resource and the need to strengthen the training and retraining processes of the
public health workforce have been pointed out as central elements of a sustainable
PHC reform (WHO et al., 2001; PAHO/WHO, 2007, 2008; WHO, 2010).
Health workers in this study faced problems of unsatisfactory working conditions,
temporary contracts, low wages, work overload and lack of economic and intrinsic
incentives, resulting in a high turnover. These issues have been commonly reported
as a major barrier to implementing health system reforms and collaborative PHC
work, because they often cause people to lose their motivation and commitment.
They also undermine any capacities for effective community participation and
© 2013 The Authors. International Journal of Health
Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
engagement. One of the long established axioms of community work is that the
worker is the instrument, and the qualities of the worker are far more important than
the programmes or services the worker helps to broker (Labonté, 1998, 2010). To
address these shortcomings, WHO has recommended staff incentive initiatives,
changes in remuneration systems, investment in human resources through training
and supervision and systematic actions in human resource management to encourage
a stable workforce (WHO et al., 2001).
Contradictions and gaps within the operationalisation process were also
identified as barriers. An important confusion was generated when PHC
operationalisation was relocated to one of the daily life settings (families) within
the PSHQL strategy. The amount and kind of activities included in the guidelines,
as well as the short periods allocated to meet the requested goals, constrained the
health teams in prioritising needs and formulating plans together with the communities. Continually changing guidelines have been identified in the literature as a
barrier to generating inter-professional and collaborative work in PHC, as it
requires a great deal of time and effort to plan and implement changes across
multiple institutions and among many stakeholders at all levels (Deber and
Bauman, 2005; West, 2011; Professional Collaboration/Pharmacy Guild of
Australia, 2012). Rigid planning guidelines imposed by central authorities have
also been recognised as a barrier to health care prioritisation processes, because
they leave very limited space at the local level for planning activities and designing
their own interventions according to community needs (Maluka et al., 2011)
Although historically active communities facilitated the PHC implementation
process, power relations and planning processes are still based on institutions
working in a vertical manner. A previous analysis conducted in Bogota has observed
that the expected impact of transforming peoples’ health and living conditions
through community participation was very limited, not because of the lack of will
or organisation but because of structural legal factors and policy content that
impeded a full community participatory process (Vega-Romero et al., 2009).
The difficulty of involving all actors at local level in the development of
comprehensive responses was identified as another limiting factor. As per findings
in other studies, insufficient communication between actors and different dynamics
in institutions outside the health sector was present. Some staff from institutions
outside the health sector perceived the effort of attending meetings regularly as a
duplication of work creating operational delays. These problems could partly be
explained by the lack of a clear role for each involved institution, which, in turn,
negatively impacted the functioning of a coordinated team to generate intersectoral
responses (Deber and Bauman, 2005; Profesional collaboration, 2012). There is a
large literature on intersectoral action for health, or what more recently has been
described as a health in all policies approach. Similar to those found in our
research, the main challenges for health in all policies are to successfully place
health criteria on the agendas of policy-makers who have not previously
considered health as part of the agenda and to convince other sectors to make
health-related decisions. Designing policies based on shared aims and integrating
impact assessment procedures would facilitate mutual gains to all sectors (Ståhl
et al., 2006; Chomik, 2007; Leppo and Ollila, 2013).
© 2013 The Authors. International Journal of Health
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Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
With regard to the limitations of the study, the question of whether the
conclusions reached are applicable to other Bogota localities is raised. Although
the use of a multiple case design serves as a major strength of this study in identifying barriers and enablers by stakeholders in different levels, the use of the seven
cases may have limited the scope for exploring factors affecting other localities.
Although generalisability was not the intention, because local context is of vital
importance to understand the processes when implementing a public health strategy,
the experiences from this study can be transferable when evaluating similar interventions. The number of strategies used to improve validity—such as researchers as
outsiders enhancing the willingness of actors to share information, independent
coding and analysis by two researchers in the team, analytical conclusions shaped
by a multi-disciplinary team and member-check on the results with the study
participants—allowed a rich description that provides a valuable contribution to
the knowledge of obstacles and facilitators to PHC advancement in Bogota.
This study has explored the challenges of implementing a PHC strategy in the city of
Bogotá. The main facilitators were related to the long-term political commitment of
the local government, the support of the local mayors and hospital managers, the
sense of belonging of the home health care teams as well as the organised communities devoted to the process of social participation.
Barriers were identified at different levels. At the national level, the structure
of the GSSSH itself, the educational and labour policies, the representative
participation system and the overall rationale of the social policies based on
neoliberal principles oriented to economic growth were core limiting factors.
At the district level, difficulties were related to the reduction of the PHC approach
by relocating it to the PSHQL, the confusing and rigid guidelines and its continuous changes, the lack of a stable funding source and the lack of connection of all
actors (insurers and private providers). At the local level, barriers were associated
with the high turnover of human resources and the limited involvement of
institutions outside the health sector in generating intersectoral responses and
promoting community participation.
Despite its limitations, it is important to recognise that the PHC strategy has
arguably helped to make the health sector visible, to improve population health
(Vega-Romero et al., 2008, 2009; Mosquera et al., 2012a) as well as to reduce health
disparities (Vega-Romero et al., 2008, 2009; Mosquera et al., 2012b). The experience of Bogota has encouraged other regions to prioritise PHC in their health policy
agendas, and the national government in 2011 launched a new law adopting the PHC
strategy through the organisation of basic health care teams, the establishment of
integrated networks of health services and the promotion of intersectoral action
and community participation. This initiative seeks to involve insurers and providers
as well as institutions outside the health sector (República de Colombia, 2011).
Significant efforts are still required to overcome the market approach of the
national health system. Interventions must be designed so as to have well-trained
© 2013 The Authors. International Journal of Health
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Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
and motivated human resources, as well as to establish an available and stable source
of financial resources for the PHC strategy.
This study was conducted under the project ‘Learning from the experience of PHC in
Bogota and Santander’, which was funded by Colciencias, DHS of Bogota (Convention 693 of 2010 Fondo Financiero Distrital de Salud-Pontificia Universidad
Javeriana) and by the Teasdale-Corti Global Health Research Partnership Program,
a collaborative health research programme developed by the four founding partners
of the Canadian Global Health Research Initiative—Canadian Institutes of Health
Research, International Development Research Centre, Health Canada and Canadian
International Development Agency—with input from the Canadian Health Services
Research Foundation. This work was also partly supported by the Global Health
Research Scholarship and the Umeå Center for Global Health Research, funded by
FAS, the Swedish Council for Working Life and Social Research (Grant no. 2006-1512).
The authors have no competing interests.
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Int J Health Plann Mgmt 2014; 29: e347–e367.
Planning and Management published by John Wiley & Sons, Ltd.
DOI: 10.1002/hpm
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