Improving surgical quality in Colombia through indicators
Authors: J H Rodríguez Moreno, Laura Vivas Martinez
Journal: The Lancet Global Health (2020)

In the past 27 years, Colombia has created a health system based on population-level insurance, assuring that each person residing in the country has access to basic health services, including general practitioners, nursing professionals, and prenatal care, and enabling early diagnosis of preventable diseases. However, access to more specialised services, such as general surgical, orthopaedic, obstetric, and urology services, has been poorer, generating a lower level of user satisfaction. To improve the quality of health services, and thereby improve patient satisfaction and health outcomes, and to make more efficient use of resources, the Colombian Government has proposed a health-care model: the Modelo de Acción Territorial.1Ministerio de Salud y Protección SocialResolución 2626 de 2019. Por el Cual se modifica la Política de Atención Integral en Salud—PAIS y adopta el Modelo de Acción Integral Territorial-MAlTE.https://www.minsalud.gov.co/Normatividad_Nuevo/Resoluci%C3%B3n%20No.%202626%20de%202019.pdfDate: Sept 27, 2019Date accessed: March 10, 2020Google Scholar This model, first, aims to generate evidence-based, comprehensive, integrated health-care care pathways for healthy patients and for at-risk groups (eg, those with cardiovascular diseases, rare diseases, nutritional diseases, or mental health concerns).2Ministerio de Salud y Protección SocialResolución 3202 de 2016. Por la cual se establece el manual metodológico para la elaboración e implementación de las rutas integrales de atención en salud.https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/resolucion-3202-de-2016.pdfDate: July 25, 2016Date accessed: March 11, 2020Google Scholar Second, the model aims to construct comprehensive health-care networks to provide high-quality health services by insurers, which will allow more timely and adequate care for the country's population through georeferencing schemes.3Ministerio de Salud y Protección SocialResolución 1441 de 2016. Por la cual se establecen los estándares, criterios y procedimientos para la habilitación de las Redes Integrales de Prestadores de Servicios de Salud.https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/resolucion-1441-2016.pdfDate: April 21, 2016Date accessed: March 11, 2020Google Scholar In the Lancet Global Health, Joseph Hanna and colleagues4Hanna JS Herrera-Almario GE Pinilla-Roncancio M et al.Use of the six core surgical indicators from the Lancet Commission on Global Surgery in Colombia: a situational analysis.Lancet Glob Health. 2020; 8: e699-e710Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar report the results of their complete situation analysis of surgical, anaesthetic, and obstetric system preparedness, service delivery, and financial risk protection using the core surgical indicators proposed by the Lancet Commission on Global Surgery. This analysis establishes a baseline dataset on which future progress regarding these indicators can be judged. These data can also be used to design improved care networks, which should lead to an improvement in patient satisfaction and more efficient use of health system resources. Allocation of resources, based on data such as provider density, for instance, is much lower than the Commission's minimum target of 20 providers per 100 000 population: Hanna and colleagues estimated that Colombia had a density of 13·7 essential surgical, anaesthetic, and obstetric health-care providers per 100 000 population in 2018. The results of the study by Hanna and colleagues should be framed in the context of the variables that determine whether citizens can access health services, especially basic surgery, anaesthetic, and obstetric services. It is important to highlight that there are hospitals in all departments in Colombia that provide these specialty services. However, this availability does not ensure effective access of patients to specialists because, for example, specialists are available only 15 days or 20 days per month in some zones and their salary is two or times higher in high rurality zones, and because these specialists tend to predominantly work in the country's larger cities, making it difficult for the population with the lowest economic resources to access these services.1Ministerio de Salud y Protección SocialResolución 2626 de 2019. Por el Cual se modifica la Política de Atención Integral en Salud—PAIS y adopta el Modelo de Acción Integral Territorial-MAlTE.https://www.minsalud.gov.co/Normatividad_Nuevo/Resoluci%C3%B3n%20No.%202626%20de%202019.pdfDate: Sept 27, 2019Date accessed: March 10, 2020Google Scholar, 5Ministerio de Salud y Protección SocialSegunda medición a las metas regionales de recursos humanos en salud 2013. Bogotá, Colombia.https://www.observatoriorh.org/sites/default/files/webfiles/fulltext/2013/segunda_medicion_metas_col.pdfDate accessed: March 12, 2020Google Scholar The study by Hanna and colleagues is important as a baseline dataset because the results are based on official information on the availability of health service providers, the distribution of services in the country, the number of procedures performed, and the resulting complications, such as postoperative mortality. However, to understand their analysis of the geographical dispersion of the population and the resultant time taken to access these services, which found that at least 7·1 million people (15·1% of the population) in Colombia did not have reasonable geographical access to these services,4Hanna JS Herrera-Almario GE Pinilla-Roncancio M et al.Use of the six core surgical indicators from the Lancet Commission on Global Surgery in Colombia: a situational analysis.Lancet Glob Health. 2020; 8: e699-e710Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar it is necessary to recognise the differences between the three types of territories defined in Colombian health policies: namely, large cities (cities with high population in urban areas), high rurality zones (towns with a high rural population) and high dispersion population zones (zones with a small population in a large territories).1Ministerio de Salud y Protección SocialResolución 2626 de 2019. Por el Cual se modifica la Política de Atención Integral en Salud—PAIS y adopta el Modelo de Acción Integral Territorial-MAlTE.https://www.minsalud.gov.co/Normatividad_Nuevo/Resoluci%C3%B3n%20No.%202626%20de%202019.pdfDate: Sept 27, 2019Date accessed: March 10, 2020Google Scholar Consideration of the rurality of territories is important in understanding regional disparities in access to services, given that the problem of access in many municipalities and rural areas of Colombia is not caused by the absence of services but by the way in which citizens must access services (ie, their mode of transport). The travelling distance to health services in these areas can increase costs to access health services, directly generating out-of-pocket expenses, which could not be fully incorporated into and evaluated in the analysis by Hanna and colleagues. One of the final perspectives to be considered by health decision makers is to understand the patient's perspective in more depth. For the health service user, territoriality is not only related to the department or district where they pay taxes, but it also affects their access to basic services such as education and health.6WHOPrimary health care systems (PRIMASYS): case study from Colombia, full version.https://www.who.int/alliance-hpsr/projects/alliancehpsr_colombiaprimasys.pdf?ua=1Date: 2017Date accessed: March 11, 2020Google Scholar For example, although the Colombian Government establishes differential premiums to be paid to insurers, based on based on types of territories, features of population, racial features, and equity, which ensures that transportation to some services and translators for indigenous populations are paid for by the health system, this policy only applies to areas with high geographical dispersion of the population (ie, areas with high rurality;7Ministerio de Salud y Protección SocialResolución 3513 de 2019. Por la cual se fijan los recursos de la UPC para financiar las tecnologías y servicios del régimen contributivo y subsidiado en el año 2020.https://www.minsalud.gov.co/Normatividad_Nuevo/Resolucion%20No.%203513%20de%202019.pdfDate: Dec 26, 2019Date accessed: March 12, 2020Google Scholar 11 departments) and does not consider factors restricting access to health services in other departments. In other departments, the patient's indirect health out-of-pocket costs therefore increase, causing inequality of access, and limiting improvement in the population's health and in the country's health indicators. Another use of these indicators is at the national government level to adjust the per capita value for each of the types of territories described, or to define human talent policies in surgical specialties. We declare no competing interests. Use of the six core surgical indicators from the Lancet Commission on Global Surgery in Colombia: a situational analysisWe did a non-modelled, indicator-based situation analysis of the Colombian SAO system, finding that it has not yet met, but is working towards achieving, the targets set by the Lancet Commission on Global Surgery. The observed interdependence of these indicators and correlation with socioeconomic status are consistent with well recognised factors and outcomes of social, health, and health-care inequity. The internal consistency observed in Colombia's situation analysis validates the use of the indicators and has now informed development of an early national SAO plan in Colombia, to set a data-informed stage for implementation and evaluation of timely, safe, and affordable SAO health care, within the National Public Health Decennial Plan, which is due in 2022. Full-Text PDF Open Access