Barreras en el acceso a la atención en salud en modelos de competencia gestionada: un estudio de caso en Colombia

Abstract

Background. The managed competition model is one of the reforms promoted in the last few decades in Latin America, in response to the objective to improve equity and efficiency of health systems. It has been characterized by the introduction of a regulated market for health insurance to correct market failure. The health sector reform in Colombia, initiated by Law 100 (1993) is considered to be one of the firsts with the implementation of managed competition in a low-income country. It was created the General Social Security System in Health, made up of two insurance schemes: the Contributory Regime for formal sector employees and the Subsidized Regime for people without ability to pay, managed by Healthcare Insurers (EPS and ARS). They were to compete for the enrolment of population and received a capitation payment to cover different benefit packages in each regime. Objective. To analyse factors and actor that influence on access to continuum of care in four integrated healthcare networks in Colombia, and proposals to improve the access, from social actors' perspective. Methods. An exploratory, descriptive-interpretative qualitative study was carried out, based on case studies of four healthcare networks. There were two areas of study: one urban -Ciudad Bolívar, Bogotá, D.C., and one rural -La Cumbre, Department of Valle del Cauca. A criterion sample was selected in three stages.: I) Cases studies: healthcare networks of both regimes, in both the rural and urban areas, II) Public and private provider networks from different levels of care, and with different ownership levels of the insurance company, and III)informants -insured and uninsured users (35), health professionals (51), administrative personnel (20), and providers' and insurers' managers (28). The final sample size was reached by saturation of the information. Individual semi-structured interviews with a topic guide were conducted. Narrative content analysis was conducted; segmented by cases, informant's groups and themes. To ensure the quality of data, the information was triangulated between groups of informants and researchers, and the results were contrasted with the informants. Findings. Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care mechanisms - authorization of services, control of clinical practice and capitation payment-; providers' networks structural and organizational limitations; and, poor living conditions. Insurers' and providers' values based on economic profit permeate all factors. Variations became apparent between the two geographical areas and insurance schemes. In the urban areas barriers related to market functioning - frequently change of contracted healthcare providers, conflict between payers and patient rejection, segmented purchasing -, whereas in the rural areas structural deficiencies in health services - shortage in the supply and limited geographic accessibility - are linked to insufficient public funding. While financial obstacles are dominant in the subsidized regime, in the contributory scheme supply shortage prevails, related to insufficient private investment. Conclusions. The origin of all of the problems of healthcare access in Colombia can not be attributed to the managed competition model, but the results show how it has contributed to worsening structural and organizational barriers of access to care, as well as to the creation of new ones that do not appear in public models without competition. They question the promotion of this model in low and middle-income countries -where market regulation is known to be particularly difficult.

Date of Award	3 Jul 2009
Original language	Undefined/Unknown
Supervisor	María Luisa Vázquez Navarrete (Director) & Miguel Luis Martin Mateo (Tutor)