The Colombian General System of Social Security in Health (GSSSH) is based on an insurance market with different public-private provider combinations. Individuals are usually enrolled under one of two different regimes: the contributory regime, funded by payroll contributions, where formally employed and independent workers contribute a proportion of their incomes; and the subsidized regime, funded by general tax revenue, where poor people do not make any insurance contribution and are partially or fully covered depending on their poverty status [1, 2]. Insurance companies from the contributory regime collect funds from the enrollees and outsource the provision of care through contracts mainly with private health care providers. Insurance companies from the subsidized regime receive funds from national transfers made by local health authorities and outsource the provision of care through contracts mostly with public health care providers.
Individuals in both, the contributory and subsidized regimes, choose their insurer and the health care providers from within the insurer’s network, and they receive a health benefits package. The contributory regime package covers all levels of care, while the subsidized covers primary care, as well as some inpatient and emergency care (40% less coverage than the contributory regime) .
The GSSSH offers a public health intervention package or Collective Intervention Plan (CIP—Plan de intervenciones colectivas in Spanish) which complements the mandatory health care insurance. Local health authorities provide health promotion and disease prevention services included in the CIP through contracts between Health Secretariats and public health providers .
Within this framework of health care segmentation [3–5] in 2004, the local government of Bogotá decided to apply a new initiative through the implementation of a Primary Health Care (PHC) strategy with a comprehensive approach. The comprehensive approach of PHC has been defined as the effective combination of promotive, preventive, curative and rehabilitative services. As an interactive model, primary health care encourages individuals and communities to be more involved in decisions about their health and its management . Thus, PHC in Bogota was conceived as a strategic model for transforming health care delivery. The main purpose of the strategy was to guarantee the right to health and to achieve the highest possible level of population’s health with the emphasis on equity, solidarity and citizen self-reliance [7, 8].
The essential elements of this strategy were: the introduction of a family and community orientation in the delivery of services; the reorganization and redistribution of primary care so that it became the gatekeeper of the health system; the implementation of an intersectoral response focused on solving community needs; and the promotion of social participation [7, 8].
The core of the strategy, from the operational point of view, was the Home Health (Salud a su Casa) program. This program was implemented exclusively within the network of the first-level public health care facilities operating under the authority of the Bogota District Health Secretariat (DHS). According to the guideline, the program’s intervention began by prioritizing poor people classified as belonging to social strataa 1 and 2, with the aim of gradual expansion to other strata. The program includes basic health care teams, comprised of a physician, a nurse, two community health workers, and an environmental technician who either provide intra- or extramural services. Twelve hundred families are assigned to each team in a geographically defined catchment area (micro-territories). These teams are supported by an expanded team consisting of a dental hygienist, dentist, physiotherapist, psychologist, and environmental engineer .
Financial resources for the implementation of the Home Health program are allocated from the DHS to public hospitals through the collective intervention plan . Resources provided by the DHS, cover full-time salaries for the two community health workers and the environmental technician and part-time salaries for the nurse and the physician. The strategy assumes that hospitals will finance the rest of the professionals’ working time to guarantee a full health care team per micro-territory.
During the first year of the PHC implementation, the staff working at Home Health care teams and senior level officials involved in coordination and management activities in public hospitals, were trained to serve as multipliers through short courses and diploma courses offered by national and international universities . Also the DHS in agreement with the National Apprenticeship Service (Servicio Nacional de Aprendizaje - SENA in Spanish) initiated a technical program to train community health workers and improve their skills in public health and health promotion strategies.
The program began its implementation in 2004 with the application of a household survey for the characterization of individuals, families and environmental health conditions in order to identify and to prioritize population needs and to design specific action plans according to the situation of the community. Once the needs have been identified, Home Health care teams provide health education at household level and when necessary, they refer people to social services and to their designated health care providers (contracted by the insurance company where they are enrolled). Priority cases (e.g. high risk pregnant women, disabled people) receive monitoring visits at home and are easier assigned to appointments in health care centers and hospitals. The program seeks to stimulate the demand for primary health care services and to facilitate access, intersectoral action and community participation through the intra- and extramural work of the teams .
By 2010, the program had achieved a 40.36% coverage (1,497,750 people) of the population in strata 1 and 2 in Bogotá, through the establishment of 358 basic health care teams. To respond to community needs, new health care facilities were created, opening hours of facilities were extended and an expansion of services was implemented .
While the above mentioned improvements are relevant, the main challenge for the Home Health program has been to provide health care according to the essential dimensions of primary care. These dimensions are first contact or gatekeeping, accessibility, longitudinality, comprehensiveness, coordination, family focus, and community orientation . In this regard, one of the priorities for policy-makers (especially those interested in facilitating the expansion and development of the strategy) should be the analysis of the performance of the PHC strategy in relation to its essential dimensions, and its relationship to the improvement of the population’s health [10–12].
In Latin America, the performance of the essential dimensions of the PHC approach has been evaluated in Brazil. The evaluation of its Family Health program was done through the adaptation and validation of the Primary Care Assessment Tool (PCAT), where Brazilians established a useful and applicable methodology to different contexts within the developing world [10–12].
In Colombia, several studies have been published regarding the PHC strategy; however most of them aim to describe the historical process of implementation , the operational and management model of PHC, and the analysis of health outcomes and equity [14–16]. Regarding performance evaluation, a pilot study adapting the methodology validated in Brazil, has been reported on one locality in Bogotá. This study found a low performance in the dimensions of family focus and community orientation, and an intermediate performance in the coordination and comprehensiveness dimensions. The research also showed a positive association between the perceived health status and the performance of the essential dimensions .
This study was carried out in close collaboration with DHS and responds to its request to evaluate the performance of the essential dimensions of the PHC strategy implemented in six localities geographically distributed throughout Bogotá city. Additional secondary objectives were to compare the performance of the PHC dimensions between public and private healthcare facilities and to identify possible associations between the global performance index of the PHC and the self-perceived health status of users. The findings of this study helped to identify dimensions in need of improvement and inform the District Health Secretariat about the challenges ahead.