Services on Demand
Journal
Article
text new page (beta)
Spanish (pdf)
Article in xml format
Article references
Automatic translation
Send this article by e-mailIndicators
-
Cited by SciELO -
Access statistics
Related links
-
Similars in
SciELO
Share
Permalink
Gestión y política pública
Print version ISSN 1405-1079
Gest. polít. pública vol.16 n.1 Ciudad de México Jan./Jun. 2007
Experiencias relevantes
La descentralización del sector salud en Colombia. Una perspectiva desde múltiples ámbitos
The Decentralization of the Health Sector in Colombia Seen from a Multiple Level Perspectives
1Gloria Molina tiene un doctorado en enfermería en la Universidad de Birmingham. Es conferencista e investigadora en la Escuela Nacional de Salud Pública, Universidad de Antioquia. Dirección postal: Calle 62 No. 5219, Medellín, Colombia. Tel.: 57-4. 256-5615, 510-6840; Fax: 57-4. 511- 2506. Correo electrónico: molinag@gua-jiros.udea.edu.co; molinag@epm.net.co.
2Peter Spurgeon es doctor en Psicología. Se desempeña como director de Gestión y Desarrollo Organizacional y Liderazgo del Management and Organization Development and Leadership at the Health Services Management Centre de la Universidad de Birmingham. Dirección postal: Park House, 40 Edgbaston Park Road, Edgbaston, Birmingham B15 2TR, Inglaterra. Tel.: 44-0121. 414-7050; Fax: 414-3673. Correo electrónico: P.Spurgeon@bham.ac.uk.
Este artículo analiza las características del desarrollo institucional (DI) y la participación comunitaria (PC), como los principales componentes de la descentralización del sector salud en Colombia. Este análisis se enmarca en el contexto de las reformas al sector salud que buscan mejorar la prestación de servicios sanitarios. Se entiende la descentralización como una política pública que interactúa mucho con el entorno político, social, económico y administrativo. El estudio incluye tres estudios de caso desde la perspectiva de los tomadores de decisiones en los ámbitos local, regional y nacional donde se recolectaron y procesaron datos cualitativos y cuantitativos. Los hallazgos sugieren que los tres municipios han progresado en ciertos aspectos de la descentralización del sector salud, pero que no cuentan con un avance integrado del DI y la PC. El sistema político ha desempeñado un papel importante en este proceso, pues el clientelismo influye en la calidad del personal y en todo el proceso. La mezcla de descentralización y privatización también creó conflictos en la prestación de servicios.
Palabras clave: reforma del sector salud; desarrollo institucional; participación comu nitaria; privatización; fallas del mercado; cualitativo; estudio de caso.
This article analyses the characteristics of Institutional Development (ID) and Community Participation (CP) as the main components of decentralization of the health sector in Colombia. This analysis is framed in the context of health sector reforms that seek to improve the provision of health services. Decentralization is understood as a public policy, which interacts strongly with the political, social, economic and administrative environment. The study involved three case studies and the perspective of the regional and national decision-makers in which qualitative and quantitative data were gathered and processed. The findings suggest that the three municipalities have progressed in some aspects of the decentralization of the health sector, but they do not have an integrated development of id and cp. The political system has played an important role in this process, in which the patronage system influences the quality of the staff and the whole process. The mixture of decentralization and privatization has also created conflicts in the provision of services.
Keywords: health sector reform; institutional development; community participation; privatization; market failures; qualitative; case study
REFERENCIAS BIBLIOGRÁFICAS
Álvarez, S. E.; E. Dagnino y A. Escobar (2001), "Introduction: The Cultural and Political in Latin American Social Movements", en L. Morgan, "Community Participation in Health: Perpetual Allure, Persistent Challenge", Health Policy and Planning, vol. 16, núm. 3, pp. 221-230. [ Links ]
Anderson, J. E. (1995), "Public Policy Making: An Introduction", en M. Howlett y M. Ramesh, Studying Public Policy. Policy Cycles and Policy Subsystems, Ontario, Oxford University Press. [ Links ]
Angell, A.; P. Lowden y R. Thorp (2001), Decentralizing Development. The Political Economy of Institutional Change in Colombia and Chile, Oxford, Oxford University Press. [ Links ]
Arrubla, M. (1996), Colombia hoy: perspectivas hacia el siglo XXI. Síntesis de la historia política contemporánea, Bogotá, T. M. [ Links ]
Asociación Nacional de Secretarías de Salud (2000), Base de Datos de Municipios y Departamentos Certificados hasta el 2000, Bogotá, Ministerio de Salud. [ Links ]
Ayee, J. R. A. (1994), An Anatomy of Public Policy Implementation. The Case of Decentralization Policies in Ghana, Evebury, Aldershot. [ Links ]
Banco Mundial/Banco Interamericano de Desarrollo (1998), Descentralización en Colombia. Nuevos desafío s, RE3-98-002, Washington, World Bank. [ Links ]
Batley, R. (1996), "Public-Private Relationships and Performance in Service Provision", Urban Studies, vol. 33, núms. 4-5, pp. 723-751. [ Links ]
Bertranou, F. M. (1999), "Are Market-Oriented Health Insurance Reforms Possible in Latin America? The Cases of Argentina, Chile and Colombia", Health Policy, vol. 47, núm. 1, pp. 19-36. [ Links ]
Bossert, T.; W. Hsiao; M. Barrera; L. Alarcon; M. Leo y C. Caseres (1998), "Transformation of Ministries of Health in the Area of Health Reform: The Case of Colombia", Health Policy and Planning, vol. 13, núm, 1, pp. 59-77. [ Links ]
Bossert, T. J.; M. Chawla; D. Bowser; J. Beauvais; U. Giedion; J. J. Arbelaez y A. López (2000a), "Applied Research on Decentralization of Health Systems in Latin America: Colombia Case Study", Health Sector Reform Initiative 32, AC.HSR. [ Links ]
Bossert, T.; O. Larrañaga y F. Ruiz (2000b), "Decentralization of Health Systems in Latin America", Revista Panamericana de Salud Pública/Pan Am JPublic Health, vol. 8, núms. 1-2. [ Links ]
Burki, S. J.; G. E. Perry y W. R. Dillinger (1999), "Mas allá de centro", La descentralización del Estado, Washington, Banco Mundial. [ Links ]
Buyck, B. (1998), "The Bank's Use of Technical Assistance for Institutional Development", en L. Montiel, Institutional Development of Local Government in a Developing Country. The Case of Venezuela, tesis doctoral, Universidad de Birmingham. [ Links ]
Cardona, A., P. Arbelaez y B. M. Chávez (1999), "Impacto de la reforma de Seguridad Social sobre la organización institucional y la prestación de servicios de salud en Colombia", Revista Facultad Nacional de Salud Pública, vol. 16, núm. 1, pp. 20-40. [ Links ]
Castañeda, T., G. Beeharry y C. Griffin (1999), "Decentralization of Health Services in Latin American Countries: issues and Some Lessons", Decentralization and Accountability of the Public Sector, Washington, World Bank, World Bank Latin American and Caribbean Studies. [ Links ]
Castaño, R. A., J. J. Arbeláez, U. Giedion y L. G. Morales (2001), Evolución de la equidad en el sistema colombiano de salud, Serie Financiamiento del desarrollo 108, Naciones Unidas, CEPAL-ECLAC, Santiago de Chile. [ Links ]
Céspedes, J. E., R. Martínez, S. Olaya, J. Reynales, C. Uribe, R. A. Castaño, E. Garzón, C. Almeida, C. Travassos, F. Basto y J. Angarita (2000), "Reforma de la seguridad social en salud en Colombia y efectos sobre la equidad en el acceso y la utilización de servicios de salud", Revista de Salud Pública, vol. 2, núm. 2, pp. 145-164. [ Links ]
Cheema, G. S. y D. A. Rondinelli (1983), Decentralization and Development, Beverley Hills, Sage. [ Links ]
Christiansen, T. (2002), "Summary of the SWOT Panel's Evaluation of the Organization and Financing of the Danish Health Care Services", Health Policy, vol. 59, pp. 173-180. [ Links ]
Collins, C. D. (1987), Local Government and its Reform in Colombia between 1974 and 1986, tesis doctoral, Institute of Local Government Studies, Universidad de Birmingham. [ Links ]
Collins, C. y A. Green (1993), "Decentralization and Primary Health Care in Developing Countries: Ten Key Questions", Journal of Management in Medicine ", vol. 7, núm. 2, pp. 58-68. [ Links ]
Collins, C. D., J. Araujo y J. Barbosa (2000), "Decentralizing the Health Sector: Issues in Brazil", Health Policy, vol. 52, pp. 113-127. [ Links ]
Collins, C. D., M. Omar y E. Tarin (2002), Decentralization, Health Care and Policy Process in the Punjab, Pakistan in the 1990s, consultado en Internet: www.intercience.wiley.com. [ Links ]
Departamento Nacional de Planeación (DNP) y PNUD (1999), Informe de Desarrollo Humano para Colombia, Bogotá, Tercer Mundo. [ Links ]
Di Matteo, L. (2000), "The Determinants of the Public-Private Mix in Canadian Health Care Expenditures, 1975-1996", Health Policy, vol. 52, pp. 87-112. [ Links ]
Dye, T. R. (1972), Understanding Public Policy, New Jersey, Prentice-Hall. [ Links ]
Esman, M. (1998), "Strategies and Strategic Choices for Institutional Development", en L. Montiel, Institutional Development of Local Government in a Developing Country. The Case of Venezuela, tesis doctoral, Universidad de Birmingham. [ Links ]
Ferrelli, R.; C. R. Serrano; P. P. Balladelli; A. Cotinois y J. Quinteros (1997), "Strengthening Local Health Care Management in Bolivian Districts Through Participatory Operational Research", International Journal of Health Planning and Management, vol. 12, pp. 29-50. [ Links ]
Forero, C. y C. Hidalgo (1997), Descentralización y participación ciudadana, Bogotá, Tercer Mundo. [ Links ]
Gastor, L. (1995), Management Skills in Decentralized Environment, Institute of Local Government Studies, the Local Government Management Boards, Birmigham, University of Birmingham. [ Links ]
Gershberg, A. I. (1998), "Decentralization, Recentralization and Performance Accountability: Building an Operationally Useful Framework for Analysis", Development Policy Review, vol. 16, pp. 405-431. [ Links ]
Glaser, B. y A. Strauss (1967), The Discovery of Grounded Theory, Nueva York, Aldine de Gruyter. [ Links ]
Granados, R. T. y M. C. Gómez (2000), "La reforma de los sistemas de salud en Chile y Colombia: Resultados y balance", Revista de Salud Pública, vol. 2, núm. 2, pp. 97-120. [ Links ]
Grindle, M. y J. Thomas (1991), Public Choices and Policy Change. The Political and Economic Reform in Developing Countries, Baltimore, Johns Hopkins University Press. [ Links ]
Haggard, S. (1999), "The Politics of Decentralization in Latin America", World Bank Latin American and Caribbean Studies, Annual World Bank Conference on Development in Latin America and the Caribbean. Decentralization and Accountability of the Public Sector, Washington, pp. 9-31. [ Links ]
Hartmann, L. F. (1999), Decentralizing Health: The Experience and Policy Lessons in Bolivia, mimeografiado, Washington, The World Bank. [ Links ]
Herrera, V. (1999), "Régimen subsidiado de salud: evolución y problemática", Revista de Salud Pública, vol. 1, núm. 3, consultado en Internet: www.medicina.unal.edu.co/revistasp/vol3n2.htm. [ Links ]
Hill, M. (1997), The Policy Process, Nueva York, Michael Hill Publisher. [ Links ]
Hogwood, B. y G. Lewis (1997), "Why 'Perfect Implementation' is Unattainable", en M. Hill, The Policy Process, Londres, Michael Hill Publisher, pp. 217-225. [ Links ]
Jenkins, W. I. (1978), Policy Analysis: A Political and Organizational Perspective. Government and Administration Series, Londres, Martin Robertson. [ Links ]
Kahssay, H. M. y P. Oakley (1999), Community Involvement in Health Development: A Review of the Concept and Practice, Ginebra, WHO. [ Links ]
Krishna A., N. Uphoff y M. J. Esman (1997), Reasonsfor Hope: Instructive Experiences in Rural Development, West Hartford, CT, Kumarian Press. [ Links ]
La Forgia, G. M. y N. Homedes (1995), Decentralizing Health Services in Colombia. A Review of Progress and Problems, Washington, World Bank. [ Links ]
López, M. R. (1995), Fiscal Decentralisation in Latin America, Washington, World Bank. [ Links ]
Martínez, P., L. A. Rodríguez y C. Agudelo (2001), "Equidad en la política de reforma del sistema de salud", Revista de Salud Pública, vol. 3, núm. 1, pp. 13-39. [ Links ]
Mascareño, C. (1996), Municipalización de los servicios sociales en América Latina, Caracas, CLAD. [ Links ]
Miles, M. y A. M. Huberman (1994), Qualitative Data Analysis: An Expanded Source-book, 2a. ed., Thousand Oaks, Sage. [ Links ]
Ministerio de Salud de Colombia (2001a), Municipio Centinela: Evaluación de la implementación del Sistema General de Seguridad en Salud 1997 -1999, Bogotá, Ministerio de Salud. [ Links ]
Ministerio de Salud de Colombia (2001b), "Situación de salud en Colombia", Boletín de indicadores básicos 2000, Bogotá, Ministerio de Salud. [ Links ]
Montiel, L. (1998), Institutional Development of Local Government in a Developing Country. The Case of Venezuela, tesis doctoral, Universidad de Birmingham. [ Links ]
Mosquera, M.; Y. Zapata; K. Lee; C. Arango y A. Varela (2001), "Strengthen User Participation Through Health Sector Reform in Colombia: A Study of Institutional Change and Social Representation", Health Policy and Planning, vol. 16, núm. 2, pp. 52-60. [ Links ]
Muller, F. (1991), Pobreza, participación y salud: casos latinoamericanos, Medellín, Universidad de Antioquia. [ Links ]
Nelson, N. y S. Wright (1995), Power and Participatory Development: Theory and Practice, Londres, Nici N. [ Links ]
Nickson, A. (1995), Local Government in Latin America, Boulder, COL/Lynne Riener, Londres. [ Links ]
Nieto, J. R. (1997), "Desarrollo y salud: la experiencia contemporánea en Colombia y América Latina. Utopía siglo XXI", Revista de la Facultad de Ciencias Sociales y Humanas, vol. 1, núm, 1, pp. 51-61. [ Links ]
Nigenda, G. y M. H. Machado (2000), "From State to Market: The Nicaraguan Labour Market for Health Personnel", Health Policy and Planning, vol. 15, núm. 3, pp. 312-318. [ Links ]
Paul, S. (1998), "Institutional Development in The World Bank Projects: A Cross-Sectoral Review", en L. Montiel, Institutional Development of Local Government in a Developing Country. The Case of Venezuela , tesis doctoral, Universidad de Birmingham. [ Links ]
Penagos, G. (1994), Descentralización administrativa, Bogotá, Librería del Profesional. [ Links ]
Perry, G. E. (1999), "Challenges of Decentralization: Accountability, Efficiency, Equity and Financial Soundness", The World Bank Latin American and Caribbean Studies, Annual Bank Conference on Development in Latin America and Caribbean. Decentralization and Accountability of the Public Sector, Washington, World Bank , pp. 431-432. [ Links ]
Plaza, B., A. B. Barona y N. Hearst (2001), "Managed Competition for the Poor or Poorly Managed Competition? Lessons from the Colombian Health Reform Experience", Health Policy and Planning, vol. 16, núm. 2, pp. 44-51. [ Links ]
Powell, M. (1999), An Analysis of Policy Implementation in the Third World, Ashgate, Aldershot. [ Links ]
Pressman, J. y A. Wildavsky (1973), Implementation: How Great Expectations in Washington are Dashed in Oakland, Londres, Berkeley-University of California Press. [ Links ]
Profamilia (2000), Encuesta nacional de demografía y salud. Salud sexual y reproductiva en Colombia, Bogotá, Profamilia. [ Links ]
Purohit, B. (2001), "Private Initiative and Policy Options: Recent Health System Experience in India", Health Policy and Planning, vol. 16, núm. 1, pp. 87-97. [ Links ]
Ramiro, L.; F. Castillo; T. Tan-Torres; C. Torres; J. Tayan; R. Talampas y L. Hawken (2001), "Community Participation in Local Health Boards in a Decentralized Set-tings: Cases From the Philippines", Health Policy and Planning, vol. 16, núm. 2, pp. 61-69. [ Links ]
República de Colombia (1990), Ley 10. [ Links ]
República de Colombia (1991), Constitución Nacional. [ Links ]
República de Colombia (1993a), Ley 100. [ Links ]
República de Colombia (1993b), Ley 60. [ Links ]
República de Colombia (2000), Ley 617. [ Links ]
Rojas, F. (1999), "The Political Context of Decentralization in Latin America", World Bank Latin American and Caribbean Studies, Annual World Bank Conference on Development in Latin America and the Caribbean, Decentralization and Accountability of the Public Sector, pp. 9-31. [ Links ]
Rondinelli, D.A. (1990), Decentralizing Urban Development Programs. A Framework for Analysing Policy, Office of Housing and Urban Programs of the US, Washington, Agency for International Development. [ Links ]
Scott, C. (2001), Public and Private Roles in Health Care Systems, Buckingham, Open University Press. [ Links ]
Silva, L.; V. Herrera y C. Agudelo (2002), "Promoción, prevención, municipalización y aseguramiento en salud en siete municipios colombianos", Revista de Salud Pública, vol. 4, núm. 1, pp. 1-20, consultado en Internet: www.medinina.unal.edu.co/ist/revistasp/v4nl/v4nlal.htm. [ Links ]
Superintendencia Nacional de Salud (1996), Recursos Humanos de Salud en Colombia, Bogotá, Ministerio de Salud. [ Links ]
Vargas, A. (1999), El Estado y las políticas públicas, Bogotá, Almudena. [ Links ]
Vargas, J. E. (1997), "Descentralización de los servicios de salud en Colombia", Revista Planeación y Desarrollo, vol. 28, núm. l, pp. 20-45. [ Links ]
Walt, G. (1994), Health Policy : An Introduction to Process and Power, Londres, Zed. [ Links ]
Webb, A. y G. Wistow (1982), Whither State Welfare?: Policy and Implementation in the Personal Social Services, Londres, Royal Institute of Public Administration. [ Links ]
Willis, E.; C. Garman y S. Haggard (1999), "The Politics of Decentralization in Latin America", Latin America Research Review, vol. 34, núm. l, pp. 7-56. [ Links ]
World Bank (1995), Local Government Capacity in Colombia. Beyond Technical Assistance, Washington, World Bank. [ Links ]
World Bank (1996), "Reflections from the Participation Sourcebook", 40, 1996, consultado el 14 de agosto de 2002 en Internet: World Bank (1996), "Reflections from the Participation Sourcebook", 40, 1996, consultado el 14 de agosto de 2002 en Internet: www-esd.worldbank.org/html/esd/env/publicat/dnotes/dn400296.htm . [ Links ]
Yepes, F. y L. H. Sánchez (2002), La descentralización de salud en Colombia. Estudio de casos y controles, Bogotá, ASALUD, inédito. [ Links ]
Yin, R. K. (1994), The Case Study Research. Designing and Methods, 2a. ed., Londres, Sage. [ Links ]
Zambrano, P. F. (1996), "La invención de la Nación. Contradicciones del sistema político colombiano", Revista Análisis 3, Conflicto Social y Violencia en Colombia, 56 CINEP. [ Links ]
1Este artículo forma parte de la tesis An Examination of the Process of Decentralization of the Health Sector in Colombia, que Gloria Molina presentó en la Universidad de Birmingham para obtener el doctorado en 2003. Los autores quieren agradecer a la Universidad de Antioquia, Medellín, Colombia, y a la Organización Panamericana de la Salud por el apoyo financiero otorgado a esta investigación. Asimismo, agradecen al Centro de Administración de Servicios de Salud de la Universidad de Birmingham y a la Facultad Nacional de Salud Pública de la Universidad de Antioquia por el respaldo académico prestado. Traducción del inglés de Susana Moreno Parada.
Recibido: 21 de Abril de 2005; Aprobado: 21 de Septiembre de 2006
Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons
