Bureaucratic itineraries in colombia abadia & oviedo by saludalderecho

ARTICLE IN PRESS Social Science & Medicine xxx (2009) 1–8

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Bureaucratic Itineraries in Colombia. A theoretical and methodological tool to assess managed-care health care systems Cesar Ernesto Abadia*, Diana G. Oviedo Department of Anthropology, Universidad Nacional de Colombia, Cra 30, No. 45-03, Bogota, Colombia

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Article history: Available online xxx

Steady increases in the number of Colombians insured by the health care system contrasts with the hundreds of thousands of legal actions interposed to warrant citizen’s right to health. This study aims to analyze the relationships among patients’ experiences of denials by the system, the country’s legal mechanisms, and the functioning of insurance companies and service providing institutions. We conducted a mixed-methods case study in Bogota´ and present a quantitative description of 458 cases, along with semi-structured interviews and an in-depth illness history. We found that Colombians’ denials of care most commonly include appointments, laboratory tests or treatments. Either insurance companies or service providing institutions use the system’s legal structure to justify the different kinds of denials. To warrant their right to health care, citizens are forced to interpose legal mechanisms, which are largely ruled in favor, but delays result in a progressive and cumulative pattern of harmful consequences, as follows: prolongation of suffering, medical complications of health status, permanent harmful consequences, permanent disability, and death. We diagram the path that Colombians need to follow to have their health care claims attended by the system in a matrix called Bureaucratic Itineraries. Bureaucratic Itineraries is a theoretical and methodological construct that links the personal experience of illness with the system’s structure and could be an important tool for understanding, evaluating and comparing different systems’ performances. In this case, it allowed us to conclude that managed care in Colombia has created complex bureaucracies that delay and limit care through cost-containment mechanisms, which has resulted in harmful consequences for people’s lives. Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Colombia Bureaucracies Managed-care system Right to health care Legal actions Illness experiences Insurance Health reform

1. Introduction 1.1. Colombia Law 100: The new insurance-based health care system Insurance-based Latin American Health Care reforms follow the Managed-Care model of the United States and were exported to this region to meet insurance companies’ needs to expand their markets once they had reached saturation (Stocker et al., 1999). Thus, managed care has become the new paradigm in health care policy reforms (Iriart, Merhy, & Waitzkin, 2001), and the problems of deepening inequalities of the United States’ market-based medicine (Rylko-Bauer & Farmer, 2002) have also started to be apparent in Latin America (Almeida, 2002; Armada & Muntaner, 2004; Armada, Muntaner, & Navarro, 2001; Homedes & Ugalde,

* Corresponding author. Tel.: þ57 1 316 5000x16313. E-mail addresses: cesar_abadia@post.harvard.edu, cesarernestoabadia@yahoo.com (C.E. Abadia).

2005b), especially, in Colombia (De Groote, De Paepe, & Unger, 2005; De Vos, De Ceukeraire, & Van der Stuyft, 2006; Hernańdez, 2002; Homedes & Ugalde, 2005a). The majority of Latin American countries have implemented aspects of managed care, but only Chile and Colombia conducted full reforms (Homedes & Ugalde, 2005b). Following the 1991 constitutional mandate that did not grant health care the status of a fundamental human right but regarded it as a public service, 1993’s law 100 changed the way health care was conceived and practiced in Colombia by establishing the end of the former National Health System and the beginning of the current insurance-based General Health Social Security System. Arguing problems of fairness, corruption and inefficiency of public health care networks, the reformers attempted to transform the state’s intervention, financing, and regulatory roles in health care. The proposed strategy, that was ruled without political consensus (Plaza, Barona, & Hearst, 2001), marked the end of the previous subsidies to supply approach (direct money transfers to public hospitals), and the beginning of subsidies to demand, in which local governments buy managed-care insurance for the poor from

Please cite this article in press as: Abadia, C.E., Ovied, D.G., Bureaucratic Itineraries in Colombia. A theoretical and methodological tool to assess..., Social Science & Medicine (2009), doi:10.1016/j.socscimed.2008.12.049

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competing insurance companies (Gaviria, Medina, & Mejia, 2006; Plaza, Barona, & Hearst, 2001). The provision of services was to adopt a ‘‘structured pluralism’’ model, defined as an organizing structure with explicit rules and functions for the interactions of a choice exerting population, a modulating state, a financing social security network of institutions, and an increased pool of service ˜ o & Frenk, 1997). This structure, considered the providers (London first large-scale experiment with managed competition in the developing world, depended on the state’s regulation of a market of new health care insurance companies (EPSdEmpresas Promotoras de Salud), service provider institutions (private clinics became IPSdInstituciones Prestadoras del Servicio and public hospitals were transformed into companies, ESEdEmpresas Sociales del Estado), and consumers, who would exert power by choosing the best services from different options, given that risk adjusted premiums ˜ o & Frenk, 1997; Plaza, Barona, & are fixed by the state (London Hearst, 2001). By changing the financing of the health care services, the new system required definitions of levels of care to be provided according to the adjusted premium (Resolution 5261 of 1994), and stratification of users according to their payment capability with the intention of eliminating free of charge care, recovering costs, and earning money to pay foreign debt (OPS, 2002). Citizens with higher payment capability are required to purchase private health care insurance plans (11% of their income, Contributory Regime), which consists of a standard benefit package with three levels of care (I basic, II intermediate, and III complex) that are part of the Health Obligatory Plan (POS-Plan Obligatorio de Salud). In addition, 1.5% of their income is transferred to a fund that along with other sources of financing, such as taxes, is used by the state to pay subsidized policies for people without payment capability (Subsidiary Regime), who receive only the first level of care plus a few treatments included in levels II and III of the contributory regime (Resolution 306 of 2005) in a package known as SubsidizedHealth Obligatory Plan (POS-S). Although these differences in what is covered by each plan were intended to be temporary, the discrepancies between the two systems have persisted, leading to a historical consolidation of class-based inequalities in regards to health care in Colombia (Hernańdez, 2002). A transitioning period was proposed with the goal of universal coverage in 2000. When people are outside of the two regimes, that is when they have proven that they cannot afford private insurance and subsidized insurance companies also do not affiliate them arguing lack of expanding-users capability, they are called, paradoxically, insiders (vinculados). Insiders receive care in public hospitals in an event by event basis through funds that health care secretariats allocate to the hospitals. All people, however, according to income and type of affiliation to the system, including insiders, are asked to pay a fixed amount for each consultation, exam or prescription, or a percentage of the particular service or event they require. 1.2. Evaluations of the reform After 15 years of the reform, there are two opposing sets of results, analyses and arguments. For reformers, the fact that the number of people with insurance increased from 13.4% in 1993 to ˜ o, 2002; 82.7% at the end of 2005 is an irrefutable success (London Ministerio de Proteccioń Social, 2006). However, critics of the reform argue that official numbers are biased, and that whether enrollment in insurance equates access to services or higher quality of care is highly debatable (De Vos, De Ceukeraire, & Van der Stuyft, 2006; Hernańdez, 2002; Plaza, Barona, & Hearst, 2001). The system’s performance and promotion of equity have also been a disputed topic. In 2000, the WHO ranked health care

systems based on a new indicator of performance, which was claimed to be a step towards evidence-based health policy (Murray & Frenk, 2000). The Colombian health care system ranked as best in the Americas in overall performance and first in the world in fairness in financial contribution, measured as households’ contribution to the system’s financing (WHO, 2000). These results that were claimed to be indicative of the country’s improvement in equity ˜ o, 2002) were highly criticized, not only because of the (London measurement’s technical problems, but also because the WHO, by using these new indicators, was favoring private interests at the expense of peoples’ health (Almeida et al., 2001; Navarro, 2000; Waitzkin, 2003). In fact, other studies of equity have found that, in Colombia, the poor have increased their health care expenses while the rich have reduced them (Homedes & Ugalde, 2005a, 2005b). The International Society for the Equity of Health ISEH (2006) presents a summary of mixed results with more poor people being insured as a significant step towards equity, and increases in out of pocket expenses as a sign of increased inequity. In addition, ISEH finds that many Colombians remain uninsured, that the significant increases in the country’s total expenditures in health care cannot be continued for much longer, and that the inequities between subsidiary and contributory regimes have not been resolved. According to official data from the Ministry of Social Protection (in charge of health and labor) and some scientific studies, the reform has been successful given that the country is closer to universal insurance coverage; quality and efficiency are improving, and users’ satisfaction is increasing (Ministerio de Proteccioń Social, 2006). Yet, other studies argue that not only have health care costs for both the state and the citizens escalated, but that traditional public health indicators, such as mortality rates, also show significant setbacks (Go´mez, 2006). Failures of the system have been related to several factors, including increases in preventable diseases associated with a decline in vaccination rates, the end of prevention and public health programs, the collapsing of the public health care networks represented by the closing of many public hospitals, the revoking of the right to adequate labor for health care workers, and the promotion of a market mentality that has shifted the focus away from health care (Acosta-Ramı´rez, Durań, Eslava, & Campuzano, 2005; Homedes & Ugalde, 2005a; OPS, 2002; ISEH, 2006; Velez, 2008). Some studies have begun to show that, when the insurance-based system transforms the hospitals to for-profit institutions with managerial mentality, problems in denial, access and quality of care start to be evident (Abadıá-Barrero et al., 2007; De Groote, De Paepe, & Unger, 2005; De Vos, De Ceukeraire, & Van der Stuyft, 2006; Defensorıá del Pueblo, 2007b; Homedes & Ugalde, 2005a; Velez, 2008). 1.3. Citizenship and health care in Colombia Although the constitution did not identify health care as a fundamental human right, it provided legal mechanisms that any citizen can implement when they feel any cultural, social, political, or health right has been violated. Tutelas (writ for the protection of constitutional rights) are the most common legal action used by citizens to ask the judiciary system to protect their rights. Of the 1,067,070 writs initiated by Colombians between 1999 and 2005 (most current data), 30.76% (328,191) asked to grant the right to health specifically (Defensorıá del Pueblo, 2007b). Right to health writs are increasing every year (21,301 in 1999, 42,734 in 2002, and 81,017 in 2005), both in numbers and as a percentage of total writs (Defensorıá del Pueblo, 2007b; Ve´lez-Arango, Realpe-Delgado, Gonzaga-Valencia, & Castro-Castro, 2007). This may reflect the international literature that reports that the system is based on failed policies that deepen inequalities and access problems (De Groote, De Paepe, & Unger, 2005; De Vos, De Ceukeraire, & Van der

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Stuyft, 2006; Homedes & Ugalde, 2005b), and local research papers, reports from the Public Prosecutor, the Attorney General, and the People’s Ombudsman, and a Supreme Court Sentence (T-760) that highlight the increasing problems in health care expenditures, access, and delivery, as well as strains on the judiciary due to the health care system’s failures. We find that in current analyses of the system, however, people’s lived experiences are overlooked. In this study, we used our backgrounds in social science and health to understand the meanings of health care denials in people’s lived experiences and we built our analysis on the Critical Medical Anthropology and the Latin American Social Medicine traditions, which emphasize the social dimensions and structural causes of suffering and disease (Singer & Baer, 1995; Waitzkin, Iriart, Estrada, & Lamadrid, 2001).1 Thus, we want to contribute to the literature with this bottom-up study that constructs quantitative and qualitative approaches to analyze and evaluate the relationships among Colombians’ experiences of their denied health care needs by the system and the system’s policies and institutions. We believe that this analysis could be extrapolated to other managed-care systems in other developed and developing regions and countries. 2. Methods For this mixed method case study (Tashakkori & Teddlie, 2003), we conducted a systematic and in-depth analysis of people who reported problems of health care access and quality of care and had received legal advice at a non-for-profit Non-Governmental Organization (NGO) called Salud al Derecho. Similar to other institutions or individual lawyers, this NGO provides judicial advice to people whose right to health has not been granted by the health care system. However, it does not charge and conducts communitybased educational projects that aim to empower people to demand their right to health care. The NGO works in Bogota´ in a volunteer basis and its administrative structure is very minimal. Its financing corresponds mostly to the voluntary work of a group of five women and seven men (five lawyers, one physician, one dentist/doctor in anthropology, three people with bachelor’s degrees in anthropology and administration, and two members of the community who have primary and secondary levels of education). Since 2005, it has received small international cooperation grants that assist with office related costs, the salary of one full-time person, who works as a director, and the necessary material for its community programs. In this paper, we focus on quantitative data from all people who received legal advice during 2006–2007 and on qualitative data from a sub-sample. The study was conducted in five phases that integrated quantitative and qualitative procedures. Phase 1: Initial quantitative description. We created a database with all information that the association had collected from the people advised in the year 2006. For each case, the association gathered three sources of information: background information, medical summary, and legal summary. Once all data were entered in the data base, we generated descriptive categories as follows: (A) Demographic information (name, age, sex, activity, socioeconomic status, type of affiliation to the system, insurance company, and city locality/region). (B) What was denied? Appointments, medications, supplies/equipment, laboratory tests, surgeries, change of service providing institution, and others. (C) Description of denied care: description of experience with denial, date of negation, institution

1 See American Journal of Public Health’s special issue on Latin American Social Medicine: 2003, 93(12). See also the following web sites: http://hsc.unm.edu/lasm/ and http://www.socialmedicine.org/.

that denied the care, and institution’s justification for denying the care. (D) Legal procedure: legal actions taken, including Tutela (Writ for the Protection of Constitutional Rights), Derecho de Peticioń (Right to Petition), Impugnacioń (Challenge), Incidente de Desacato (Contempt of Court), Recurso de Reposicioń (Motion for Reversal), verbal advice, and no-need of legal advice. (E) Result of the legal action: in favor of citizen after first attempt, in favor of citizen after second attempt, against citizen, and in process. Phase 2: Short conversations, semi-structured interviews and case studies through in-depth interviews. In order to get a full picture of what it takes to face the health care system and the meaning of the patterns identified in the database, we helped conduct intake interviews, collaborated in the legal processes, followed up on their results, and conducted a series of informal conversations and semi-structured interviews with 12 people to explore how the illness experiences (Kleinman & Seeman, 2000) had been transformed by larger social contexts, in this case the interactions with the health care and legal systems. Based on qualitative analyses, we created the analytical category consequences of the denial of the right to health for the person’s life in order to describe the implications of the problems with the health care system in the personal experience of illness. We selected one particular case for a series of three in-depth interviews that seemed to exemplify much of the complaints expressed by the general population served by the NGO. We presented the cases and results of this phase to medical experts to clarify the medical conditions and prognosis of each case and to validate our analysis. Phase 3: Improvement of the database. With insights from the previous phase, we reorganized the database, called people with missing information, and inquired how their health care process had evolved since the beginning of the collaboration with the NGO. We used a universal sampling technique and included all cases of 2006 and 2007 (n ¼ 458). Phase 4. We reviewed the qualitative material and started to triangulate the information among researchers (Maxwell, 1996). We explored deeply the personal narratives and started to identify a common pattern of transits, trajectories, and time-demands imposed by the system in the people’s illness narratives. Through several working sessions, we were able to conceptualize Bureaucratic Itineraries as the overarching framework that represents the personal experience of the Colombian health care system. Phase 5. We constructed a diagram that represents an integration of quantitative and qualitative data, and started to present the results of the study and the final matrix to the NGO group, to people who had been legally advised, and in academic forums to validate (Maxwell, 1996) the matrix as representative of a general sense of how Colombians experience their health care system. 3. Results From January 2006 to December 2007, 458 people sought to initiate legal actions through Salud al Derecho, 283 (61.8%) women and 175 (38.2%) men. From the 0–6 scale used to stratify Colombians based on their socioeconomic status, 87.3% belonged to the three lowest levels (0, 1 and 2) which is utilized as a poverty index and means that they qualify for subsidized health care insurance. Of the total sample size, 15.75% were younger than 18; 30.34% were within the 19–40 age range; 27.07% were within the 41–55 age range; 22.48% were older than 56; and 4.36% did not indicate their age. When citizens arrived to the health care institutions, 17% were denied the assessment of their medical problem, (including first time appointments with the primary care doctor or specialists, follow ups, or changing the institution/provider). If seen by the health care professional, we found that people were denied either the laboratory tests (24.9%) or the required treatment (45%), which

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included medications (21.4%), surgeries (13.1%), or supplies/equipment and other materials (10.5%) (i.e., glasses, colostomy bags, glucometers, catheters, girdles, mechanical sutures, etc.) (Table 1). All institutions (EPS, IPS, or ESE) express different justifications for the health care activities they deny. We found that the kinds of justifications that entities give for denying care are in fact failures of the system that can be classified in five categories (Table 1): (1) Administrative Problems with the Insurance-Based System (APIBS) includes cases in which people cannot change institutions or providers, do not appear in the system, have two or more affiliations, have not fulfilled all administrative requirements, or are insiders. (2) Economic Barriers (EB) includes delays in monthly payments of their policies or recovery cost quotas, which includes a range of extra payments charged both to people from the contributory and subsidiary regimes and to insiders and are based on the cost of each service and the individual’s socioeconomic level. (3) Institutional Deficiencies (ID) means lack of human and physical resources or a mismatch in people’s expectations of care and the treatment provided, referred to as poor quality of the service, or when the institutions claim that users do not need a prescribed treatment. (4) Problems of Limited Coverage of the Policy (PLCP) is when people are told that their required service is not covered by the POS. (5) No Apparent Denial, Other Complaints, and Unknown (ND/O/U). Legal actions were interposed against many different health care system institutions; 48.47% belonged to the subsidiary system and interposed legal actions against 21 different Subsidiary EPSs, 36.24% belonged to the contributory system and interposed legal actions against 20 different Contributory EPSs, and 14.64% were insiders and interposed legal actions against the regional health care secretariat, the institution legally obliged to provide for their care (0.65% were unknown in terms of affiliation). The most common and effective legal action, Writ, needs support documents that make evident the denial of services. In cases in which institutions refuse to give any documentation, people need to ask for an official response through a Right to Petition, to which a written answer should be produced in fifteen working days. Challenge (when citizens disagree with the first ruling), Contempt of Court/Motion for Reversal (when institutions do not comply with the ruling) were less common. The fact that giving verbal advice, in many cases, was effective at solving access and quality of care problems regardless of people’s socioeconomic level or type of policy (data not shown) not only speaks to the complexity of the system’s bureaucracy, but also to the fact that people need institutional support to have their claims heard and solved (data not shown). Our data also confirmed that people’s

social and cultural capitals (including educational level) help them overcome the obstacles imposed by the system, including the use of the legal mechanisms, which has been discussed as individual tools that protect rights yet deepen inequalities (Hernańdez, 2002). Although the majority of the legal actions were ruled in favor of the citizens (84.27%), people’s stories demonstrated that the process of health care seeking, denial, interposing legal mechanisms and waiting for their results to start treatment had increased their suffering and, in many cases, had been detrimental for their health. We identified a progressive and cumulative pattern of harmful consequences in people’s narratives about the aforementioned process and constructed the qualitative category Consequences of the denial of the right to health for the person’s life (Table 2). Clearly, these consequences of the health care system’s denied and delayed care have repercussions for the person, their families, and larger social networks. 4. Bureaucratic Itineraries As presented in Tables 2 and 3, institutional demands, the different kinds of insurance plans, the recovery cost quotas, the cost of insurance policies, and even the judiciary system itself have become a bureaucratic social dynamic that trumps health care. The Colombian health care system has created new kinds of itineraries in which health care does not depend on people’s needs or medical assessment, but on meeting successfully the system’s administrative norms and financial costs (new access and quality barriers). When it is impossible to receive the necessary care, access depends on knowing and performing legal processes, the results of which are based not only on the judges’ interpretations, but also on the institutions’ compliance with the ruling. These itineraries have a profound effect on the person’s health, quality of life, and even life expectancy. As a difference from classic medical anthropology therapeutic itineraries in which patients seek to satisfy their healing beliefs by making a voluntary trajectory among the several therapeutic options available, the new itineraries in the Colombian managedcare system are obligatory administrative, financial and legal demands imposed on patients to access services or receive adequate care. We propose to call these paths Bureaucratic Itineraries of the health care systems, which are composed of citizens’ struggles to access care, the structural malfunctioning of the system, and the detrimental consequences in their lives. The matrix of Bureaucratic Itineraries (Fig. 1) represents the interaction of every citizen with the Colombian health care system.

Table 1 Sum totals of problems with the health care system and legal actions interpose by the 458 legally advised cases at the NGO Salud al Derecho, 2006–2007. Type of denial

Medical assessment Laboratory tests Treatment/medications Treatment/supplies, equipment Treatment/surgeries Change EPS/IPS No denial/others Total n (%)

System failures

Legal actions

APIBS

PLCP

37 24 8 0

7 20 11 2

20 16 18 2

10 50 59 42

1 4 12 86 (18.8%)

8 1 3 52 (11.3%)

8 0 11 75 (16.4%)

39 0 9 209 (45.6%)

ND/O/ U 4 4 2 2 4 0 20 36 (7.9%)

Results of legal action

Total

WRIT

CC/MR P/U

FPC

APC

P/U

n (%)

29 30 13 11

34 45 32 10

13 31 36 20

1 4 4 2

1 2 13 3

0 2 0 2

65 98 84 39

5 6 6 5

8 10 8 4

78 114 98 48

(17%) (24.9%) (21.4%) (10.5%)

8 1 12 104 (22.7%)

17 4 32 174 (38%)

31 0 8 139 (30.3%)

2 0 1 14 (3.1%)

2 0 1 22 (4.8%)

0 0 1 5 (1.1%)

49 5 46 386 (84.3%)

8 0 4 34 (7.4%)

3 0 5 38 (8.3%)

60 5 55 458

(13.1%) (1.1%) (12%) (100%)

SYSTEM FAILURES (Justiﬁcation of the entities for denying care): APIBS, Administrative problems with the insurance-based system; EB, Economic barriers; ID, Institutional deﬁciency; PLCP, Problems of limited coverage of the policy; DN/O/U, No denial/others/unknown. LEGAL ACTIONS: VA, Verbal advice; RP, Right to petition; Writ; CH, Challenge; CC/MR, Contempt of court/motion for reversal; P/U, Pending/unknown. RESULTS OF LEGAL ACTION: FPC, In favor of patient’s claim; APC, Against patient’s claim; P/U, Pending/unknown.

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Table 2 Consequences of The Denial of the Right to Health for the Person’s Life, short version.

Table 3 Rosalı´a’s case description.

1. PROLONGATION OF SUFFERING Case description: In August 2006, Gladys, a six-month pregnant woman had not been able to receive prenatal care and know the status of her baby because the system reports that she has two different subsidized afﬁliations. The service is blocked until she ﬁxes the problem. Consequence analysis: Prolongation of Suffering is the emotional distress caused by the lengthening of people’s waiting time to be seen and treated. Their health care status, however, is not altered by the delay or lack of care.

In-depth exploration of the illness experience and the health care system through Rosalıá’s story Rosalıá told us in detail the many difficulties that she has faced to have her youngest daughter, Tatiana, treated. Since birth, Tatiana has suffered such gastrointestinal problems that feeding her has become a major ordeal, leading to malnutrition and developmental and physical delays. The pediatricians have given her several referrals to specialists and orders for tests, but both the hospitals where she has taken Tatiana for treatment and the EPS that manages their subsidized insurance demand from her many visits to meet the necessary paperwork. In addition, appointments and tests are always scheduled on different days, causing an extra burden in her constant negotiation for days off with her boss. She remembers one particular day in August 2005 when, after many unsuccessful trips to schedule the appointments, she stood in line since 4 a.m. to be among the first served, but once she reached the scheduling window she did not have enough money to pay the recovery cost quota (about U.S.$1.05) and was asked to come another day when she had all the money. When she finally got the appointment in October, the gastroenterologist ordered 20 tests to evaluate Tatiana’s health, but the hospital and the EPS refused to perform them indicating that they were not covered in her subsidized plan (POS-S). In December of that year, she initiated a legal process (writ) to ask the judiciary system to grant Tatiana’s right to health care, including the 20 tests. The judge that ruled the case, however, argued that it was impossible to determine the future health care needs of Tatiana and that, if the treatments were too expensive, Tatiana’s case could threaten the financial equilibrium of the system. Thus, she did not rule integral care in the writ, but only ordered the institutions to provide the tests. The result of this partial legal ruling was that once the tests were performed in January 2006, Rosalıá could not have them read by the necessary specialists because the institution argued that these visits were not included in Tatiana’s writ or in the POS-S. Advised by Salud al Derecho, Rosalıá initiates a new writ on July 7, 2006 in order to get a ruling of integral care. Fifteen days later with this second writ in hand, Rosalıá takes Tatiana again to the hospital but finds that the tests were too old and she needed to start a new process of appointments, orders, and tests, even though Tatiana’s health continued to deteriorate without receiving the necessary care.

2. MEDICAL COMPLICATIONS OF HEALTH STATUS Case description: Following Nancy’s two pregnancies, her weight increased to 120 kg (264 pounds) causing joint pain and shortness of breath, and over time, depression and an emergency visit in which MI is ruled out. After a year of struggle to find responses from her health care service, an interdisciplinary team rules that she is a good candidate for gastric bypass surgery. The insurance company denies the surgery because it is not included in her policy. She presents a writ, which is ruled in her favor and forces the insurance company to do the procedure. She recovers uneventfully from the surgery, and after six months her overall medical and emotional condition has improved significantly. Consequence analysis: Medical Complications of Health Status are the result of the lapse of time between health care seeking and the effective provision of care, and in which the person’s medical condition worsens and either reduces the possibilities for full recovery or requires a more aggressive treatment. Medical harm, however, is reversible. 3. PERMANENT HARMFUL CONSEQUENCE Case description: On April 4, 2006, Astrid takes her three-year-old daughter, Lucıá, to the hospital, but no adequate care is received. After several visits to the emergency room and poor medical care, Lucıá is finally diagnosed with right lower-lobe necrotizing pneumonia that requires a mini thoracotomy to clean the area. The damage to her lung is permanent. Consequence analysis: Permanent Harmful Consequence occurs when the lapse of time between health care seeking and the effective provision of care is such that the persons’ medical condition worsens to the point that there is a permanent or long-term consequence. Hence, biological harm is irreversible. 4. PERMANENT DISABILITY Case description: On August 2006, Rosalıá reports that her husband had an accident with a recycling machine and that several fingers were amputated. They rushed to the hospital where a successful hand reconstructive surgery is performed. In order to regain mobility, however, the surgeon prescribes 20 physical therapy sessions, which were not covered by the policy and led to permanent disability. Consequence analysis: Disability can occur as a result of the system’s failures when the lapse of time between health care seeking and the effective provision of care is such that the persons’ medical condition worsens to the extent that he/she becomes disabled. 5. DEATH Case description: On June 2005, Constanza, a fifty-four year-old woman who holds a contributory regime health care plan, seeks care because of a six-month unresolved stomach pain that has been treated as chronic gastritis. After months of struggle with the insurance company that denies further testing and a visit to a private gastroenterologist, an endoscopy is performed with a diagnosis of diffuse signet-ring cell gastric adenocarcinoma. Given the extensive surgery now needed she dies 12 days after the procedure. Consequence analysis: Deaths are related to the system’s failures when delayed care decreases significantly the probability of surviving the disease. Deaths can also be attributed to the system when the person seeks emergency health care but access is denied and so the person dies without having received any medical care.

were denied (column 3). The justification of the entity for denying them (System Failures/column 4), was that the tests are not included in the POS (problems of limited coverage of the policy), and Rosalıá was forced to initiate a writ (Legal Actions, column 5), and wait for the judges ruling (Result of Legal Action, column 6). When they finally exit the matrix, significant life consequences accompany them (column 7); as Tatiana’s health had further deteriorated. The journey, however, did not start and does not end here. Citizens are forced constantly into new itineraries returning either to the beginning or a previous step; for example, in Rosalıá’s case there are two more itineraries. The first one (that ended in August 2005) occurred when, after several attempts, she did not have enough money for the recovery cost quotas, and the third one (January to July 2006) when she finally received an integral care ruling through the second writ. Currently, she has continued with more itineraries as the institutions continue denying and delaying several procedures, despite the last ruling.

For a longer version of the table with more extensive case descriptions and case analyses, see the electronic (web-accessible) supplementary material.

5. Discussion

Each interaction can be depicted as a path (itinerary) that goes from left to right and is determined by the kind of health care plan a person has, their health care needs and their socioeconomic context. In order to explain it, we will use the second paragraph of Rosalıá’s story (see Table 3), from October 2005 to January 2006 (her ‘‘second itinerary’’ or second time navigating left to right through the matrix). Since Rosalia’s family was classified as very poor (level I poverty index), they received health care through the subsidized system (Insurance Affiliation, column 1). They sought care at an institution (IPS or ESE, column 2) that ordered tests that

Our results confirm previous studies that show that all societal groups, regardless of their insurance plan, and whether they are insiders, are not receiving adequate health care from the country’s health care system, and that the Colombian health care system is in a deep crisis (De Groote, De Paepe, & Unger, 2005; De Vos, De Ceukeraire, & Van der Stuyft, 2006; Hernańdez, 2002; Homedes & Ugalde, 2005a; OPS, 2002; ISEH, 2006). This research also allows us to claim that number of insured people neither equates with access nor represents a success, as proposed by managed-care reformers ˜ o, 2002; Ministerio de Proteccioń Social, 2006). Thus, our (London results stand in contrast to studies in developed countries that

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BUREAUCRATIC ITINERARIES OF THE COLOMBIAN HEALTH CARE SYSTEM 1.INSURANCE AFFILIATION

2. SERVICE PROVIDING INSTITUTION

3. SERVICE REQUESTED /REQUIRED AND DENIED

4. SYSTEM FAILURES

MEDICAL ASSESSMENT/ APPOINTMENT

CONTRIBUTIVE EPS

5. LEGAL ACTIONS

6. RESULTS OF LEGAL ACTION

7. LIFE CONSEQUENCES

VERBAL ADVICE

LABS

ADMINISTRATIVE PROBLEMS WITH THE INSURANCE –BASED SYSTEM

- MUST MEET ALL ADMINISTRATIVE RECQUIREMENTS - DOES NOT SHOW IN THE SYSTEM - INSIDER - CAN NOT CHANGE INSTITUTION

RIGHT TO PETITION

IN FAVOR OF PATIENT FIRST ATTEMPT

PROLONGATION OF SUFFERING

TREATMENT/ MEDICATIONS

ECONOMIC BARRIERS

COPAYMENTS OR MONTHLY PAYMENTS ARE RECQUIRED

WRIT FOR THE PROTECTION OF CONSTITUTIO NAL RIGHTS

IN FAVOR OF PATIENT SECOND ATTEMPT

MEDICAL COMPLICATION OF HEALTH STATUS

TREATMENT/ SURGERIES

INSTITUTIONAL DEFICIENCIES

- LACK OF PHYSICAL OR HUMAN RESOURCES - INSTITUTION CLAIMS PATIENT DOES NOT REQUIRE ACTIVITY - POOR QUALITY OF SERVICES

CHALLENGE

AGAINST PATIENTS CLAIM

PERMANENT HARMFUL CONSEQUENCES

TREATMENT/ SUPPLIES, EQUIPMENT

PROBLEMS OF LIMITED COVERAGE OF THE POLICY –NO POS

ACTIVITY IS NOT INCLUIDED IN THE POS

CONTEMPT OF COURT

PENDING/ UNKNOWN

DISABILITY

CHANGE EPS/ IPS

NO DENIAL/ OTHERS/ UNKNOWN

IPS

SUBSIDIZED EPS

ESE

INSIDERS/ UNINSURED TERRITORIAL ENTITIES

OTHER DENIALS

MOTION FOR REVERSAL

DEATH

PENDING/ UNKNOWN

OTHER COMPLAINTS

Fig. 1. Matrix of bureaucratic itineraries of the Colombian health care system.

show access barriers mainly for those uninsured (Schoen & Doty, 2004) and to Colombian studies proposing that the managed-care system simply needs modifications to solve its problems and deficits (Ve´lez-Arango, Realpe-Delgado, Gonzaga-Valencia, & Castro-Castro, 2007). Complex studies of insurance-based health care systems that evaluate critically the relationships among user-provider-insurance companies are urgently needed (Hernańdez, 2002; Lamphere, 2005; Rylko-Bauer & Farmer, 2002), including more ethnographic accounts of managed care (Horton, McCloskey, Todd, & Henriksen, 2001; Lamphere, 2005; Waitzkin, Williams, Bock, McCloskey, Willging, & Wagner, 2002). We found that, in the current system, access problems are similar to those traditionally identified in any health care system (costs, distance, number of visits, inequities due to insurance payments or co-payments, or cultural adequacy) (Castro, 2008; Schoen & Doty, 2004). However, given that both quantitative and qualitative data indicated clear relationships between access problems and system’s failures, we build on structural theories (Farmer, 2004; Wolf, 1999) to claim that the country’s system should be considered itself a structural access barrier. In addition, the deleterious life consequences that occur as the result of delays in the Bureaucratic Itineraries help us postulate promptness and/or timely care as a significant public health indicator. Our study confirms that the legal mechanisms established in the 1991 constitution are indeed important to protect citizen’s rights (Gaviria, 2002; Ve´lez-Arango, Realpe-Delgado, Gonzaga-Valencia, &

Castro-Castro, 2007). The fact that official governmental data report that 328,121 health care right writs had been interposed from 1999 to 2005, with over 80,000 writs in recent years, strongly signals that our results by no means represent infrequent claims. Furthermore, writs represent only a fraction of the legal procedures people use to protect the right to health (30.34% in our sample). Thus, not only is the actual number of people whose right to health had been protected through legal mechanisms larger, but there also may be many unreported cases of problems with the system, including people who obtain health care outside the system (Ramı´rez, 2004) or simply give up and continue living with deteriorating health. With this research, we contribute to this literature by showing how legal mechanisms have become part of the obligatory bureaucratic steps that delay care, and question whether legal proficiency should decide people’s health care needs. Furthermore, the fact that many of the writs that are ruled in favor are later on disregarded or ‘‘reversed’’ by the institutions (as in Astrid’s case, see Table 2, electronic (web-accessible) supplementary material), indicates that legal mechanisms to protect the right to health are simply not enough. Moreover, in many cases (as in Rosalıá’s husband’s case, see Table 2) health care actions are extremely time sensitive and do not allow the time that the legal process takes. In these cases, the system lacks any answer to these kinds of ‘‘urgent’’ but not ‘‘emergency’’ demands, and also shows important costeffectiveness problems given that an expensive surgery was not followed by other less expensive therapy and the final result was

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a failed treatment and permanent disability. Thus, our results demonstrate that care received does not necessarily correspond to health care needs being met, suggesting that the managed-care focus on cost-effective analysis and strategies is inadequate (RylkoBauer & Farmer, 2002). Also worrisome is the fact that our qualitative data not only includes cases of inadequate care related to medical malpractice, poor judgment, or error, but also lack of care and humanity in clinical practice. We raise the question as to whether this is related to restrictions that insurance companies are imposing on the autonomy of Colombian physicians (Defensorıá del Pueblo, 2007a). But perhaps a bigger question is: who should be held responsible for the life consequences of inadequate care? In the United States context it has already been argued that when health care institutions’ deliberate delays lead to people’s deaths, they should be criminally charged with homicide (‘‘death-by-omission’’) (Humbach, 2001). In order to understand the new system’s administrative and legal demands and their effects on people’s illness experiences, we build on traditional social science studies of bureaucracies (Weber, 2001) and the new conceptualizations that see them as representatives of structural power (Heyman, 2004). If risk adjusted premiums are fixed, insurance companies can be more profitable if they establish cost-containment strategies, reported in the data as difficulties accessing level III care procedures or obtaining referrals to specialists even when included in the policies. Institutions profit from creating administrative access barriers given that they do not incur treatment costs, and when legal processes are ruled in favor of the patient’s petitions, it is a public common fund that pays for the treatments. Hence, insurance companies do not use the premium’s money, but the clinics (many of them owned by the insurance companies) are still paid for the procedure and even charge the patients for recovery cost quotas when there is no cost to recover. Thus, we can see how the system makes bureaucratic practices (administrative and legal) necessary for cost containment, which not only translates into denying and delaying care, but also helps us to understand why the insurance companies have become a very profitable sector in the Colombian economy, ranking among the fastest growing industries for several consecutive years. Bureaucratic Itineraries, as the proposed model for understanding managed care in Colombia, effectively links the massive profits of insurance companies with experiences in the system characterized by harmful consequences in people’s lives. This model compels us to agree with the policy recommendation that managed care in Colombia is a failing system that needs to be changed (Homedes & Ugalde, 2005b). Thus, this paper contributes to the current policy debate in which some see current managedcare systems as a valid approach to health care that can be improved versus those who argue for the need to re-evaluate overall approaches to health care policies and systems. We believe that Bureaucratic Itineraries is a valuable framework given that it links everyday experiences of health care seeking and effective provision of care with health care systems’ institutions and policies, allowing a new way to evaluate how prompt and efficacious health care systems are in responding to citizens’ health care needs and confronting diseases. We suggest that Bureaucratic Itineraries can be used as a theoretical and methodological tool to study and compare different health care systems: theoretical, in that it links people’s experiences of illness and care with the health care system institutions and policies, and methodological, in that its several steps can provide a frame for interview protocols, which helps people to organize their narratives through time given the difficulties of describing what seems to be a confusing series of events that occur without apparent context. We encourage other researchers to assess and discuss the relevance and adequacy of

Bureaucratic Itineraries in future studies, and we maintain that national and international health organizations should incorporate the consequences of delayed and inadequate care in their assessments of health care system performances and reforms. Acknowledgments We want to thank the people legally advised at Salud al Derecho, who shared their stories with us and allowed us to help them. We also want to thank the Salud al Derecho team, and El Fondo Nor˜ os proyectos de uego para los Derechos Humanos, Fondo de Pequen Pan para el Mundo for their financial support to Salud al Derecho. We also want to thank the research group Critical Medical Anthropology (Antropologıá Me´dica Crı´tica), the group of professors and students at the research seminar of the Doctorate in Public Health Program of the National University, as well as Drs. Marıá LaRusso, Ariel Ruiz, Rau´l Sastre, Elena Fino, Miguel Barrios, Bernardo Useche, and Liliana Obregoń for their valuable comments. Social Science & Medicine’s reviewers also made detailed comments that improved the final version of the manuscript. This work was partially supported by a research grant from the research division of the National University of Colombia, grant # 20101009365. Appendix A. Supplemental material Supplementary information for this manuscript can be downloaded at doi: 10.1016/j.socscimed.2008.12.049. References Abadıá-Barrero, C., Corte´s, G., Fino, E., Garcıá, C., Oviedo, D., Pinilla Alfonso, M. Y., et al. (2007). Perspectivas inter-situadas al capitalismo en salud: Desde Colombia y sobre Colombia. Palimpsestus, 6. Acosta-Ramı´rez, N., Durań, L., Eslava, J., & Campuzano, J. (2005). Determinants of ´ de Pu ´ blica, vaccination after the Colombian health system reform. Revista de Sau 39(3), 421–429. Almeida, C. (2002). Reforma de sistemas de servicios de salud y equidad en Ame´rica ´ de Latina y el Caribe: Algunas lecciones de los anõs 80 y 90. Cadernos de Sau Publica, 18(4), 905–925. Almeida, C., Bravement, P., Gold, M., Szwarcwald, C. L., Mendes Ribero, J., Miglionico, A., et al. (2001). Methodological concerns and recommendations on policy consequences of the world health report 2000. The Lancet, 357(9269), 1692–1697. Armada, F., & Muntaner, C. (2004). The visible fist of the market: Health reforms in Latin America. In A. Castro, & M. Singer (Eds.), Unhealthy health policy. A critical anthropological examination (pp. 29–42). Walnut Creek: Altamira Press. Armada, F., Muntaner, C., & Navarro, V. (2001). Health and social security reforms in Latin America: The convergence of the World Health Organization, the World Bank and Transnational Corporations. International Journal of Health Services, 31(4), 729–768. Castro, A. (2008). In and out: User fees and other unfortunate events during ´ de Pu ´ blica., 24(5), 1174–1178. hospital admission and discharge. Cadernos de Sau De Groote, T., De Paepe, P., & Unger, J. P. (2005). The consequences of neoliberalism. Colombia: In vivo test of health sector privatization in the developing world. International Journal of Health Services, 35(1), 125–141. De Vos, P., De Ceukeraire, W., & Van der Stuyft, P. (2006). Colombia and Cuba, contrasting models in Latin America’s health sector reform. Tropical Medicine International Health, 11(10), 1604–1612. ń con la prestacio ń de Defensorıá del Pueblo. (2007a). Autonomıá me´dica y su relacio los servicios. Bogota´: Defensorıá del Pueblo. Defensorıá del Pueblo. (2007b). La tutela y el derecho a la salud periodo 2003–2005. Bogota´. Farmer, P. (2004). An anthropology of structural violence. Current Anthropology, 45(3), 305–326. Gaviria, A., Medina, C., & Mejia, C. (2006). Evaluating the impact of health care reform in Colombia: From theory to practice. Bogota´: Universidad de los Andes. Gaviria, C. (2002). El derecho a la salud en el derecho constitucional colombiano. In ´ neos ´ blica hoy: Enfoques y dilemas contempora S. Franco Agudelo (Ed.), La salud pu ´ blica (pp. 305–312). Bogota´: Universidad Nacional de Colombia. en salud pu õ de la Go´mez, R. D. (2006). La mortalidad evitable como indicador de desempen polı´tica sanitaria. Colombia 1985–2001. Alicante: Universidad de Alicante. Hernańdez, M. (2002). Reforma sanitaria, equidad y derecho a la salud en colombia. ´ de Pu ´ blica, 18(4), 991–1001. Cadernos de Sau Heyman, J. M. (2004). The anthropology of power-wielding bureaucracies. Human Organization, 64(4), 487–500.

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