Romero-González Mauricio, González Gerardo, Rosenheck Robert A
Department of Psychiatry, Colegio Mayor de Nuestra Señora de Rosario.
J Ment Health Policy Econ. 2003 Dec;6(4):189-94.
In 1993, Colombia underwent an ambitious and comprehensive process of health system reform based on managed competition and structured pluralism, but did not include coverage for mental health services.
In this study, we sought to evaluate the impact of the reform on access to mental health services and whether there were changes in the pattern of mental health service delivery during the period after the reform.
Changes in national economic indicators and in measures of mental health and non-mental health service delivery for the years 1987 and 1997 were compared. Data were obtained from the National Administrative Department of Statistics of Colombia (DANE), the Department of National Planning and Ministry of the Treasury of Colombia, and from national official reports of mental health and non-mental health service delivery from the Ministry of Health of Colombia for the same years.
While population-adjusted access to mental health outpatient services declined by -2.7% (-11.2% among women and +5.8% among men), access to general medical outpatient services increased dramatically by 46%. In-patient admissions showed smaller differences, with a 7% increase in mental health admissions, as compared to 22.5% increase in general medical admissions.
The health reform in Colombia imposed competition across all health institutions with the intention of encouraging efficiency and financial autonomy. However, the challenge of institutional survival appears to have fallen heavily on mental health care institutions that were also expected to participate in managed competition, but that were at a serious disadvantage because their services were excluded from the compulsory standardized package of health benefits. While the Colombian health care reform intended to close the gap between those who had and those who did not have access to health services, it appears to have failed to address access to specialized mental health services, although it does seem to have promoted a change in the pattern of mental health service delivery from a reliance on costly inpatient care to more efficient outpatient services.
Health reform in Colombia improved access to health services for the general medical services, but not for specialized mental health services. Although the primary goal of the health reform was to provide universal medical coverage, by not including mental health services in the standardized benefits package, inequities in the delivery of mental health services appear to have been perpetuated or even exacerbated. IMPLICATIONS FOR HEALTH CARE AND POLICY FORMULATION: If health reform in Colombia and elsewhere is to provide universal coverage and adequate access to comprehensive health care, mental health services must be added to the standardized package of health benefits and efforts to develop accessible and effective mental health treatment at the primary care level should continue.
Mental health services research in Colombia should focus future studies on the differential impact of health reform on access to mental health services across regions, and between urban and rural areas.
1993年，哥伦比亚基于管理竞争和结构化多元主义开展了一项雄心勃勃且全面的卫生系统改革，但未将精神卫生服务纳入其中。
在本研究中，我们试图评估改革对获得精神卫生服务的影响，以及改革后期间精神卫生服务提供模式是否发生了变化。
比较了1987年和1997年国家经济指标以及精神卫生和非精神卫生服务提供措施的变化。数据来自哥伦比亚国家统计局（DANE）、国家规划部和财政部，以及哥伦比亚卫生部关于同年份精神卫生和非精神卫生服务提供的国家官方报告。
经人口调整后，精神卫生门诊服务的可及性下降了-2.7%（女性下降11.2%，男性上升5.8%），而普通医疗门诊服务的可及性大幅提高了46%。住院收治情况的差异较小，精神卫生住院收治增加了7%，而普通医疗住院收治增加了22.5%。
哥伦比亚的卫生改革在所有卫生机构中引入了竞争，旨在提高效率和实现财务自主。然而，机构生存的挑战似乎严重落在了精神卫生保健机构身上，这些机构也被期望参与管理竞争，但处于严重劣势，因为其服务被排除在强制性标准化健康福利套餐之外。虽然哥伦比亚的医疗改革旨在缩小有卫生服务可及性者和无卫生服务可及性者之间的差距，但似乎未能解决获得专门精神卫生服务的问题，尽管它似乎确实推动了精神卫生服务提供模式从依赖昂贵的住院治疗向更高效的门诊服务转变。
哥伦比亚的卫生改革改善了普通医疗服务的可及性，但未改善专门精神卫生服务的可及性。尽管卫生改革的主要目标是提供全民医疗保险，但由于未将精神卫生服务纳入标准化福利套餐，精神卫生服务提供方面的不平等似乎一直存在甚至加剧。对医疗保健和政策制定的启示：如果哥伦比亚及其他地方的卫生改革要实现全民覆盖并提供充分的综合医疗服务可及性，必须将精神卫生服务纳入标准化健康福利套餐，并且应继续努力在初级保健层面发展可及且有效的精神卫生治疗。
哥伦比亚的精神卫生服务研究应将未来的研究重点放在卫生改革对不同地区以及城乡之间获得精神卫生服务的差异影响上。
