Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Av Tibidabo 21, Barcelona 08022, Spain.
BMC Health Serv Res. 2010 Oct 29;10:297. doi: 10.1186/1472-6963-10-297.
The health sector reform in Colombia, initiated by Law 100 (1993) that introduced a managed competition model, is generally presented as a successful experience of improving access to care through a health insurance regulated market. The study's objective is to improve our understanding of the factors influencing access to the continuum of care in the Colombian managed competition model, from the social actors' point of view.
An exploratory, descriptive-interpretative qualitative study was carried out, based on case studies of four healthcare networks in rural and urban areas. Individual semi-structured interviews were conducted to a three stage theoretical sample: I) cases, II) providers and III) informants: insured and uninsured users (35), health professionals (51), administrative personnel (20), and providers' (18) and insurers' (10) managers. Narrative content analysis was conducted; segmented by cases, informant's groups and themes.
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 and purchasing mechanisms; 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 predominate, whereas in the rural areas structural deficiencies in health services 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.
The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment. They provide evidence to question the promotion of the managed competition model in low and middle-income countries.
哥伦比亚的卫生部门改革始于 1993 年的第 100 号法案，该法案引入了管理竞争模式，通常被认为是通过监管市场的医疗保险改善医疗服务可及性的成功经验。本研究的目的是从社会行为者的角度，提高我们对影响哥伦比亚管理竞争模式中医疗服务连续性可及性的因素的理解。
本研究采用基于案例的探索性、描述性-解释性定性研究方法，对农村和城市地区的四个医疗保健网络进行了案例研究。对三个阶段的理论样本进行了个体半结构化访谈：I）案例、II）提供者和 III）信息提供者：参保和未参保的用户（35 人）、卫生专业人员（51 人）、行政人员（20 人）、提供者（18 人）和保险人（10 人）的管理人员。对叙事内容进行了分析；根据案例、信息提供者群体和主题进行了分段。
特别是由于以下四组具有协同效应的障碍，获得医疗服务，特别是二级医疗服务，被认为是复杂的：保险设计碎片化，服务覆盖不足；保险人的管理式医疗和购买机制；提供者网络的结构和组织限制；以及较差的生活条件。保险人的和提供者的以经济利润为基础的价值观贯穿所有因素。在两个地理区域和保险计划之间出现了差异。在城市地区，与市场运作相关的障碍占主导地位，而在农村地区，与公共资金不足相关的卫生服务结构性缺陷则与公共资金不足有关。在补贴制度中，财务障碍占主导地位，而在缴费制度中，供应短缺与私人投资不足有关。
研究结果表明，在哥伦比亚的医疗保健系统中，发展中国家常见的获取医疗服务的结构性和组织性障碍，由于保险人使用限制利用的机制以及公共医疗保健提供者在竞争环境下改变行为，而进一步扩大。这些结果为在中低收入国家推广管理竞争模式提出了质疑。
