In matters concerning social issues, Colombia’s great challenge is to coordinate economic and social development. And to achieve this, the National Development Plan 2010-2014 (National Planning Office DNP, 2011) submits building prosperity for all, on eight pillars: 1) convergence and regional development; 2) growth and competitiveness; 3) equal opportunities; 4) consolidation of peace; 5) innovation; 6) environmental sustainability; 7) good governance; and 8) international relevance. According to the National Development Plan 2010-2014, Colombia faces great challenges in public health, many of them originating from the large differences between regions and population groups:
[... ] although public health policy and its instruments recognize regional differences, in many cases province and municipal management shows weaknesses in efficiency, prioritization and targeting of available resources, contributing to the persistence of disparities between regions and local authorities. (National Development Plan 2010-2014)
The 2012-2021 Ten-Year Public Health Plan is a political gamble for health equity, defined as the “absence of differences in health between social groups, differences that are unnecessary, avoidable and unfair” (Whitehead, 1992). This implies that health equity is achieved when all people reach their health potential regardless of their social, cultural and economic conditions.
The 2012-2021 Ten-Year Public Health Plan has been formulated within the National Development Plan 2010-2014, and it seeks to reduce health inequity under the following objectives: 1) to work towards ensuring the effective enjoyment of the right to health; 2) to improve the living conditions which alter the health and reduce the burden of existing disease; 3) to maintain zero tolerance for mortality, morbidity and avoidable disability. One of the biggest challenges of the 2012-2021 Ten-Year Public Health Plan is to strengthen the notion of health as the result of the harmonious interaction of the biological, mental, social and cultural conditions of the individual as well as with his or her environment and with society, in order to access a higher level of wellbeing as an essential condition for life.
Public health is a commitment to society with its ideal conception of health. Therefore, the 2012-2021 Ten-Year Public Health Plan is a social contract and a citizen mandate that defines the coordinated action between public, private and community actors and sectors to create conditions that ensure the well-being and quality of life in Colombia. The 2012-2021 Ten-Year Public Health Plan is the navigational chart to address the current challenges in public health and to consolidate, under the social protection system, technical capabilities in the national and local arena for the planning, implementation, monitoring and evaluation of interventions, according to the Millennium Development Goals (UN, 2000). It also presents strategies for individual and collective action, involving the health sector and others, within and outside health services.
The Ministry of Health and Social Protection is responsible for the stewardship in the process of building the 2012-2021 Ten-Year Public Health Plan, according to Law 1438 of 2011, but its implementation implies local leadership of governors and mayors to achieve integration of and commitment by all sectors and actors in their territory, in order to harmonize the concurrence of assets and liabilities from other sectors related to public health, as well as the development of inter-sector strategies that impact the social and economic determinants of health.
The 2012-2021 Ten-Year Public Health Plan is indicative and it contains policy guiding principles and key actions of environmental intervention, behavior, health services and social participation. Province, district and local governments must adapt it to their own conditions and must manage it for execution. It is comprehensive because its design originates from the priority dimensions for the life of every person; and it is dynamic, because it must be permanently adjusted according to the evaluation of its own results and of the shifts in the social environment within the territorial planning process defined in Law 152 of 1994 (Congress of the Republic of Colombia, 1994).
The 2012-2021 Ten-Year Public Health Plan has been drawn up based on the best available scientific evidence in the national and international literature regarding successful interventions and strategies, together with the contributions by broad community and national, sector and inter-sector participation.
The 2012-2021 Ten-Year Public Health Plan incorporates different complementary approaches: 1) the human rights approach; 2) the gender approach and life cycle (senior, adult, youth and children) approach; 3) differential approach (taking into consideration the specific needs of populations with disabilities, victims of violence and displacement situations, of sexual diversity, and of ethnic groups); and 4) the Social Determinants of Health model, given that health inequities are determined by processes that refer to the conditions into which people are born, grow, live, work and age, and have been recognized as the underlying problem, dominant in the health situation in the Americas, including Colombia.
The 2012-2021 Ten-Year Public Health Plan, in tune with the 2010-2014 National Development Plan (National Planning Office, 2011), has been created with a regional focus, and it recognizes differences as the reference for drawing up public policy and programs consistent with the characteristics, specific capabilities and idiosyncrasies of the various population groups (Congress of the Republic of Colombia, Law 1450, 2011). The 2012-2021 Ten-Year Public Health Plan is built from the perspective of the regions so defined for purposes of formulation: Amazon - Orinoco (Amazonas, Caquetá, Guanía, Guaviare and Vaupés); Bogota - Cundinamarca; Caribbean and island (Atlantic, Cesar, Córdoba, Bolívar, Magdalena, Guajira, San Andres Island and Sucre); Central (Antioquia, Caldas, Huila, Risaralda, Tolima and Quindio); Oriental (Arauca, Boyaca, Casanare, Meta, Norte de Santander, Santander and Vichada), and the Pacific (Cauca, Chocó, Nariño, Valle del Cauca and Putumayo).
Building the 2012-2021 Ten-Year Public Health Plan is a landmark as an exercise of unprecedented social mobilization in Colombia. In the population consultation, the citizens validated the 2012-2021 Ten-Year Public Health Plan as the material expression of State policy that recognizes health as an interdependent right and a central dimension of human development. It also highlights the coordinated participation across sectors, actors, community and individuals responsible for effective and positive intervention of the health-disease process, by addressing the Social Determinants of Health, in order to create conditions to ensure the well-being and quality of life in Colombia.
How was it built?
The Ten-Year Health Plan was built with the joint participation of all sectors of the country, through a participatory, discussion, reflection and consultation process, directly summoning 153,397 Colombians.
•210 face-to-face consultation workshops at the zonal, province and regional levels, involving more than 900 municipalities, Colombians of all ages, including children and adolescents, women, seniors, family organizations, religious communities, LGBTI groups, groups with different abilities and people with rare and orphan diseases.
•Health sector entities and other sectors were also consulted, since it is a cross-sector Plan
•Also, the consultation route with indigenous peoples, Afro-Colombian and Roma, and victims of various conflicts was agreed, which will allow building an ethnic chapter and a victims chapter in 2013 and it will be adapted as a technical annex to the 2012-2021 Ten-Year Public Health Plan.
•Finally, the Plan received input from various international cooperation agencies and the United Nations in Colombia; it was validated with a group of 65 public health experts associated with the Academy and the health sector; and it was agreed with the 16 Ministries of the National Government, the High Counsels and Affiliated Offices.
DIMENSIONS OF THE TEN-YEAR PUBLIC HEALTH PLAN
The 2012-2021 Ten-Year Public Health Plan seeks to “achieve equity in health and human development” of all Colombians through eight priority and two transverse dimensions, which represent those key aspects which, given their magnitude or importance, should be intervened, preserved or improved, to ensure the health and welfare of all Colombians, regardless of gender, ethnicity, life cycle, socioeconomic status or any other differential status.
Each dimension in turn develops a cross-sector and sector component that incorporates a set of actions (common and specific strategies).
Environmental Health Dimension:
A set of policies, planned and developed in a cross-sector fashion, with the participation of the different social stakeholders, which aim to encourage and promote the quality of life and health of the population of present and future generations, and realize the right to a healthy environment through the positive transformation of the social, health and environmental determinants, under the methodological approach of the drivers or driving forces (DPSEEA: Driving Force, Pressure, State, Exposure, Effects, Action). This model identifies five cause and effect levels in order to establish relationships between environmental conditions and health. Its application demonstrates the link between environmental factors and effects on health, necessary to establish interventions aimed at improving relations between environment and health, more specifically, it suggests that efforts to control the ‘drivers’ and ‘pressures’ causing environmental degradation may be the most effective forms of intervention, since they act on the structural issues, requiring greater political will and commitment. This model is, therefore, the thread of the analysis of the interrelationships between health and environment, including the common aspects of the driving forces, pressures and actions for all environmental conditions, exposure analysis, the state and the specific effects of each priority environmental condition. This methodology allows national and local governments to identify and characterize the structural, intermediate and proximal determinants, and in turn identify competent actors and sectors and submit preventive and corrective sector and cross-sector actions.
a.To promote the health of populations, which, due to their social condition, are vulnerable to environmental processes by the positive modifying of the social, health and environmental determinants, strengthening inter-sector management and social and community participation at the local, regional, national and international levels.
b.To promote sustainable development through technology and clean production models and responsible consumption, articulated to policies and social, political and economic development processes, at the national and local levels.
c.To address, as a priority, the environmental and health needs of vulnerable populations, with differential focus.
d.To help improve the living conditions of the Colombian population through health prevention, surveillance and monitoring.
Mental Health and Social Coexistence
A venue for cross-sector and community construction, participation and action that, by promoting mental health and coexistence, transformation of prevalent mental health problems and disorders, and intervention on the different forms of violence will contribute to the human and social welfare and development in all stages of the life cycle, with equity and differential approach in everyday life.
a. To create spaces that contribute to the development of opportunities and capabilities in people to allow the enjoyment of life and the employment of individual and collective potential for strengthening mental health, coexistence and human and social development.
b.To contribute to the management of the risks associated with mental health and social coexistence, through the intervention of risk factors and improving institutional and community responsiveness in this area.
c.To reduce the impact of the disease burden caused by the events, issues and mental disorders and various forms of violence, by strengthening and expanding the range of institutional and community services in mental health, to increase access to those who require them and to allow preventing chronicity and deterioration and mitigating avoidable damage.
Food and nutrition security dimension
Actions seeking to guarantee the right to healthy food with equity, at different stages of the life cycle, through the reduction and prevention of malnutrition, control of sanitary and phytosanitary risks of food, and cross-sector management of food and nutritional safety with a territorial perspective.
Objective: strive for Nutrition and Food Safety (SAN for initials in Spanish) of the Colombian population through the implementation, monitoring and evaluation of cross-sector actions, in order to ensure the health of individuals and the rights of consumers.
Sexuality and sexual and reproductive rights dimension
A combination of sector, cross-sector and community actions to promote the social, economic, political and cultural factors that allow, from a human rights, gender and differential perspective, the free, autonomous and informed exercise of sexuality; the development of people’s potential throughout their entire life cycle; and the social development groups and communities.
Objective: To promote, generate and develop ways and means to ensure social, economic, political and cultural conditions to impact on the full and autonomous sexual and reproductive rights of individuals, groups and communities in the context of gender and differential approaches, ensuring the reduction of the vulnerability and ensuring comprehensive care of people.
Healthy living and communicable diseases
A venue for sector, cross-sector and community action that seeks to guarantee the enjoyment of a healthy lifestyle at different stages of the life cycle, promoting modes, conditions and lifestyles in everyday life of individuals, families and communities, as well as access to integrated care in communicable situations, conditions and events, with differential and social equity approach, from a perspective of sustainable human development.
The dimension proposes, as a work structure, a model of cross-sector intervention called Integrated Management Strategy
(EGI for its initials in Spanish). This model aims to recognize, study, put into context and intervene the intermediate and deep causes of negative impacts and outcomes associated with prevalent, emerging and neglected communicable diseases; the Integrated Social Management Strategy conceives the active role of the sector in reducing health inequalities through two major ways:
• Directly, ensuring equitable access to quality health services and comprehensive and effective public health programs
• Cross-sector, involving other government agents and civil society in the intervention of the structural causes of situation and exposure generated by communicable diseases.
a. To ensure and realize the right of the Colombian population to live free of communicable diseases at all stages of the life cycle and daily life, with differential and equity approach, by the positive transformation of endemic, epidemic, emerging, re-emerging and neglected situations and conditions, to promote human, social and sustainable development.
b.To gradually and persistently reduce exposure to environmental, biological and health risk conditions and factors, and strive for accessibility, comprehensiveness, continuity, connection and sustainability of care, of contingencies and damage from communicable disease.
c.To create conditions and capacities in the sector and in other sectors, organizations, institutions, health services and in the community for management of plans, programs and projects that reduce the population’s differential vulnerability and exposure to diseases.
Public health in emergencies and disasters dimension
A venue for sector, cross-sector and community action, which aims for the protection of individuals and groups from the risks of emergencies or disasters that impact public health, aiming to reduce the negative effects on human and environmental health through the integrated management of risk as a social process that guides the formulation, implementation, monitoring and evaluation of policies, plans, programs, projects and ongoing actions for knowledge, risk reduction and emergency and disaster management, in order to contribute to the health security, welfare, quality of life of people and sustainable development in the country.
Objective: to promote disaster risk management as a systematic practice, in order to ensure the protection of individuals, groups and the environment, to educate, prevent, cope and handle emergency or disaster situations, as well as to increase resilience and recovery of communities, providing health security and improving the living and health conditions of the population.
Healthy living and non-communicable conditions dimension
A set of policies and sector, cross-sector and community interventions seeking wellness and enjoyment of a healthy life at different stages of the course of life, promoting healthy modes, conditions and lifestyles in everyday spaces of individuals, families and communities as well as access to integrated care of non-communicable conditions (see glossary) with differential focus.
a. To promote, develop and implement a cross-sector agenda to raise as a priority, in policies of all sectors, the promotion of health, control of non-communicable diseases (NCDs) and oral health, visual, auditory and communicative disorders, from social and health programs, to combat poverty and strengthen economic development.
c.To create conditions and strengthen the management capacity of services to improve accessibility and comprehensive and integrated care of NCDs and oral health, visual and auditory disorders, reducing gaps in morbidity, mortality, disability, avoidable events and modifiable risk factors.
d.To strengthen the country’s capacity to manage and develop surveillance, social and economic monitoring of public health policies and interventions, in line with global and regional framework for NCDs, including oral, vision and hearing health disorders and related Social Determinants of Health.
e.To support and encourage the development of research capacity in the field of health promotion, prevention and control of NCDs, including oral, visual and auditory health disorders and their Social Determinants of Health.
Workplace and health dimension
Set of policies and sector and cross-sector interventions seeking workers’ wellness and health protection by the promotion of healthy modes, conditions and lifestyles in the workplace; the maintenance of physical, mental and social wellness of people in all occupations; and promoting interventions that positively modify the situations and conditions of concern to the health of workers in the formal and informal sectors of the economy.
a.Expand coverage in the Occupational Risk System
b.Contribute to the improvement of the working environment and health conditions of the working population in Colombia, through the prevention of occupational hazards that may adversely affect their health and welfare status.
c.To promote the health of populations vulnerable to occupational hazards working with differential focus, joining forces to prevent, mitigate and overcome the risks of this population, strengthening inter-sector management and social participation at the local, regional and national levels.
Differential management of vulnerable populations cross dimension
Access to healthcare is a fundamental right, regardless of socioeconomic or financial status. This right should be particularly protected for vulnerable groups and at greater risk of experiencing barriers to access (Convention for the Protection of Human Rights and Fundamental Freedoms, 1950). The debate over which is the best approach to ensure and improve access to health of vulnerable and excluded populations is analyzed by middle and lower income countries. However, through knowledge management and the promotion of the use of information, policies and strategies are geared to greatly affect inequalities commonly experienced by the most vulnerable populations (children, adolescents, victims of armed conflict, ethnic groups, persons with disabilities and the elderly), who access the health care system.
In this scenario, the Government guarantees the right to recognition of social differences and, therefore, the implementation of measures in favor of those social groups in which those differences mean disadvantage or greater vulnerability situation, thus fulfilling the constitutional principle that states: “All human beings are born free and equal before the law; they are entitled to equal protection and treatment by the authorities and they will enjoy the same rights, freedoms and opportunities without discrimination on grounds of sex, sexual orientation, race, national origin, language, religion, political or philosophical opinion” (Constitution of Colombia, Article 18, 1991). Therefore, “[... ] the State shall promote the conditions for equality to be real, effective and it will take action in favor of groups discriminated against or marginalized” (Constitution of Colombia, 1991).
The differential approach is conceived as “[... ] a method of analysis that takes into account the diversity and inequities in our reality, in order to provide adequate care and protection of the rights” of individuals and groups (CODHES, 2008). Gender, sexual and ethnic identity, age and health status differences, among others, are taken into account, in order to highlight the forms of exclusion, discrimination and domination exerted on individuals and groups, as an effect of the various asymmetries in their power relations (Montealegre, 2010).
Following are the health objectives, differential goals and strategies for 1) early childhood, childhood and adolescence; 2) aging and old age; 3) health and gender; 4) health in ethnic populations; 5) disability; and 6) victims of armed conflict, aimed at achieving equity in health in the context of the rights of individuals and groups. It is important to clarify that within the eight priority dimensions (see the previous chapter) affirmative actions are developed to complement these cross guidelines.
1. To address the particular determinants involving persistent social and health inequities in early childhood, childhood and adolescence; aging and old age; health and gender; health in ethnic populations; disability; and victims of armed conflict
2.To encourage good management practices and capacity building to promote social mobilization of all sectors, the participation of civil society and organized groups in the processes of planning and social control of implementation of interventions and resources, controlling conflicts of interest.
Strengthening the Health Authority to manage health
Joint sector and community actions aimed at recovering the basic capabilities of the health authority in the nation and locally to act as planners and integrators of actions related to the social production of health within and outside the health sector, and the response of the sector, through strategies under the following component:
- Strengthening of the health authority for: regulation, leadership, financial management, monitoring the general social security system in health, epidemiological and health surveillance, social mobilization, implementation of collective action and guarantee of assurance and adequate provision of healthcare.