versión impresa ISSN 0034-7434
Rev Colomb Obstet Ginecol v.62 n.4 Bogotá oct./dic. 2011
The benefits’ plan has been defined as “providing people with a set of activities, procedures, supplies, and recognition, aimed at maintaining or recovering their health and avoiding affecting their economic capacity derived from temporary disability caused by general illness, maternity, and incapacity, handicap or invalidity arising from the risk of accidents at work and professional disease.”1
Colombian law 100 initially created three benefit plans: the basic attention plan (plan de atención básica -PAB), the obligatory contribution-type plan (plan obligatorio de salud contributivo POS) and the subsidised obligatory health plan (plan obligatorio de salud subsidiado POSS), being different in their origin and regarding the services which they included for the benefiting population. Constitutional Court ruling T 760/2008 ordered the following regarding benefit plans, “measures should be adopted for eliminating uncertainty about the content of benefit plans and they must be periodically updated; benefit plans (POS and POSS) must be unified, firstly in the case of children and then, progressively, in the case of adults, bearing their suitable funding in mind.”2
According to the above ruling, the former Ministry of Social Protection, today the Ministry of Health and Social Protection began to take a series of steps towards fulfilling that ordered by the Constitutional Court. The Ministry circulated a petition from the Health Regulation Commission (Comisión de Regulación en Salud – CRES) in 2009; such document was aimed at the integral updating of obligatory health plans.3 Central elements of this document concerned updating benefit plans: prioritising problems concerning health which should be dealt with by the benefits’ plan, developing guidelines for evidence-based integral attention and evaluating health technology.
Health technology refers to any intervention which might be used for promoting health, preventing, diagnosing or treating disease or for its rehabilitation in long-term care, including medicine, medical devices, procedures, and organizational systems used in health care.4 These are not mutually exclusive and in daily practice may be combined. A procedure (total hip replacement) may thus involve using medical devices (prostheses), and drugs (anaesthetics, antibiotics). One can thus see that a benefit plan is closely tied to health technology.
Health technology has significantly determined the increase in people’s life expectancy which has occurred since the 1970s5 and the increased cost of medical attention during the last few years in all countries. For example, the USA health expenditure in 2000 totaled 13.5% of its GNP, whereas the figure for 2006 was 15.3%. This represented 7.8% in Colombia for this period, 5.3% in Chile, 6.6% in Mexico and 4.4% in Peru.6
The increase in the costs of the technologies used in Colombia for treating some pathologies, many of them not being included in the benefits’ plan thereby needing to be recouped as they are covered by the Solidarity and Guarantees’ fund (Fondo de Solidaridad y Garantía - FOSyGA) was the argument which was considered to have been initially responsible for the financial crisis which affected the health sector in 2009 and motivated the issuing of decree 4975/2009 which decreed a state of social emergency,7 this later being declared unconstitutional by the Constitutional Court via ruling C 252/2010.8
It is worth remembering that what was really responsible for the health sector crisis was, above all, corruption followed by a lack of vigilance by control entities and also by a lack of political willingness by regulating organisms,9 leading to it giving way when faced by pressure from particular groups working in their own interests, thereby triggering the crisis concerning resources availability in the sector. Such groups have been those responsible for the production of these technologies, those distributing them, those who prescribe them, and their beneficiaries, the patients themselves.10
Society as a whole must be vigilant and exercise control over all the players in the system to overcome such crisis in an effective manner; Dr Javier Eslava in his article about corruption in the health sector has proposed such approach in an interesting way. A change is also needed in how Colombian society assesses the ways in which money can be made. The concept of what is a public good must be reconstructed, this being understood as “a good which is available to all and whose use by a single person is not at the expense of its use by others”.11 Such effort must spring from the family and the educational sector, as stated by Eslava.
On the other hand, the entities regulating and controlling the sector must be strengthened so that they can exercise control over the prices of the available technologies and over the profit margins of the companies participating in the health market.10 Systematic methodologies must also be used for evaluating health technology. This aspect has been taken into account by law 1438/2011; article 92 foresaw the creation of a Health Technology Assessment Institute.12
Health technology assessment is defined as “the systematic evaluation of the properties, effects, and other impacts of interventions in healthcare. Its main purpose is to ensure that healthcare attention decision-making is updated, whether at individual, institutional, payee or local, regional or international level.”13 It is a multidisciplinary field covering the impact of health technology, considering the specific context in which health attention is provided, as well as the available alternatives;14 it implies that the observations for a health attention scenario directed towards an individual, population or country are not necessarily valid for others.
Assessing technology evaluates and reports aspects related to the use of technology such as its efficacy, effectiveness, safety, technical properties, economic, ethical, social, and legal impact and political implications. This is based on applying evidence-based medicine as it plays a key role in making informed decisions, and uses the best available evidence from scientific and medical research, accompanied by applying clinical experience and observation in individual patient care. It uses a broad range of methods including primary research, be this experimental from randomised clinical trials or observational studies and secondary or integrative studies such as systematic reviews, meta-analyses and economic assessment when available or from different sources of information by modelling different scenarios.13
One of the main considerations in assessing technology is transparency pertaining to aspects such as the unbiased search for relevant evidence, the prioritisation of the topics to be assessed and the declaration of potential conflicts of interest which could lead to bias in such assessment.13,15
Assessing technology leads to important challenges when this is done in scenarios involving restricted resources such as having available a critical mass of researchers who are suitably trained in using methodologies supporting it, the limitation of economic resources, meaning that it is preferable to construct economies of scale allowing costs to be reduced and thus ensure that processes are transparent so that they are credible and valid for all interested parties and do not respond in a biased way to the interests of particular groups.
The Universidad de Antioquia, the Universidad Javeriana and the Universidad Nacional de Colombia have thus formed an alliance known as the Health Technology Assessment and Research Centre (Centro de Investigación y Evaluación de Tecnologías en Salud – CINETS) to respond to such challenges. They bring together many researchers having experience in the methodologies underlying technology assessment, documented by multiple publications in this field. They are currently developing (together with several scientific societies including Fecolsog) nine of the 13 Integral Attention Guidelines16 and participating in international networks regarding the topic, such as International Health Technology Assessment (HTA), the Cochrane Collaboration and Guidelines International Network (GIN), the National Institute for Clinical Excellence (NICE), among others.
The above mentioned alliance seeks to assist the Colombian government’s Technology Assessment Institute and the local governments and those institutions requiring it in making informed decisions regarding any type of health technology which they may be trying to set up, preparing public health reports (policy briefs) and developing clinical practice guidelines. It seeks to provide greater clarity, independence, and efficiency regarding the required assessments; it also seeks to provide training activities for other universities, hospitals, and scientific societies.
The participation of scientific societies, the Colombian Academy of Medicine and the Colombian Medical Federation is not limited to receiving training but also includes active participation in organisms to which they have been designated, such as the aforementioned Technology Assessment Institute; active participation in producing the best proposals, and the constitution of working groups for responding to Colombia’s urgent need for constructing guidelines and technology assessment reports concerning social vigilance and control so that the Health Regulation Committee, the Ministry of Health, and Colciencias can hold transparent competitions/calls for projects, according to Colombia’s needs; in our case this would mean prioritising the field of sexual, reproductive, maternal and perinatal health.
An impeccable approach must thus be adopted by the Ministry of Health, the CRES, and Colciencias in leading such new processes marking the route towards providing the best benefit plans for the Colombian population in line with criteria of quality, efficiency, and equity. The scientific societies and the academic world must construct proposals assuring that such investment benefits the Colombian population and does not end up in corrupt hands, as it has happened before.
Lastly, and in the name of transparency, I make my declaration of possible conflicts of interest regarding the topic, as a member of the Federación Colombiana de Obstetricia y Ginecología and professor at the Universidad Nacional de Colombia.
Editor Fulltime Professor Universidad Nacional de Colombia, Obstetrics and Gynaecology Department
1.Universidad de Antioquia. Aprende en línea. Curso de Seguridad Social en Salud. Definición de plan de beneficios. Visited on Dec 29th 2011. Available from: http://aprendeenlinea.udea.edu.co/lms/moodle/course/view.php?id=319
2. Corte Constitucional. Sentencia T 760 de 2008. Visited on Dec 29th 2011. Available from: http://www.corteconstitucional.gov.co/relatoria/2008/T-760-08.htm
3. Ministerio de la Protección Social. Documento para la garantía y protección del derecho a la salud de los colombianos. Actualización integral de los Planes Obligatorios de Salud. 2009. Visited on Dec 29th 2011. Available from: http://www.pos.gov.co/Paginas/Documentost%C3%A9cnicos-POS.aspx
4. INATHA. HTA Resources. Visited on Dec 29th 2011. Available from: http://www.inahta.org/HTA/
5. World Bank. Life Expectancy. Visited on Dec 23rd 2011. Available from: http://www.worldbank.org/depweb/english/modules/social/life/index.html
6. Organización Mundial de la Salud. Estadísticas Sanitarias Mundiales 2009. ISBN 978 92 4 356381 Visited on Dec 29th 2011. Available from http://www.who.int/whosis/whostat/ES_WHS09_Full.pdf
7. Presidencia de la República de Colombia. Ministerio de la Protección Social. Decreto 4975/23rd December 2009.
8. Corte Constitucional. Sentencia C 262/16th April 2010. Visited on Dec 23rd 2011. Available from: http://www.actualicese.com/normatividad/2009/12/23/decreto-4975-de-23-12-2009/
9. Revista Semana. Recobros en salud, un desfalco anunciado. 3rd May 2011 edition. Visited on Dec 29th 2011. Available from: http://www.semana.com/nacion/recobros-health-desfalco-anunciado/156077-3.aspx
10. Ess SM, Schneeweiss S, Szucs TD. European healthcare policies for controlling drug expenditure. Pharmacoeconomics 2003;21:89-103.
11. Ostrom E. Glosario sobre el Conocimiento como bien común. Visited on Dec 29th 2011. Available from: http://gruizlegal.blogspot.com/2009/10/elinor-ostrom-nobel-de-economia.html
12. Congreso de Colombia. Ley 1438 de 2011. Diario Oficial No. 47.957/19th January 2011. Visited on Dec 29th 2011. Available from: http://www.secretariasenado.gov.co/senado/basedoc/ley/2011/ley_1438_2011.html
13. Resources for HTA - HTAi and INAHTA’s White Paper to WHO. Visited on Dec 29th 2011. Available from: http://www.inahta.org/HTA/
14. INATHA. Health Technology Assessment (HTA) Glossary. Visited on Dec 29th 2011. Available from: http://www.inahta.org/GO-DIRECT-TO/Members/
15. Lavis JN, Permanand G, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 13: Preparing and using policy briefs to support evidence-informed policymaking. Health Res Policy Syst 2009;7:S13.
16. Centro de Investigación y Evaluación de Tecnologías en Salud – CINETS. Guías de Atención Integral. Available from: http://www.alianzacinets.org/
10. Ess SM, Schneeweiss S, Szucs TD. European healthcare policies for controlling drug expenditure. Pharmacoeconomics 2003;21:89-103.