RETURN TO RESTRICTED PO|RS DESK FILE COPY Report No. WH-200a WITHIN 1N E WEEK This report was prepared for use within the Bank and its affiliated organizations. They do not accept responsibility for its accuracy or completeness. The report may not be published nor may it be quoted as representing their views. INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT INTERNATIONAL DEVELOPMENT ASSOCIATION ECONOMIC GROWTH OF COLOMBIA: PROBLEMS AND PROSPECTS (in XII Volumes) VOLUME XI PUBLIC HEALTH November 1, 1970 South America Department CURRENCY EQUIVALENTS (Certificate Market Selling Rate of Exchange) End 1968 1 US$ = 16.91 Pesos 1 Peso US$0.05913 End 1969 1 US$ = 17.90 Pesos 1 Peso US$o.o5586 End-March 1970 1 US$ = 18.20 Pesos 1 Peso = us$0.05494 End-June 1970 1 US$ = 18.h8 Pesos 1 Peso US$0.05411 End-September 1970 1 US$ = 18.80 Pesos 1 Peso = US$0.05319 TABLE OF COPJ TEi'CTS Page No. SUiM4ARY AND WNCLUSIONS 1. HEALTH AND M*EDICAL CAW4, AS Cktl'1ICAL ASPECTS OF ECONOMIC AND SOCIAL DEVELOPAENT 1T4 CO4LOMBIA . . . . . 1 . . A. Definitions and Orientations . . . . . . . . . . . . . 1 B. The Health Care System . . . . . . . . . . . . . . . . 4 1. Governmental Programs . . . . . . . . . . . . . . . 4 2. hne Private Sector . . . . . . . . . . . . . . . . 5 C. Sources of Funds arid Major Outlays for Health and Medical Care . . . . . . . . . . . . . . . . . . . o II. AS'SESSI1ENT OF THE PRESENT HEALLTH SITUATION . . . . . . . . 13 A. Significant Demographic Variables Associated with Health and Medical Care in Colombia . . . . . . . 13 1. Population Characteristics . . . . . . . . . . . . 13 2. Socio-Economic Characteristics . . . . . . . . . . 19 B. Morbidity Indices and 'Their Socio-Economic Relationships . . . . . . . . . . . . . . . . . . 25 1. Illness and Restricted Activity . . . . . . . . . . 25 2. Utilization of Health Services . . . . . . . . . . 26 3. Socio-Economic Correlates of Morbidity and the Utilization of Health Care Resources . . . . . 23 C. Major Categories of Health Problemus in Colombia . . . . 31 1. Di.arrheal Diseases and Blelated. Conditions . . . . . 31 2. 'The Common Acute In.f.ectious Diseases (of childhood) 31 3. Malnutrition . . . . . . . . . . . . . . . . . . . 32 4. Tuberculosis and Other Chronic Infectious iLiseases 32 5. High ithrtility aid Abortions . . . . . . . . . . . 35 6. Accidernts . . . . . . . . . . . . . . . . . . . . . 37 7. Dental D)isease . . . . . . . . . . . . . . . . . . l4o d. Mental IlUless . . . . . . . . . . . . . . . . . . 40 D. lnstitutional Resources for Health . . . . . . . . . . 41 E. Health Personnel-Supply and Dis tribution . . . . . . . 45 1. Physicians . . . . . . . . . . . . . . . . . . . . 45 2. DenLLtists . . . . . . . . . . . . . . . . . . . . . 47 3. Professional Nurses . . . . . . . . . . . . . . . . 47 14. Auxiliary Nurses . . . . . . . . . . . . . . . . . 4 5. Other Healti Manpower . . . . . . . . . . . . . . . .149 Page No. F. Education and Training for the Health Occupations . . .49 1. Medical Biucation . . . . . . . . . . . . . . . . . 49 2. Nursing Education ................ . 51 3. Auxiliary Nurse Education . . . . . . . . . . . . . 51 4. Dental and Other Health Professions and Occupations Education . . . . . . . . . . . . . . . 52 III. THE NATIONAL TEN YEAR HEALTH PLAN FOR COLOMBIA (1968-1977) 53 A. Origins and Evolution of the Plan . . . . . . . . . . . 53 B. Major Elements of the Plan . . . . . . . . . . . . . . 55 C. The Ten-Year Health Plan - Analysis and Comments . . . 56 1. National Support for the Plan . . . . . . . . . . . 57 2. Support Within the Health Sector . . . . . . . . . 58 3. Financing of the Health Plan . . . . . . . . . . . 59 4. Manpower Requirements . . . . . . . . . . . . . . . 62 5. Suggested Areas for Further Development of the Ten Year Health Plan ............... . 64 IV. RECOMMENDED PROJECT PROPOSALS . . . . . . . . . . . . . . . 71 A. Health Project Proposal Colombia - I . . . . . . . . . 72 B. Health Project Proposal Colombia - II . . . . . . . . . 73 C. Health Project Proposal Colombia - III . . . . . . . .7 D. Health Project Proposal Colombia - IV . . . . . . . . . 75 E. Health Project Proposal Colombia - V . . . . . . . . . 76 V. INVENTORY OF DEVELOPMENT STUDIES IN PROGRESS . . . . . . . 77, A. Human Resources for Health - Phase II . . . . . . . . . 77 B. Experimental Study of Health Services in Colombia - Phase II . . . . . . . . . . . . . . . . . . . . . . . 78 C. Development of a Comprehensive Health Planning System at the Local Level - Phase I . . . . . . . . . . 78 D. Integrated Nutrition Program of Applied Nutrition - Phase II . . . . . . . . . . . . . . . . . 79 E. Family Planning Programs in Colombia . . . . . . . . . 80 F. Nutrition and Development - Phase II . . . . . . . . . 81 Page No. VI. RECOMMENDED PREINVESTMENT PROGRAM PROPOSALS . . . . . . . 83 VII. EXTERNAL ASSISTANCE IN THE COLOMBIAN HEALTH SECTOR . . . 84 VIII. BIBLIOGRAPHY AND REFERENCES . . . . . . . . . . . . . . . 85- ANNEX 1 - -to Chapter VI. APPENDIX A - to Chapter VII. STJIfrD1A rr AND CONCLITJSIQNcl 1. This is the first time, in recent years, that the World Bank has incluided a total survey of the health sector of a country as part of a gene:ral appraisal of development problems, policies and prospects. The information assembled in this general appraisal is to be utilized as the basis for fur-ther discussion by the Bank, other international instituitions, goverrnmen-ets and inter-governmental agencies with the country concerned (Colombia) on its development policies and plans including those affecting the health sector. Among the major objectives set for the survey and applied in this report on the health sector are: (1) The assessment of the domestic and external financing requirements and of the possibilities that those requirements can be met; (2) an analysis of the principal pre- invest;rnent surveys and studies required to carry out the development pro- gram; and (3) an analysis of the problems of investment and resource mobilization within the health sector. 2. For this survey the hea-ilth sector has been Lroadly defined to incluide all planned and orginize7d publi a endeavor directed at the national level toward the promotion of health, the prevention of illness and dis- abilli.ty, the care of the sick and the restoration to useful work or activit.- of all. those whose health statuis has been impaired. Part A of this renort, Chanters J-ITTT describes the (olombian health care system, assesses the mna lor health problems of the country and provides a detailed analysis of the l'ational Ten Year Heal th Plan (.1.)A-19i77). Part FB, Chapters JV- _, cc.nsiders selected proposals and projects that could accelerate the pa-e of achievement or consolidate the sound obJectives of the Ten Year Health Plzan. Separate reports consider the special health related problems o.f water supply and sewage disposal ari( of housing and community development. 'S fiAs in many develc.ping oclin-tries thle health care system of Colon- i)J. is prelominantly a functioln of government. The Ministry of Health, th.( ugh at. the apex of this system, is only one of miultiple governmental aghencies directly concerned wit.h the pro'vision of health and medical services. rn recent rears the 2cl.ombzia n or.i tute of 2oci.al Cccii vi ty :nri t-.h.he NLlJonal Caia',an (we:Lfare funr.l-s have ga31ined prcmi nence in the hea-llth sector. I?ecrn t Jlegi s.].ali on has )dded tlo the oper:O iin;4l responnSi- TJi l ti ca of t.he Mr:ir s try o lIe Ith bJy an:ifJ grti.ng t.o . t .lle.rly ic f:i ned ,in thri ti re for na; iJ ona,l healthh p1. nun ni a nd cl:o (li.na. t i 1n and for the c.ontinnirnv evaluation and supervision of all healt.h services at. regional --nd ic alcl levels. IJiLthin the last two ye:.rs, and For the first. t.ire, r(sl.mhi;in possesses an integrate(i network of heal Li programs and LJi. vi Li ef wi lii hiifh potential for the e.rly dievel.orment of a comprehensive. and e.fi - -i7ant heal lh ciJre systcem. - ij - heal t,h e, x end :i t.ires hi re r:isell t'] VEa-'P0l(d :iJ.- the rril , period, i)1-1 , f'ro in T rvI Ii Jlion pesos a,nr .a; u J, to ? Y r"iiI I i pesos wittl a si.,eable furl'li(t,- increa.se budrge t.eX for CI ( h Il, pun i*, or goreTnrnnentally coat;ro' le ezipenldi Llres for he:eIlth fo ny r 'f i r'y constantly at the level pI ercent are now t , ' r.ii ( in GNP. Lip,nificant.Lly, e voen w:itr subsattarhLiai nro sin a,; ini3 i r to the TYirnistry of THeall,Ji its share oft thre ijncrea :fer- 1pu .Ihlr. exrlrendi! for health has faillen Iron 30 to 20 percent anc ie* c -i t_a e"ren ':i tu-E:s for health services for t,ULe gener I.] poult Li o.;cr, are ric;i a t, the s:rie Level! they were 1(0 years ear:!ier, namineiy ;2 pesos per capitra. lin can O expendliitures for hospi4t-S an( mcdi r'a care .for the f'.ive ,.-cfeo f po'pula ti.i n covered by 11 se ri t, or the we:l.fare F'u :nds of i. ] ini-L stries have risen hijr I ir, tle sarmF :i. tlrvnl tram i2r Lu 7"' -,; . peI caT)ita and the a,ggr'i t, c rt .a Lhese ser-vice-s now reupreserni. over' h;lf (p53 percent ) oIL' a11 publAic expendi !,reg -f'or hP.i-L v , a.e exnen(iiLtures t'or he;a I h, thou''h s ubLiar Lia]l . 1 a nra. L re.L ii' y Uc 3d Ca aJ ta-l invews, Lftfri ts made in t'he Tpas;l, 4'or he;al Lii th Li ,; equilpment have rint ber., si.ije.]t e:ither tLa aria.lyJs3s or p1la ever v t,h!an h-h tfhere is abundant. evidenc- that .al:l evel.s of'' govermer,ent aind rnr-ny aIlbliu spiri ted in,dividuals ar-, groups !rave m.de a? v.o Lahle si zerible fu id these purposes. I?ecer,t.l,y , a. par 0of a new tIatria l. lHospi.1 a 1 Plan Ifn;: with thfe recent incorra or *,f t.he NLion,i Al Tnst i tLte f'or 1'1uni j v-,1 Development w:i thin the i.',11nistry o'' liea t,h.Lhat Minist r'v has LaVlishecr an ordJerly system cf pl-mnng anzj budg,etiri for capitLal c i I'UC tior,, maderni zation and eui.,)rnerit, of health racilj Lies coverin g tiCe enti re country. A rough arfiniryimltiun pl;rices the healtuh iinves tmente brudgelt. i n 1970 at slightly un1der I() percernt, of to'al public expendi tures tr hor all, . 6. 'The health I)robleiis ari( needs of' Colombia are identil-iable with a rapidly growing population currenratly estimeated to number 21.6 mrdillj ian. The population is concentra3ted in the yonger age grours anr, increasingly in urban centers al-t,hough almost half (ImP. percent) reside in small vi:],lagges and on farms. A high bLt nct precisely determined birth rate, coupled with a declinring death rate - which may be associated niore wi.th a youth- ful vigorous poaulption anrd with imrroved levels of income and eduication than with widely availnble and successfully utilized publi.c health ser- vices -- has resul.ted in a high rate of n.atural increase in thle p07l.atlon. This high rate of population increase shows snme evidence of bavi.rlg ptoJssedl its peak yet it places heavy burdens on the current national effort to extend and irniprove heal.th ard medical. care services for all segment+s of the population. The impact; of this large and rapid.:Ly growing popnnlation is also bei.ng severe:ly felt in other areas of econcmic and social develo'- ment -- in the need for schoo-ls and teachers, in emplo,vrent opportulni.ties in housing and coTmmuity development, in the per capita share of the gross domestic product and in many others. - iii - 7. The socio-econoric profile of the population is also charac- teristic of a developing society with a low median family income (1965) of 4348 pesos (U19$ 290) rising to 6645 pesos (US$ 443) in urban areas and falling to 2872 pesos (US$ 191) in rural households. The per capita share of the gross domestic product is estimated (1967) at US!, 282 having risen from USI 246 ten years earlier. Occupational pursuits are heavily weighted by unskilled employment. Educational levels are low with only 13 percent of Colombians over the age of 15 having had some secondary schooling and less than 2 percent with some university or professional training. Thirty-five percent of rural dwellers have had no schooling and only 3 percent have advanced to secondary school levels. B. Rates for all illness, restricted activity and confinement to bed due to illness are high and are inversely correlated with low levels of education, income and occupation. The same observations hold for the utilization of health care services, attendance by a physician or visits to a hospital. Rural dwellers fare far less well than their urban counter- parts whether it be in relation to risk of illness or to the utilization of health care services. 9. The major categorical disease problems of Colombia are, again, typical of a developing society. The foremost, diarrheal disease and related conditions, including intestinal parasitism, are clearly associated with low levels of environmental sanitation. Others include the acute communicable diseases (of childhood), malnutrition -- much of which is occult rather than overt - tuberculosis, venereal disease, induced abor- tions, accidents, dental disease and mental illness. Many, if not all of these conditions are amenable to modern preventive measures and yet until very recently all but a fractional share of national health effort has been consumed in attempting to cope with the huge burden of morbidity these problems create. Other significant public health problems charac- teristic of Colombia's geographic and climatic circumstances -- malaria, yellow fever, yaws and leprosy -- are in sight of successful attack yet major efforts and continued vigilance are required to bring them under total control or possible eradication. 10. Sizeable investments have been made in the past in the build- ing equipment and operation of hospitals, health centers and health posts throughout the country. These dispersed institutions have, until recently, been independently operated, usually inefficiently and without supervision or regulation based on nationally agreed upon norms and standards. A national hospital plan is now in operation with the objective of weaving together a nationally directed and supervised system of health institutions and facilities. This plan, calling for modernization, regionalization and adequate staffing of the health care system gives promise of providing comprehensive health services available to all segments of the Colombian population. - iv - 11. Shortages of all categories of essential health personnel and the maldistribution of the limited health manpower supply comprise the most difficult and demanding problems currently being faced by the coun- try's health leaders. These shortages and maldistributions are severe for the higher professional categories -- physicians, dentists, profes- sional nurses, sanitary engineers, nutritionists, health educators, statisticians, hospital administrators and other supervisory level personnel. A major problem also exists, due to the larger numbers re- quired, at middle levels -- auxiliary nurses, technicians of all types, medical and dental assistants, sanitarians, statistical assistants and higher level clerical workers. Lower level supporting personnel are also in short supply with insecurity of jobs and rapid turnover in em- ployment conspicuous problems. 12. These manpower problems require reorientation and augmentation of education and training at all levels and particularly for middle level personnel. This will be feasible provided other educational institutions, in addition to the university medical schools, are fully mobilized for this purpose. Special attention should be given to the need for close integra- tion of all training programs and the development of a national plan for the training of all categories of required health manpower. Stabilization of the available health manpower supply also requires a recasting of the salary system, improved incentives and conditions of employment as well as the acceleration and reinforcement of the adopted policy of delegation of tasks to trained middle and lower level personnel to be nerformed under competent supervision. 13. A sound Ten Year National Health Plan, 1968-1977, has been adopted and is currently being implemented. This Plan has gained the support of the top levels of the national government and is backed by all significant elements within the health sector. Under the provisions of the Plan, mechanisms have been created for the close integration of all health activity in the country whether these be under governmental or non-governmental auspices. Also, for the first time, national,regional and local health programs are fully coordinated, under the direction of the Ministry of Health, and offer promise of the early institution of a comprehensive health and medical care system available to all segments of the population. For the present, the Ministry of Health retains responsibility for the administration of nation-wide campaigns that focus on major health problems requiring mass preventive measures, e.g., environ- mental sanitation inclucding water supplies and sewage disposal, malaria, leprosy, yaws and yellow fever eradication, nutrition and vaccination against communicable disease but these programs too will ultimately be decentralized. 1. Despite conspicuouis increases in public or governmentally con- trolled expenditures for health, current trends, sustained over the ten year period 1961-1970, indicate that insufficient resources are being directed toward the improvement and extension of general health services, -v- the objectives of the National Health Plan. In response to a rapidly rising demand for hospital and therapeutic care on the part of insured workers, a larger and larger share of expenditures is being consumed for the benefit of this small but important element of the population. The balance of increased expenditures, at least on a per capita basis, is also being consumed by increases in the total population and the depreciating purchasing power of the peso. To fully implement the National Health Plan will require additional funds derived from public sources and earmarked for general health services. A rise of 50 percent in such expenditures is desirable with emphasis on the utilization of such increased expenditures for preventive measures. 15. An extension and consolidation of the social security system is under consideration. Because such a system involves contributory mecha- nisms -- contributions by the workers, by the employer and by the govern- ment -- it has appeal to those who recognize the need for broadening the base for the funding of essential health care services. Such an extension, however, warrants careful study of the current costs and the efficiency of operation of the existing system and its more effective integration with the general health services directed by the Ministry of Health. There are already evidences that a two class system of health and medical care services -- one for the employed, the other for the rest of the population -- is developing. Furthermore, preventive medicine and health promotive mea- sures should receive greater emphasis in the services available to social security and welfare fund beneficiaries. 16. A weakness in the existing mechanisms for the financing of health services, now in the process of correction, has been insufficient attention to and the planning of long-term capital investments in required health care facilities and equipment. The establishment of the National Hospital Fund and the National Institute for Municipal Development give promise of correcting these deficiencies. External assistance in the form of long-term loans, on favorable terms, is needed to augment domestic resources. 17. Opportunities exist for further advances in the health status of the Colombian population through the conjoint action of the Ministry of Health with other ministries of government: with the Ministry of Education for the education and training of health personnel and the health education of the public; with the Ministry of Agriculture in nutrition and the adaptation of food resources to the feeding and nutri- tional needs of the population; and with the Ministries of Public Works and Interior in housing and community development. Other examples could be cited including industry and agriculture in improving the health con- ditions of employment. The National Health Plan calls for more of such endeavor and the Ministry of Health has already made significant strides in this direction. National policy should encourage such efforts. - vi- 18. The Government of Colombia has recognized the urgent and mounting problems of a rapidly increasing population complicated by mass migrations to urban centers and has launched a significant family planning program to cope with these problems. Family planning informational and medical services are being developed under both governmental and voluntary ausDices to meet a genuine and increasing public demand. The limitations of these programs are related more to needs for trained manpower and the organiza- tions of health services than to the availability of funds for program financing. Social forces -- improved educational levels, increased family income, better housing and recreational opportunities and more ready access to general health care -- have all been demonstrated to foster a declining birth rate. Improved knowledge of these forces and its translation into national policy and social action is still required to bring the excessive rate of population increase under reasonable control. 19. At present, five significant health projects are sufficiently developed in terms of plan, scope and cost to warrant careful considera- tion for external financial assistance. Each represents an area of high priority determined by the National Health Plan. Domestic funds already committed to these projects in the annual budget of the Ministry are in- sufficient to realize their objectives as rapidly as the need dictates. These recommended projects are: (a) Development of Institutional Resources for Health (Hospitals, Health Centers and Health Pcsts), (b) Control of Communicable Disease by Expansion and Acceleration of National Mass Vaccina- tion Programs, (c) Expansion and Completion of the National Taboratorv of Health, (d) Expansion and Development of the Colombian School of Public Hlealth, and (e) Fluoridation of Urban Wsater Supplies. 20. Developmental studies are currently in progress to refine and extend the National Health Plan. These studies are being funded from both domestic and external sources and several involve extensive collabora- tion with international assistance agencies and with scientific institu- tions in other countries. Six additional preinvestment program studies are recommended for consideration at this time: (a) An Action Program for Education and Training in the Health Sector, (b) Study of Medical Care Institutions, (c) Nutrition Study - Phase III, (d) Health Care Under the Social Security System, (e) Vital Statistics and Morbidity Data - Registration and Analysis, and (f) Sample Studies of the Health Status and Health Resources of Colombia. More detailed outlines of these proposed preinvestment program studies are provided. I. HEALTH AND MEDICAL CARE AS CRITICAL ASPECTS OF ECONOMIC AND SOCIAL DEVELOPMENT IN COLOMBIA A. Defiritions and Orientations 1. In the past, public health measures were commonly limited to those governmental or philanthropic efforts initiated as a means of mitigating the disruptiorn to commerce brouight about by the importation of epidemic infectious disease into a local population. The organization of such services was invariably simple and discontinuous, and the health personnel employed were usually housed in the basemenit of the local city hall, not infrequently next to the city jail. Gradually, safeguarding the community water supply, sanitary inspection of public places and other relatively simple activities were added functions of the public health officials. In enlightened communities episodic medical care was also extended through charity hospitals, dispensaries and custodial institutions to that segment of the population which, when incapacitated by illness, was considered incapable of fending for itself through private means. These institutions were autonomous, were answerable only to their own independent boards of trustees, and dealt only with those problems which met their own admission policies. Services offered terminated with the death or discharge of their patients. 2. Improved public understanding of the causes of illness and its economic and social consequences, technical advances in the medical and social sciences, and the assignment to government of greater responsibilitv and authority for promoting the total well-being of the population it serves, have made so limited a definition of public health obsolete and no longer a tenable one. Today, the field of public health is almost univers- ally recogrnized as encompassing a planned and organized public endeavor direc-ted orn a national level toward the promotion of health, the prevention of illness and disability, the care of the sick, and the restoration to useful work or activity of all those whose health status has been impaired. As such, health care for many has lost the stigma of charity services, or the beneficence of the rich for the poor, and has become an integral part of a rising tide of national aspirations for the interdependent goals of better health, education, housing, and job opportunities. 3. So defined the scope of public health activity has been enlarged in many directions. It must involve a national network of programs and acti-vities reaching down through every jurisdiction of government to 1the local level where people live and work. It must engage the efforts of every ministry of the national government, and must incorporate the re- sources of professional groups and private enterprise outside the frame- work of government. Public health today includes the protection of the human population against all of the hazards of its environment, whether these hazards arise from naturally occurring noxious agents, or from dangerous polutants of the environment created by man himself; it in- cl-21des l;hJe for-tification of man's ov resistance to disease by the applica- 4-ion of the de-eloping sciences of nutrition, imntinization, and chemo- proply].axirs; the provis-ion of the ins4titu-tional reso-urces required to care -2- for the sick (hospitals, dispensaries, health centers, etc.); and the training and deployment of health personnel -- both professional and auxiliary -- required to staff the complex services demanded in a modern health and medical care system. 4. Two other essential ingredients of such a system should not be overlooked. First, it is widely recognized -- and will be amply documented in this report -- that an illiterate population is an unhealthy population, and a health-illiterate population cannot, or will not, take those measures which it alone must apply to safeguard or promote its own well-being, nor will it utilize effectively and efficiently the public health resources available to it to meet those needs which the individual alone cannot pro- vide. Thus, a national public education system, adapted to the special need for increasing enlightenment in matters of health, is an indispensable requirement of a sound national public health program. Secondly, there must be clearly defined leadership within -the national government -- appropriately within the Ministry of Health -- to take stock of the ever- changing health situation, to plan and promote the needed programs, and to mobilize all resources -- governmental and private -- to the end that the services required by the public are provided within the resources available. 5. In a developing country, such as Colombia, the burden of public health endeavor falls heavi:Ly on the national government, and particularly, on the national Ministry of Health. Despite its nominal designation and its legal authorities, the Ministry of Health does not always provide the sole, or even the major channel for the expenditure of funds for public health activity. Funds available for public health are at best limited and other areas of national development are in severe competition for the resources of the national treasury. The tax base of local and state (Departmental) governments is severely limited and may be nonexistent; private enterprise in health and medical care is rudimentary, and public .philanthropy which has pioneered so extensively in expanding the scope of public health endeavor in -the more advanced countries, is episodic and essentially unorganized. 6. Despite the above assessment, the public health system in Colombia is an extensive one, and many organizations within and outside of govern- ment, and at national, departmental and local levels are vigorously engaged in a modern public health program in Colombia that clearly meets the defini- tions and criteria set forth in this section. A unique attribute of the public health movement in Colombia is the availability of an extensive array of basic data on the health situation and the available health resources within the country. These were assembled in 1965-66 through a cooperative enterprise of the Ministry of Health and the Association of Colombian Medical Schools with financial and other assistance provided by the Milbank Memorial Fund of New York and the Pan American Health Organiza- tion (Regional Office for the Americas, World Health Organization). (3, 4) Many of these data were of fundamental value in the formulation by the Ministry of Health of a Ten-Year Health Program for Colombia (1968-77). (12) 7. A final point of orientation is in order. In reviewing the health problems of a developing country, such as Colombia, the observer is immediately made aware of the wide discrepancies that exist in the major health indicators of that country when these are compared with similar indicators for the more advanced nations of the world, as for example, those in Western Europe or in North America. A direct com- parison of such data is frequentlyodious and sometimes hazardous. For example, mnatching the infant mortality rate for all of Colombia and the U.S. national rate, fails to reflect the variable components within each set of data or that approximately half of the Colombian population resides in a rural setting where levels of literacy are low and family income meagre. The infant mortality rates of rural Negro communities in the Mississippi Delta are of the same order of magnitude as those for a local population in a rural Colombian village. Similar direct comparisons could be made for a Bogotan barrio with an urban ghetto area in any one of several mwajor U.S. cities. 8. Again, in Colombia the ratio of physicians to total population is low, about 4X: 10,000, whereas, in the U.S. this ratio is 16.4:10,00C (1). The uneven distribution of physicians in the U.S. has evoked much concern but nowhere does it approach the maldistribution recorded in Colombia where almost 3 out of 4 doctors reside in the principal cities, and serve less than 1/3 of the total population; only 10% of the medical manpower in Colombia is available to the 2/3 of the populati-on residing in places of 20,000 population or less. (4-o). Probably of even greater significance is the observation that with the resources at present in sight, it would take no less t;han 100 years for the medical training instituti-ons of Colombia to produce the number of physicians required to approach current U.S. physician/population ratios. Herein lies an importan-t -inference for Colom- bian health planners: It would be folly for them to set as their goal the uncritical adoption of health care patterns and norms observed in the so-called advanced countries of the world. Rather, by applying innova- tive approaches they must devise new techniques and new concepts appropriate to their own health problems and their available or potential resources. For example, impressive evidence is rapidly accumulating in Colombia and elsewhere demonstrating that the skills and professional lkowledge of a limited number of physicians can be extended to serve a larger segment of the population. This can be accomplished by the greater utilization of auxiliary worlcers trained to work as members of an integrated health care team. The role of the physician rmairts a dominant one. However, his functionas assume more of a directing and supervising nature and he becomes more the manager of health services than the sole provider of medical care. Thus, in utilizing data presented in this report the purpose to be served is less to compare the Colombian situation unfavorably with that of the more advan-taged areas of the world, but more to provide suit- able starting points or bench marks to Colombian health planiners, and those who would assist them in their tasks, to develop unique and even experimental approaches to realistic goal objectives. 3. T'l :1 c tIJ t;, C;I'I , 1. ri- t Ju;!ii i- . l Cr , r.-r inirJ tiud control of all activi- ties relative to health, t,he t.1 jr I Ie (; f c regirri Iationis arild. Upervision f'or their fulfil.-Lment." ' There are oi.hei natioiial orgaiiizationis concerned with the provision of' healt.1 services for specif.'ic popuLlatciori groups and these include the Colombia' i:rbt.itrit. Lfor :-c;;:lo S-(ecurity, the Military Health Services, the Min.Jist-ries of F'rva1tlo.r0, labor, Public Works, Police, the National F ail-ways, thel Ports of ('Colo1nbia arnd other agencies with smaller programs which ei.ther I-provide health ser-if.ces directly to their employees or -through Welfare Funrds (_Jasas). These sn:ecial health programs, focused on both publicly and prii/ately emrroloyed wro ke.rs, are limited to approxi- niately 1.3 million benefic lari.es- out -,! a la,or force estimatted in 1970 to be about 6.5 million arnd a I-1otal populatio osf 91.6 million. (33). The Colombian National Red Cross Assc),. iatiorvn has also been recognized by the National Government and assI:'ii -ied responsibilities for "attending to every class of accidents, calanri-ties, catastrophes, epidemics and other humani- tarian works." In addition , tlhr benefiericias and lotteries are legally recognized as autonomous reg. onial organizaitions which devote part of their income to the support of hospitals and. merdical care institutiorns. 11. As a consequence of recent legi-slation (Decrees 3224, (1963); 1499, (1966); and 2470, (.1968) most, if not all, of these separately administered programs are coo:rd-inated through a National Health Council, chaired by the Minister of Heal-th. This legislation also authorized internal reorganizations wi',hin the Ministry and provided for the coordina- tion of regional ard oc;al. health programT1s and -the unification of their financial resources. For tire first -time a rnational network of health activity now exists with consolidated mechanisms established within the Min:istry for supervision, control, prograWdning and periodic evaluation 1/ Public hospitals, many of which are governed by independent or semi- autonomous boards of directors, are defined as receiving all or part of their fumds from the public treasury; the medical care services they provide are subject to the supervision of the Ministry of Health. 2/ In general, health benefits in these plans are restricted to the employed workers; some provide limited, benefits to dependents of insured workers, e.g., maternity care and inLfarLt care during the first six months of life. at all levels. In addition a series of semi-autonomous institutes were either assigned to or created under the aegis of the Ministry with the authority and flexibility to undertake urgent and major health programs of national significance. As a consequence of these recent organizational adaptations the Ministry of Health currently includes the following func- tional elements: (17). a. Policy Determination and National Planning i. Office of the Minister ii. Office of Planning iii. Office of Human Resources for Health iv. Office of the Legal Counsel b. Assigned Agencies i. Colombian Institute for Family Welfare (ICBF) (includes Division of Nutrition -- formerly, National Nutrition Institute). ii. National Institute for Municipal Development (INSFOPAL) (responsible for water supplies and sewerage systems for connunities over 2500 population). iii. National Institute for Special Health Programs (INPES) (includes the formerly separately administered National Institute of Health and is responsible for water supplies and environmental sanitation in rural areas). iv. National Hospital Fund (responsible for financing the construction of hospitals and health centers with funds loaned by the Colombian Institute for Social Security). v. National Cancer Institute. vi. Supplies Corporation for Social Welfare Institutions (CORPAL). c. Administrative Divisions i. Medical Care ii. Direct Campaigns iii. Environmental Sanitation iv. General Administration 2. ThTe Private Secttor 12. In Colombia, as in many other developing countries, the privately operated and financed health sector is of relatively small magnitude when compared with governmentally directed or controlled operations. Through various channiels, however, the private sector exerts considerable influence on national policies and governmental programs. As was stated earlier, approximately 20 percent of all hospitals, with about 12 percent of the available beds, are privately operated. Yet, the vast najority of the public hospitals throughout the counltry were established by local groups and municipalities and continue to be directed by independenfli char-ity or other boards. These instit;utions are now dependent in prepond(erant degree for support from the public treasury and the medical care provided is subject to the supervision of the Ministry of Health, yet they still retain considerable autonoim and independence in their operations. 13. As for the medica:L profession, private practice appears to be the ambition of most physiciains, though this may be as much due to lower remuneration and less satisfac-tory working conditions in salaried posi- tions as to philosophical orientation. Only 14 percent of physicians in Colombia are engaged exclusively in private practice and 24 percent ex- clusively in salaried positions; the majority, 62 percent, combine private and non-private work in various proportions. However, after age 50, two- thirds or more physicians concentrate their efforts on the private sector whereas under age 35, over 75 percent of doctors are dependent on salaries as the major source of their income. (4o). Also in the private sector the drug and pharmaceutical manufactu-riing arnd distribution indlustry appears to be a large and profitable one. In 1966, its gross product exceeded 1,200 million pesos, about 7 percent of total soft consumption goods manufacture in the country. (33). This sum is larger than the total public expenditures for health that year. (See paragraph 16 below). 14. No discussion of the role of the non-governmental sector in meeting the health needs of the Colombian population would be complete without reference to the Association of Colombian Medical Colleges. This association representing the seven (now nine) university medical schools in Colombia has provided outstanding leadership in the health sector over the 10 years of its existence. It has contributed particularly to the development of public awareness of health as a necessary condition of social and economic development of the country. In addition, it has cooperated with and supported the efforts of the Ministry of Health in a series of unique studies encompassing a national health survey of Colombia as well as an investigation of health manpower resources and professional education. (3.4.5). These studies conducted in 1965-66 have placed in the hands of Colombia policy makers and planners a wealth of vital data that is the envy of their counterparts in many advanced countries of the world. What is more, the Association has been instrumental in seeing that many of the findings, which are still in process of analysis and publica- tion, are utilized as the basis for new national programs now in process of implementation. C. Sources of F'Lnds and Mlajor Outlays for Health and Mledical Care 15. In the 10 year irrLerval 1961-1970 there has been a dramatic rise in recorded health expenditures in Colombia. In 1961, 543 million pesos were devoted to these purposes at all levels of governmental expenditure -7- and by 1969 this figure had reached 2,763 million pesos, a five fold increase. In the former year health expenditures represented 1.8 per- cent of the gross national product and in the latter, 2.5 percent. For 1970 an additional rise is planned to 3,507 million pesos, 2.8 percent of the gross national product, a further reflection of the established national policy to give greater emphasis to health activity and an equi- valent reflection of the surging demand on the part of at least some elements of the Colombian population for health and medical care services. 16. Table I-1 shows the recorded expenditures for public health and medical care for each of the years 1961-1969 and budget estimates for 1970. The major sources of these funds are also displayed. It should be noted that expenditures for water and sewerage in urban communities (population 2,500 and over) have been omitted from the tabulation. Some, but probably a minor fraction, of the annual increases in total health expenditures is attributable to improved accounting and reporting procedures. The depreciation in the purchasing value of the pesos during this ten year interval also must be considered. However, the increase is so substantial and the accelerating rise in annual increments so notable in recent years that there can be little question that with improving economic conditions in the country the Government of Colombia has established as national policy the earmarking of larger and larger expenditures for public health and medical care services. 17. In the same table it may be noted also that appropriations for the Ministry of Health have risen from 162 million pesos in 1961 to 578 million pesos in 1969. This represents a rise of approximately 140 percent, in terms of the 1961 purchasing power of the peso, in the eight year period. However, during this same interval appropriations for the Ministry of Health have become a significantly smaller fraction of the total expenditures for health and medical care, falling from 30 percent of the total in 1961 to 20 percent in 1969. If expenditures through the National Institute for Social Security, the Cajas and by other national agencies -- i.e., costs of providing medical care for special employed groups -- are subtracted from the totals it becomes apparent that general health care for the total Colombian popula- tion has not been as much the beneficiary of this rising tide of health expenditures as might be initially surmised. In 1961 general health care represented 72 percent of total costs and about 1 percent of the gross national product; in 1969 general health care had fallen to 47 percent of total costs and remained at about 1 percent of gross national product. 18. Conversely, the beneficiaries of the social security system and of the Cajas and other special programs are now receiving a substantially different level of health care than that received by their own dependents and by the balance of the population. It has been estimated that such beneficiaries now number about 1.3 million workers, or about 5 percent of the total population. In their behalf about 785 pesos were spent in 1969 for medical care for each of them, an increase of 240 percent per individ- ual since 1961. For the general population about 52 pesos were expended per individual in both 1961 and 1969 with the intervening years showing lower average annual expenditures (see Table I-2). No Table I-1. EXPENDITURES FOR PUBLIC HEALTH, BY SOURCE DF FUNDS, 2/ COLOMBIA, 19l6-1970 (in millions of current pesos) 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 21 Pesos % Pesos % Pesos % Pesos % Pesos % Pesos % Pesos % Pesos % Pesos % Pesos % Total 542.9 100 599.5 100 790.6 100 956.b 100 1,101.5 100 1,371.3 100 1,642.4 100 2,017.1 100 2,762.9 100 (3,5O7.0 100) I. Internal Sources 538.2 99 589.7 98 781.8 99 942.6 99 1,091.4 99 1,361.1 99 1,632.1 99 2,006.7 99 2,630.1 95 (3,374.1 96) a) Ministry of Health 162.6 30 181.5 30 178.6 23 203.5 21 208.5 19 307.0 22 346.5 21 406.6 20 578.2 21 67i.2 19 b) Other Ministries 23-6 4 37.5 6 35.4 Li 57.3 6 63.5 6 (75.6 6) (90.0 5) (107.1 5) (127.4 5) ( 151.6 4) c) Social Security and National Cajas 121.9 22 132.0 22 212.L 27 245.2 26 3r9.2 32 (483.6 35) (669.8 41) (927.6 46) (1,284.7 46) (1,779.3 51) d) Other Central Agencies 10 2 2 21.5 3 23.6 3 34.9 a 31.6 3 35.9 3) ( 40.8 2) ( 46.4 2) ( 52 8 2) ( 60.0 2) e) Lotteries, 5 and 6, Totogol, etc., (Beneficencias) 112.8 21 99.2 17 181.4 23 230.0 22 254.6 23 (287.0 21) (323.0 20) (364.o 18) 411 0 15 ( 463.0 13) f) Departments and Municipalities 88.3 16 93.1 16 118.1 15 137.0 14 146.0 13 (128.0 9) (112.0 7) ( 98-0 5) 86.0 3 ( 75.0 3) g) Payments for Hospital Services 22.0 4 24.9 4 32.3 4 3h.5 4 38.0 3 ( 44.0 3) ( 50.0 3) C 57.0 3) 65.o 2 ( 74.0 2) h) Taxes on Beer - - - - - - 25.0 1 ( 100.0 2) II. External Sources 3/ 4.0 1 9.8 2 8.8 1 13.8 1 10.1 1 ( 10.2 1) ( 10.3 1) ( 10.4 1) 132-8 5 132.9 4 a Gross National Product 4/ 30,067.0 34,199.2 h3,525.5 53,760.3 60,797.6 73,612.3 83,525.2 94,550.5 (109,300.4) (126,897.8) Health Expenditures as percent of GNP 1.8% 1.8% I-A% 1.8% 1.8S.9 2.0% 2.1% (2.5%) (2.8%) 1/ Does not include expenditures for water and sewerage in urban areas. 2/ 1970 figures represent budget as opposed to expenditures; bracketed figures are estimates. 3/ Included in 1969 and 1970 figures are World Food Program contributions- 4/ 1969 and 1970 estimated by National Planning Department. Sources: Study of Human Resources for Health and Medical Education in Colombia - Ministry of Health, Association of Colombian Medical Schools, 1967; National Hospital Plan, Bank of the Republic; Economic rnvestigations National Planning Department. Note: The listings for Beneficencias, Departments and MNnicipalities, Payment for Services and Ministry of Health take into account data from the historical series up to 1965 and estimates for 1969 prepared by the Ministry of Health: for other years figures have been developed by interpolation and projection - Human Resources Unit - Department of National Planning - March 5, 1970. data on medical care expenditures are available for the estimated 15 per- cent of the total Colombian population which is believed to receive such services through private channels. Roemer estimates that in other develop- ing countries of the world health services as a whole consumed between three and four percent of the gross national product. (20). Assuming for Colombia a median figure of 3.5 percent, this would imply -that the true health ex- penditures for Colombia are at the level of 3,526 million pesos (1969) rather than the 2,762 million pesos shown in Table I-1. It would follow that pri- vate medical care expenditures are at the level of 1,062 million pesos annually or about 328 pesos per person for the 15 percent of the total popu- lation that receives care through private channels. This figure is obviously quite low compared with expenditures under the ICSS - Caja systems suggesting that Roemer's assumptions do not apply to Colombia, the 15 percent private care estimate is too high, or social security and other welfare fund bene- ficiaries are receiving an unusually costly form of medical care services when compared with recipients of private medical practice. It also follows that public expenditures for medical care for the general population are very low. These issues deserve further study and analysis. 1 9. Considerable difficulty is encountered in analyzi.ng available Colombian data to differentiate continuing operational expenses from those of an investment nature - expendituxres for the construction of new facilities and their initial equipment. This is in part die to recent changes -i-n the organizational structure of agencies at the national level of government involved in the provision of health and medical care services and in part to changing patterns of budget formulation, along with changing definitions of "investments" as opposed to "operational expenditures". 20. For example, for 1965, 5 percent of the total expenditures for health of 1,101.5 million pesos, or 55.5 rrillion pesos, were allocated to capital investment; 50.4 million pesos were devobed to construction of hospitals and other facilities and 5.1 million pesos for constnrution of rural water supplies. (3). Costs of construction of water supply and sewerage systems in cormunities larger than 2,500 popul1.-tion were omitted from this tabulation, presumably because national responsibility for financial assistance in this area to such communi.ties had been assigned to the Ministry of Economic Development. This situati.on was changed in 1969 with the transfer of the National Institute for Municipal Development (INSFOPAL) from the Ministry of Ecomomic Development to the Ministry of Health. In the 1970 national budget investment expenditures for water supply and sewerage systems are consolidated in the 507 million pesos Ministry of Health capital investment budget; 137 million pesos of these funds are earmarked f'or INSFOPAL subsidies of water and sewerage systems in communities larger than 2,500 population. An additional 61 million pesos are also earmarked for municipal water supplies and sewerage systems. (In Table I-1, these 198 millio:n pesos are not included in the Total Tabullation for 1970 to maintain the consistency of the historical seri.es of health expenditu-es). 21. On the other hand, more detailed scrutiny of the 1970 budge t reveals that the 507 million pesos capital investrent budge-t of the Ministry of Health includes in addition to(a) the 198 million pesos, mentioned Table I-2. PUBLIC EXPE? .TT7L?3 FCOR HnAL7h T3Y AGENCIES ,W HICH SERVE THE GE!E,RA POPULATION, AND WHICH SEPVE SPEACIA OPULATICL7 GORUPS, COLOICB 4", 196I -l "7 (in millions of current pescs) Expenditltures for 'the ETenditiures for Specific Gereral PoDlaRtior 1/ _Poimiiation Gov-oups 2, ear 'inota oPesos ILdex Pescs ndex 1'61 "L42.2 A c 100 V~~~~~~ v / / * 5 ; C * / )rSO I C ~~~~~~~~~~~~~~~~~~~~~~ 1 )'j 196 3 7 . 0 I 2 ; v v a v 5 ~64 A 1 196: 1 101.5 r-3z7 171, >'. 282' 1-66 71371. R 76,2 21 5 . 3,. 1567 196LL2.L _ LI.$ - ' 68 25,17.1 936.C 2 L - 1965 29 762 O- 5c'1L. 9! CI 1 5 7 C 3 5 50 70 CO 15161 3 8 1, 28 1/ Includes in ns t of He -lt, Nat ionaI tatr4iti o,n m 7ti tu' - on.al Olarner Institute. J HeaItr. Ser-vices of the Depart`-'rnts, cities, anc healt. c-'e _es-ituticrLs which rece:ve support from the "tbeneficencias" through lotteries, W and 6, 5ot ool. and own -ncome. 2/ Includes : Health services of the l'Iinistry of Defense, Militr -osii.,-, Colcmvian ThsLst4 jt- of Social Security, Medical Services of INati-onal a mr -ees, of M'ni-, rty- oCf Cc=nufcin 7, of the INIational Teleconmmun-iications CcrDoration, of the Yi>,nistryr of Labor. oL the MNris,-ry of Public ,;iorks, of th-,e Naticnal >a-ilways, of -.the For-,s of Ci olhcia, ad ot,.r agenoes with smaller programs. Soorces: Study of Human Resources for Health and M;ledical :dduc2- on ir inOC,ioR Ministry of Health, Association of Colombfian MFjedical Schools, 19,7; Econom,1 c Inesti- gations - Depariaen,t of Natura_ Planning - c L4ach ,, 1970. - 11 - above, for water and sewerage systems of communities writh populations of 2,500 or more, (b) another 1 million pesos for Departmental water and waste disposal plants, and (c) a fourth item for water and waste disposal resources, in this instance in rural areas, administered by INPES - the National Institute for Special Health Program&s. Thus, in the aggregate, the IMEinistry of Health, in 1970, is making capital investments for water supply and sewage disposal totaling 266 million pesos. The balance of the 507 million pesos capital investment budget of the Ministry of Health includes: (d) about 47 million pesos for hospital and health center construction and equipment, and (e) approximately 173 mi.llion pesos, for a variety of activities in which cons-tnlction or the purchase of fixed equipment - the usual basis for inclusion in a capital investment budget - are minor or absen-t elements in the uses of these funds. Included in such "investnents' are the nmalJaria eradication campaign (61 million pesos). Mtass vaccination programs (24 million pesos), leprosy control (12 million pesos), tuberculosis control (3 million pesos), maternal and child health services (49 million pe.ios), and education and. training of personnr (17 million pesos). 22. Other factors to be considered in assembling a national invest- merit budget for health include the new roles recently assumed by the Colombian Institute for Social Security and the National Hospital Fund in the direct construction or the funding of construction of medica.l care facilities throughout Colombia. In 1969, for example, the former built,with its own funds, medical care facilities to meet the needs of its beneficiaries and inffested for this purpose approximately 48 million pesos; in 1970 its budget provides for about 56 million pesos for similar construction. In 1969 the National Hospital Fund borrowed from ICS about 43 million pesos to assist the construction of hospitals and health centers meeting the requirements of the now approved National Hospital Plan; in 1970, the Fund anticipates similar borrowing in the range of 50 million pesos. 23. Based on the above, a reasonable approximation of a minimum investment budget for health facilities construction in Colombia assumes the following proportions: Total Health Budget - 1970 Prom Table I-1 3,507 million pesos + Urban water & sewage 198 million pesos + National. Hospital Fund 50 million pesos Total ,755 million pesos Investment Budget - 1Q70 Mii mstry of Health Hospital Construction 47 million pesos Water & Sewerage 286 million pesos Institute for Social Security 56 million pesos National Hospital Fund 50 million pesos Total 39 mill.ic)n pesos - 12 - Accordingly, national capital investments in health facilities construction in 1970 are estimated to be 11.7 percent of the total public expenditures for health and medical care services this year. (439 million pesos/3,755 million pesos). This ratio is not directly comparable with the figure of 5 percent for 1965, quoted above, inasmuch as the estimation made for that earlier year does not include capital expenditures made by the Ministry of Economic Development for water supply and sewerage systems in urban commu.nities or any investments for hospit.al construction that the Colombian Institute for Social Security may have made that year. It also is not clear whether Departmental or municipal. expenditures for health facilities construction are included in total health expenditures for either years (Table I-1). 24. For the period 1961-1968, financial assistance in the health sector from external sources has been small ranging from 4.0 to 13.8 million pesos per year with an average of 9.7 million pesos. Such assistance has amounted to well under 2 percent of total public expenditures for health and for the most part has been earmarked for special projects in the form of stimrulatory or initiating grants. These figures undoubtedly under-reflect the amount of external assistance received over the years by Colombia for many of the assisting agencies have, in addition, provided substantial technical consultation and assistance, supplies and fellowships for the training of professional personnel abroad. The Pan American Health Organization and the United Nations Children's Fund have been major donors as has been the U.S. Agency for Int&ernational Development and its predecessor agencies. In the non-governmental area the Rockefeller Foundation, the Milbank Memorial Fund and the Hope prograum have been conspicuous for their assistance in recent years. Since 1969, the World Food Program in cooperation with UNICEF ahd PAHO has been a substantial source of external financial assistance to meet the requirements of the current country wide nutrition campaign. This aid, amounting to about 133 million pesos per year for five years, brings the percentage of foreign aid to the total health expenditures to just under 5 percent in 1969. II. ASSESSMENT OF THE PRESENT HEALTH SITUATION A. Significant Demographic Variables Associated with Health and Medical Care in Colombia 1. Population Characteristics 25. The Colombian demographic picture is very similar to that of many countries in the process of development: a fast growth in size of popula- tion, a high fecundity rate, a declining mortality rate, a concentration of oopulation in childhood and young adult years, great movements in the spatial distribution of the population, a rapid growth of the urban nucleus and the incipient formation of a middle class (see Table I1-1). 26. In 1970, the population of Colombia is estimated to number 21.6 million individuals. The next national census is planned for 1972; the last, in 1964, which, because of technical problems may have resulted in an under-enumeration, placed the population at 17.5 million inhabitants residing in an area of 439,519 square miles. At that time about 98.7 per- cent lived in the Departments making up 53.6 percent of the national territory. Population density of these Departments was about 73 inhabitants per square mile. The remaining 1.3 percent of the population occupied the 46.4 percent of the territory included in the Llanos Orientales. The population density of that area is about one inhabitant per square mile. 27. In 1905 the country had 4.4 million inhabitants; 33 years later, in 1938 the population had doubled (8.7 million); 26 years later, (196h) the phenomenon was repeated (17.5 million) and it is possible that it will double aga:in in 22 years. This period of duplication is in contrast with that of some other countries, such as Italy (117 years), Portugal (100 years), Spain (88 years), Uruguay (58 years) and Argentina (47 years). 28. This rate of growth varies in different sections of the country. For example, Bogota, the capital city, is doubling its population every 10-15 years, whereas some of the predominantly rural Departments require over 55 years to double their population. Table II-2 illustrates the relative change in the population of localities in the last three censuses. It may be observed from this table that, over a brief span of years, the Colombian population has shifted from predominantly rural (69 percent in 1938) to one almost equally divided; the largest rate of growth may be seen in the metlropolitan centers. Estimates for 1970 place 41.5 percent of the country's inhabitants in the 30 largest cities. 29. The economic resources of this population are limited. The average per capita production in 1966 was 1,622 pesos, representing a 20 percent rise from the 1,300 pesos figure for 1950. (In dollar equivalents to 1958 pesos these figures represent a rise in per capita production from $203 in 1950 to $253 in 1966.) Associated with this low per capita production are the umeven levels of family income: one-third of the population earns 3,600 pesos or less per year and only 14 percent 12,000 pesos or more. In the rural areas almost half (48 percent) have family incomes in the lower category and less than 5 percent in the higher. Table II-1. D4MOGRAPBIC DATA FOR SOME LATIN-AMERICAN COUNTRIES Countries Population Rate of Years Birth Rate Death Rate Life Population Inhabitants/Km2 Increase Required (per booO) (per 1000) Expect- under age (per 1000) to ancy at 15 In Double birth - (percent) Cultivable in yesars Total Areas Argentina (1960) 20,010 17 42 23 8 66 31 7 14 Bolivia (1960) 3,696 23 31 44 21 41 42 3 26 Brazil (1960) 70,119 29 25 39 10 56 43 8 44 Colombia (1964)1/ 17,485 32 21 47 15 51 47 15 92 Chile (1960) 75374 25 28 37 12 57 0o 10 57 Ecuador (1962) 4,476 34 21 48 1-4 53 45 17 88 Mexico (1960) 34,923 33 21 45 12 58 44 18 31 Peru (1961) 9,907 29 24 45 16 52 43 8 46 Uruguay (1963) 2,593 13 54 22 9 69 28 14 16 Venezuela (1961) 7,524 38 18 46 8 - 45 8 39 Latin America 214,000 29 24 40 11 57 42 11 37 H Total World (1960) 3,005,000 18 39 34 16 - - 25 j/ Figures for Colombia taken from census data and some estimates based on special studies. Source: United Nations, Demographic Yearbooks. - 15 - Table 1I- 2. RELATIVE CHLANGE ITN THE POPUJLATION OF LOCAXITIFS OF DIFFERENT SITZSS _ 1938 1951 l]6 Size of Locality Tiosands- Tholsands r Thousan-idsf; Metropolitan (100,000 or iiore, 608 7.0 1,6,9 14.7 l4,66 26 6 .6 Urban (20,no -99,000) 500 5.6 88o 7.6 1,646) 9.5 Semi-urban (2,000-19,000) 1,594 18.3 1,89c0 16.4 2,773 15.9 Total of Above '2, 692 30.9 ,468 38.7 9,093 52.0 Rural 6,010 69.1 7,080 61.3 8,391 48.0 Total Country 8,702 100.0 11,548 100.0 17,484 100.0 Source: National Department of Statistics. Factors Involved in Po_lton transition 30. Birth Rates. In Colombia as well as in nirvn other developing countries, vital statistics are recorded with considerable error and are underestimated. Throughout the country baptismal certificates are still used as a substitute for civil registration and the baptismal ceremony usually takes place about seven months after birth. Lopez Toro, a leading Colombian demographer, has calculated this under-registration of births as amounting to 28.8 percent for the period 1938-1951, and to 18.6 percent for the period 1951 1964. (7). 31. As may be noted in Table 1I-3, the official birth rates, reported by the National Department of Statistics, indicate that a peak of Just under 41 live births per 1,000 total population was reached in 1959 and these rates have since declined. By 1965, the last year for which official. data are available, the birth rate had fallen to approximately the 36.5 level reported for 1950, sixteen years earlier. On the other hiand, Lopez Toro has concluded that for the country as a whole, the crude birth rate has remained constant for a relatively long period of years. Taking into account the corrective factors he had developed, he estimated the average annual crude birth rate in the intervals 1938-1951 as 46.5 and 1951-1964 as 47.2 live births per thousand population (7). 32. It is well recognized that differences in birth and death rates exist between urban centers and rural areas. These differences are com- pounded by less complete registration as one moves away from the major popu- lation centers. These variations are reflected in the birth rates reported by the National Department of Statistics for the year 1965 for the different political subdivisions of the country. The lack of a statistically reliable birth and death registration system in Colombia adds to the difficulties of deriving sound estimates of the rate of natural increase in the population particularly during intercensal periods. These problems are given additional consideration later in this report and provide the bases for two of the high priority preinvestment study proposals recommended in Chapter VI. - 16 _ 33. .Another' sLudy, Li-idartrtaken in ]9(>5-1966 a; ;.,rt o1' the National Health Sil3nrvey, suggestLs that, 1-te Lopez Tlo-ro estimat.e:; of the Colomb-iarr birth rate may he_ too higlh. 11giiaiirrq:i.a and his asso i.ates reported, onl the basis otl household JuiLt errv-[euws of' a carefiilly sele(-ted representative sample oL f ombiari faini i -- at rhn :r.ll.e of b() . -.r tile country as a whole (6) . ie also ILO tel highll.y si.grl'i;aiit variatiotts identifiable not only witlh irban-IraUral roniLderi(ce hot, wi-thlJ. ed-icatioiiaei -:tatus of the parents and with fami:Ly irncorme. For 'exarVrrle, [or' urban diwel.lers, ani over-alL birth rate of 34 4 prevai Led ,et vyre-t from 38.L i1.rt fawilies with incomes of 3,600 pesos or less dcm,i to :J7.,3 'i;r families earni.ng over, 12,000 pesos. In contrast, t;lhe over-al.l. r tral bi.rth ' rat.e was 45.. ranging from 4h9.3 to 28.8 depending on TfTia-lny i-collie. 34. It should alsc. te tiot-.ed. that-l in a youngr population the crude birth rate may underestimate the poltential for population increase. Accord ingly, a more appropriate mea.3u.'e, the specific fertility rate (number of live births per 1,000 -wonmen in the child-bearing ages) is frequently used to reflect this potential fur p)opulation increase. Based on Agualimpia's data the specific fertility rate for' Colombia in 1965 has been calculated to be 193.7 for the couintry as a whole, 1)49.3 in urban areas and 251.6 in rural sections of the cowitry. Comparing thie specific fertility rate for the country as a whole (.1.93.7) with comparable rates for other countries it is found that Colombin. co(mpares favorab:Ly with Venezuela (212.6) and Mexico (219.1) and unifavorably -wit,h Irkgent1ina (103.6) and the United States (117.8) (1). Table 11-3. 1ItTrlf AND DEATH RATE3 FOR COLOJ'BDi 194'].1;';:, I Y e ~~~~~~~~~~~A r o 1 Qul ....<_ ) t i:: ilolt . g ~~~~~~~~~~S A NTy N D E R . ;7. .... O LIVMAR.A- 41~ ~ ~ ~~* Y~~~~~~ ~ ~~~~~~~~~~~~~~~~~~~~~ 0s Y A. A x,,C H U C A __,- y~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. _, . L < _._ t., ;JCJUA DkC .. / 1 IC N~~~~~~2 A R I N - b IRNEc NLSCA1R CA C A U C A \ 80 YAC A C K 1951 -D C :,1 7 -' I E:' I 5 0 I, ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ -5.0.0 - 22 - illness and disability and the receipt of health services. Household interviews were conducted on a representative sample of 8,961 households comprised of 51,476 individuals. A clinical examination was made of a sub-sample of 5,000 persons. The survey covered the civilian, ambulatory, non-institutional population of the 18 "Departments" existing in 1964. The universe from which the sample was drawn included 98.7 percent of the national population living in 52.7 percent of the country's area. 46. In interpreting the following data it should be kept in mind that they are now five years old and that changes undoubtedly have taken place, patticularly in economic status, in several parts of the country. It is probable that such changes are more pronounced in the urban centers of the country and that less or no changes have occurred in the rural areas. How- ever, these are surmises and though Colombia is fortunate among developing countries to have such background information available on which to plan its health programs the continuing need for current and precise data demands special emphasis. 47. Urban-Rural Residence. The survey found 51.5 percent of the popula- tion living in towns with T70T or more inhabitants. The remainder, 48.5 percent, lived in small villages or farms. For Colombia as a whole 49.1 per- cent of the males lived in towns and cities and 50.9 percent were country dwellers. In contrast, 53.8 percent of females were town dwellers and 46.2 percent were in rural areas. 48. Household Size. The average size of households for the nation is 5.9 members. 24 percent of the population lived in households with five or six members, 25 percent in households with seven to eight members, 18 per- cent in households with nine to ten members and 17 percent in households with eleven or more members. Thus only about 1 in 6 Colombians share living space with 3 or less other household members. In urban households, the average size is 5.8 members in comparison with 6.1 members among their rural counterparts. Although large families are characteristic of both urban and rural areas, small families are more prevalent in towns. Among women who have reached the age of 30, the modal range of previous live births is 6-9, with significant nunbers having had 15 or more children born alive. 49. Housing. Fifty-nine percent of households live in a house or apartment, 10 percent in a room, 26 percent in huts or shacks, 1 percent in other types of accommodations and information is lacking for the remaining 4 percent of households. Among city dwellers 85 percent live in apartments, houses or rooms, with 10 percent in huts or shacks; in the country only 51 percent reside in houses or rooms and 44 percent made their homes in huts or shacks. 50. Over two-fifths (44 percent) of the households have water piped into their home, while an additional 25 percent had a source outside their dwelling. Thus, almost one-third of the households (31 percent) had no water supply. Twice as many of the homes in the towns and cities (89 per- cent) were supplied with water as rural homes (46 percent). (3b). Over half of the homes in the countryside (54 percent) do not have a near supply of water (Table II-7). - 23 - 51. Even fewer homes are supplied with sewage facilities than with running water (Table II-8). Forty-two percent have toilets, 15 percent latrines and 43 percent are without any sanitary facilities. While the majority of urban dwellings (86 percent) had either toilets or latrines, only 24 percent of rural homes have such facilities. Table II-7. AVAILABILITY OF WATER SERVICE IN COLOMBIA IN URBAN AND RURAL AREAS, 1965 Water Supply Total Urban Rural Inside house 44.3 69.0 16.3 Outside house 24.5 20.2 29.5 No service 30.6 10.2 53.6 No information o.6 o.6 0.6 Total 100.0 100.0 100.0 Table II-8. AVAILABILITY OF SEWAGE DISPOSAL SYSTEMS IN COLOMBIA TN URBAN AND RURAL AREAS, 1965 .t ems Iotal Urban Rura_ Toilet 41.5 71.7 7.4 Latrine 14.8 14.0 15.6 No service 43.0 13.6 76.3 No information 0.7 0.7 0.7 Total 100.0 100.0 100.0 Source: National Household Survey, Study on Health Manpower and Medical Education in Colombia, Ministry of Health and Association of Colombian Medical Schools. 52. Education. Approximately one-fourth of the population, age 15 and over, has never been to school. Fifty-five percent more has not advanced beyond some primary education and for an additional 5.6 percent educational achievement is not known; it is probable that most of this latter group has little or no formal education. A firm level for effective literacy is difficult to establish, yet it is notable that about 85 percent of the country's population has had no formal education or less than six full years of primary school education. Thirteen percent of Colombians over the age of 15 have had some secondary schooling and 1.8 percent have some university or professional training. - 2)4 - 53. The educational experience of the population varies by residence. In general, people in cities have had more educational opportumity than those in rural areas. Over twice as many of those living in rural areas as in the cities (35 percent arnd 14 percent respectively) have had no -chooling. Twenty-six percent of the inhabitants of the cities have gone to secozidary schools or to more advanced s-tuldies, but only 3 percent of' the r1uraJ. inhabitants (Table II-9). 54. Occupation. The most frequently reported occupations for the heads of households are farming and fishing (39 percent), followed in order by- artisans and production workers (15 percent), salesmen (9 percent), housewives (8percent)and service workers '(8 percent). Relatively few are involved in professional (3 percent) managerial (2 percent) or clerical (3 percent) work. The occupations of the heads of the remaining 12 percent of households includes the armed forces, mining and transportation. These findings do not yield an occupational profile for persons other than the heads of household, many of whom are gainfully employed. Nor do these data indicate the degree of utilization of the manpower resources of the coimtry for there are substantial evid'ences of unemployment, under-employment and, particularly in the agricultural sector, of seasonal employment. 55. Income. The median household annual income reported (1965) was 4,348 pesos. (In their current equivalents - $290 U.S.). This varied by residence, the median urban income being 6,645 pesos (U.S. $443) and the median for rural households only 2,872:pesos (U.S. $191). (Table II-10). 56. The median income (1965) has been calculated for each occupational grouping. There is a close correlation between what a man does and how much income he reports. T'he highest median incomes are found for professionals (19,962 pesos), followed by business executives (13,309 pesos),office workers (11,183), transportation (7,540 pesos) and salesmen (7,134 pesos). Farmers, who constitute almost two-f'if hs of the heads of households, have a median income of 2,818 pesos and ranked next to the bottom. 57. The median amnual family income reported for each household varies not only by occupation and residence but is also related to the level of education of the head of the household and the size of his family. For example, 57.8 percent of those with a primary school education, 18.1 percent who have attended secondary schools and only 2.5 percent with an education beyond the secondary school level report an income of 6,000 pesos or less. Over 81.8 percent of those with a superior education have an annual income greater than 6,000 pesos, 69.7 percent with a secondary education and only 28.4 percent with a primary education earn a similar annual income. 58. Annual income also varies on a per capita basis by the size of a household. The median per capita family income for families with only two members was 1,715 pesos, for three to four member families 1,134 pesos, five to six mamber families 774 pesos, seven to eight member families 612 pesos and nine to ten member families 528 pesos. - 25 - Table II-9. EDUJCATIONAL ACHIEVFMENT IN THE COLOMBIAN POPULATION 15 YEARS AND OLDER, URBAN AND RURAL, 1965 Education Total Urban Rural None 23.8 14.0 35.0 Primary 55.4 55.1 55.7 Secondary 13.4 22.8 2.7 Higher 1.8 3.2 0.2 UJnknown 5.6 4.9 6.4 Total .100.0 100.0 100.0 Table II-10. PERCENT DISTRIBUTION OF INCOME OF HEAD OF HOUSEHOLD IN COLOMBIA, URBAN AND RURAL, 1965 Income (in Pesos) Total Urban Rural Under 3,600 36.2 22.2 52.2 3,601 - 6,000 18.0 17.2 18.9 6,001 - 12,000 17.5 25.2 8.7 12,001 - 30,000 8.3 13.5 2.4 30,001 and over 3.7 6.o 1.0 No information 16.3 16.0 16.8 Source: National Household Survey, Study on Health Manpower and Medical Education in Colombia, Ministry of Health and Association of Colombian Medical Schools. B. Morbidity Indices and Their Socio- Economic Relationships (3a) 1. Illness and Restricted Activity 59. Based on the 1965-1966 household surveys four out of every ten Colombians reported that they had been ill during the preceding two week period, with more than half of these illnesses (57 percent) beginning during that period and slightly less than half (43 percent) of a more prolonged nature. A slightly higher rate of illness occured in rural areas than in cities (399 versus 378 per 1000) and women were more prone to reported ill- ness than were men (4O0 versus 363 per 1000), a difference which persisted over all ages. For males the minimum sickness rate was in the age group 15-2)4 years and for females in the age group 5-14; following these minima, the rates rose steadily with age to a maximum for ages 65 and over. Part- ictularly noteworthy is the very high illness rate among infants. - 26 - 60. Many of the illnesses reported were mild and caused no restric- tion of activity or disability. However, the activity of approximately one person out of ten (108 per 1000) was restricted during this same two week period. Again, the rate for those in the country was higher than for city dwellers (115 versus 164 per 1000). Females had a slightly higher rate of restricted activity than males (113 versus 103 per 1000) although over age 45 the rates for males were higher; for both males and females, re- stricted activity rates increased with age. From these data it has been calculated that the average Colombian loses about 13.6 days per year from his usual activity because of illness. The rates for women are slightly higher than for men (14.5 days versus 12.7 days) and there is a sharp increase with age. On the average, those between 25 and 44 years lose 3 weeks per year (19.8 days) those between 45-64 years over four weeks (29.6 days) and those over age 65 years almost two months (53.6 days). 61. In the course of a year disability in bed due to illness averaged about a week (7.3 days) for every Colombian. Variations by age and sex were similar to those reported for the number of days of restricted activity. As might be expected, the annual average was higher for women than for men (8.6 days versus 5.8) and for both sexes there were sharp increases with age. Men over 65 years old had almost three weeks a year of illness which confined them to bed in contrast to four weeks for women. Although the rural population reports more days of restricted activity they tend to be confined to bed less frequently (6.9 days versus 7.7 days) than city dwellers. Tables II-ll, II-12 and TI-13 show some of the above illness and restricted activity indices by age and sex. 2. Utilization of Health Services 62. How, when and to whom the Colombian population turns for medical attention are questions of more than passing interest. These questions were asked in the 1965 household sample survey for the two week period immediately preceding the interview. Almost 9 percent of the population (88.6 per 1000) sought consultation for reasons of health during that period. When persons are not ill they rarely seek consultation for health services (17.1 per 1000) but even when they are, only about one in five seek such aid (201.3 per 1000). The overall rate of consulting with a physician is 63.2 per thousand, con- stituting 72 percent of all contacts with health personnel. The rates for visiting a doctor are three times greater for the urban population than the rural. 63. When the sickness rates, reported above, are further compared with consultation rates it becomes even clearer that only a relatively small proportion of individuals when they are ill are consulting any type of health personnel for their complaints. In urban areas where the sickness rate was 363 per 1000, the consultation rate was 118, only a third as much, and the consultation rate for physicians was 93, about one-fourth of the sickness rate. Among the rural population, these differentials are even more pro- nounced. With a sickness rate of 410, the total consultation rate was 57; consultation with a physician, 31 per thousand. Thus, when an individual living in the country feels ill there is 1 chance in seven that he will seek any type of health assistance and 1 chance in 13 that he will be seen by a physician. - 27 - Table II-ll. SICKNESS DURING TWO-WEEK PERIOD, PER/1000 POPULATION IN COLOMBIA, BY AGE AND SEX, 1965 All Under Sex Ages 1 1-4 5-14 15-24 25-44 45-64 65 + Males 363 429 403 289 284 389 489 630 Females 410 435 404 300 349 482 472 674 Both Sexes 387 432 403 294 319 439 531 654 Table II-12. RESTRICTED ACTIVITY DURING TWO-WEEK PERIOD, PER/1000 POPULATION IN COLOMBIA, BY AGE AND SEX, 1965 All Sex Ages 6+ 6-14 15-24 25-44 45-64 65+ Males 103 74 74 111 160 250 Female 113 78 90 138 154 198 Both Sexes 108 76 83 125 157 222 Table II-13. DAYS OF RESTRICTED ACTIVITY AND IN BED PER PERSON PER/YEAR IN COLOMBIA, BY AGE AND SEX, 1965 All Sex Ages 6+ 6-14 15-24 25-44 45-64 65+ Restricted Activity Days Males 12.7 8.8 9.8 16.2 31.1 57.4 Females 14.5 8.9 11.9 22.8 28.1 50.4 Both Sexes 13.6 8.9 10.9 19.8 29.6 53.6 Days in Bed Males 5.8 5.4 4.7 7.5 11.3 20.4 Females 8.6 6.1 7.7 13.8 13.9 28.8 Both Sexes 7.3 5.8 6.3 10.9 12.7 24.9 Source: See Table II-10. - 2j8 - 64. Of aLl. consultatiors provided by a phys itiali abouit; one-third took pl,ace i-ri IhJie physiciafns prjivate office, arn ecqual proportiorn in institutitons fl0bt-pai.tienft departmen Lls, clinics, h^-alth cerlters, etc.), 11 percent in h-louse calls and the balan ce, about 17 percent. through other arrar-gements. There is cor- i,derable variation between urbaii and ruiral areas. For the urban popiuLat;ioin, LW.*h per thousand saw physic(i.ans in institutions as compared to i11. 3 pet 1000 in ruralL areas, p.? per 1000 urbarn residents,; had hoJuse 1alls but only 9.1 in rural areas. 65. After the physicianr, the mosit frequently consultedi hea.lth workers were pharmacists (9.2 per l\00) arid nulrses (2.2 per 1000). The urhan-rural difference in the consultaltiorts -wil;h health personLnel persi3st:d but:. were less pronounced. ,7Note: it is not pos;sible to difTerentiai:,e whet;her nurse consultations were wit.h profeoisioncilly brainried nurses, pract ical nurses (auxiliary nurses) or aides_.7 66. Approximately 13 percent of the consultations about health are with other types of health workers *-- the tegua, the midwif'e and others -- unsanctioned and often unrecognized by the medical profession. These groups provide a significant proportion of all medical care available to the population. If patterns of heaL-th care consultation with unisanctioned, so-called indigenous, practitioners comnmon to ot.her parts of the world apply in Colombia these figures may be gross understatements of the true picture of the population's search f'or relief from their medical ills. 67. Hospital utilization - Almnost 23 percent of -the population has had some past experience with hospitals and 5 percent has been hospitalized within a year. Of the latter gIo'up 89 percent had been hospitalized once, 8.6 percent twice and over 2 percen.t three or more times. More urban re- sidents seek hospitalization thatn rural dwellers. In a year, more women are hospitalized than men, 64.2 and 35.9 per 1.000 respectively. Thi-s differential is everi more irw .ud in the age period l5-54 years when women in the child bear ing period are hospitalized primarily because of complica- tions of pregnancy, delivery or in the post partem. 3. Socio-Economic Correlates of Morbidity and the Utilization of Health Care Resources 68. The close associations of disease, malnutrition, lack of sanitation, poverty, crowding, illiteracy and. the other stigmata of underdevelopment are all well recognized aind well documented. In Colombia, data are available from the National Health Survey to demonstrate sorme of these direct correla- tions and a few are selected in this section for illustrative purposes.(3b) 69. As shown in Table II-1)4 the rate of reported illness is twice as high for individuals wit;h no formal educational experience (oll per 1000) as for those with education beyond the secondary level (199 per 1000). Similar differences characterize the associationi of reported illness with income - 29 - and occupation. Restricted activity due to illness can also be correlated inversely with these three social variables -- education, income and occupational level. Those whose annual income is over 30,000 pesos have half of the rate of restricted activity experienced by those who earned less than 3600 pesos (64 versus 126 per 1000), and almost half the number of days of restriction due to illness (9.4 versus 17.0). The correlation between the rate of restricted activity and education and occupation follows a similar trend as well. Those with high incomes spent on the average fewer days in bed at home due to illness and are hospitalized slightly less than those with more modest incomes. 70. Social circumstances are also directly correlated with access to health care and the type of consultation sought for illness (Table II-15). Urban dwellers visit all types of health workers twice as frequently as the rural population (118 versus 57 per thousand and the rate of visiting a doctor in the cities is three times that in the country (93 versus 31 per 1000). Although those with high incomes living in the country see a doctor almost twice as often as the rural poor (49 versus 27 per thousand), their rate of medical visits is still lower than for the poorest urban dwellers (49 versus 66 per 1000). The decision to visit a doctor or another type of health worker is influenced by income and place of residence. Those with high incomes living in the city will turn to a physician nine times out of ten when they seek health care. The rural poor utilize other personnel just as often as they turn to doctors when they seek health care. Similar correlations are found with levels of education. Table II-14. RATE OF ILLNESS, PER 1000 POPULATION, IN COLOMBIA BY EDUCATION AND URBAN OR RURAL RESIDENCE, 1965 Fducation National Urban Rural Superior 198.7 200.7 161.0 Secondary 323.4 322.4 332.3 Primary 385.8 373.3 400.7 None 411.3 418.9 407.2 Don't Know 436.6 404.1 475.7 No Information 391.4 400.2 383.3 Total 381.1 377.0 397.8 Source: See Table II-10. - 30 - Table II-15. RATES' OF CONSUJLTATION WITH HEALTH PERSONNEL PER 1000 POPULATION, BY INCOME AND ZONE, 1965 Median Income M.D. Pharmacist Nurse Tegua Other Total National Unider 3,600 38.6 8.8 2.7 9.8 9.2 71.1 3,601-6,000 47.4 10.9 1.6 7.3 5.6 85.8 6,001-12,000 86.) 10.7 2.1 4.1 6.0 112.1 12,001-30,000 107.6 10.3 1.9 1.4 3.1 127.7 30,001 + 105o. 5.5 .8 3.1 3.4 125.0 No information 55.9 6.4 2.2 6.9 5.8 83.4 Total 63.2 9.2 2.2 6.7 5.9 91.0 Urban Under 3,600 65.8 14.0 4.5 9.3 9.3 104.3 3,601-6,000 85.8 12.9 1.5 4.5 5.6 110.8 6,001-12,000 102.5 12.1 1.8 2.2 6.4 125.4 12,000-30,000 120.0 10.1 2.1 1.4 3.0 136.7 30,001 + 116.1 6.2 .9 1.0 3.3 127.6 No information 82.6 7.2 3.2 3.7 6.3 105.3 Total 93.3 11.1 2.5 4.0 6.1 117.7 Rural Under 3,6000 27.2 6.6 1.9 10.0 6.2 54.0 3,601-6,000 32.8 9.2 1.6 9.7 5.5 59.4 6,001-12,000 43.0 6.6 2.9 9.2 4.8 67.0 12,001-30,000 46.8 11.4 .9 1.7 3.8 66.3 30,001 d 48.9 1.4 - 14.6 3.8 68.6 No information 29.5 5.7 1.3 10.1 5.3 53.1 Total 31.3 7.1 1.8 9.6 5.7 56.8 Source: See Table II-10. - 21 - C. Mfajor Categories of Health Problems in Colombia 71. Dependnble data on the frequency of specific disease enti ties or other major he1lnth problems - either as causes of death or of morbidity - are limited for a variety of reasons. First, there a:re severe shortnges of rFlrysWIciars or cther hea7th -ersonnel qualified to reach even reasonably accurate diagnoses. Choose who are available Rre highly concentrated in the Lew large cities of the country. Sncondly, the system for registration of imnortant vital events is poorly mannred, inefficient., cumbersome and very ta.rdy in the t-abula-tion and of even annual sumnaries. As pointed out; in a previous section (.Section B. 2), for large parts of the country, oniy I in 13 of those rep-ortng illness of any type were seen by a physician during that illnRss . Also, it. has been esti-m,rated that up to one-third of the deaths occurrTIg in Colombia fail to reach the notice of the official registrars; of the notified deac,hs less than 60% are medically cert.fied, even thougn such certificatin does not imply that the individual concerned received m,edical attenti on durinL his- terminal- illness. 7.- The Natioln. HeltSh 5,JC\Oy of 1965 nndl ot,er speci.al studies conducted more recently, indicate tha,t. this si tuatior! is improving, at least; in some areas of the country. Foweveer, considernble cautjiorn must be applied in interpreting currently a4va--iilable data for they undoubtedly underestimnate the magnit)ude of each of the mna,jor deve-lopmenta9l henlt..h problems that conf'ront the health auttonj ti es of the country. The following bri;ef sunmaries of selected manjjor disease categori es and he_.lth problems are -ncluded for illus3trati-ve purposes. 1. Diarrheal Diseases and Related Conditions '(3 T' Is grotin of conditJions Is clea3rly associ nted with the low levels of envi ronrriental7 sanitation still prevalent in the country particul.,rly auts`ide of the nmajor cities nd. n the rural areas (see Tables 11-7 and T1-B) It casn be estimated th.t no less thian orne in edgiht of a11 deaths are ,ssoci ated with enterinc infections. They g,ive ri se t,o almost 8.5 percent of all ronsiji tati oars w1 th heaI th personnel and compri se the second, or po.sSiiJy t-he third, most frequent cause of' hosrpi fiKi ration. The toll of (i.rcheal iesses is grea-test in the early years of l.ife but no age group s s - lored L] in kedi tc, tLiese condi t ors .-re the paras: i rc trfections of the gIsstrGin,testnal tract which i.n addition to causi tin' fhei r ownm morbidity annd moI'tri.j Iy add a significant. burden to the nutritinnal requirements of the popula-Jonr As n speci.al phlase of the National hlealth Su)rvey it was found -that over- 60 percent of the popula-tion harbors one or more variet.es of p.athogenic: intestit al worms and other rarasites; infestation is h-alvest in childhood and thne tyoung adultIt years and in the rural areas where lowet in- come and levels of educatiorn prevail and ;where there -s the least ac-ess t5o . tanmtation of rAamer supplies and sewq,age disoos.a] . (gp). 2. Th Corrmrorn Acute ITrfectious (iseases (of childhcod) 'I. fea; tsi ndi moBrbi di t;y ir i nr 'ncy a:n d early chiildhood rerri n hu:k i7 in1 PcI omhi ilaivl e vonl thou gh. approlweci 7Abe reduc ti ens have heen nm....e it r ,n.n' yelrL . UulenlrlyJig mr lilut rI ;i on air-- gsn tIrolr oesti nal in fectionris are,in al - '12 - probability, the most si.gnJi'icant. factors for even in mild for- t.hey can aLso severely i.ncreasti t;he t.oil oJ lhe common infections of ch-i L.iood. Modern medical technology has dievej nped simple a--nd re] ativeLy inexpensive immunization procedures to prevent many of' these common inf'ecti onF but on1 y 1imited success hns yet been attai ne( in protectirni the Colombi-a populi a Lion. For exim lp e onl y :13 percent of the susceptaible popul iti on (unde(r age .5) h:tve beern immuinize(d a>gainst whooirigr cough , ' percent. (under ]5) ag-inst. diphtheri a and 5 percent against poi i eo (under age 5). VMeasles vracci nati on, one of the newest yet most. usefull. pro)hyl .acti c procedures, ha.s not yet been sup)li ed through publi c hea1 th channels aind tetanus toxoid has been gi ven to ibout 1 percent ol' the general pop'ili.ati on. On the other hand smai] -oy vaccin;tion has beern gyiven to 5z percentl. of a].l afge groups, a level of' protection whi.ch is considered low were this devas-t.ating infec tion to be rei.ntroduced into the population. The neniiAh auijthorities have adopted the policy of' givingg BCG -vaiccinitdion as :i means of' protection against tuberculosis but; efforts to date have not e..oee.1e-l the immuni .-tien of B percent of the podul -,ti on . 3. Malnutrition 75. Colombhi an authori-ities and external .ssi.st,Lnce agernci.es h-ve recog- ni.zed the needl for correcti.ng thle severe nutr;.tionnl deficiencies of' the Colombian pooulatl 0!.on and curr0rent.I; i>'xtensi.ve progr.aims, costing in the range of U.S. $5 ail 1li orq arird a ar c nr s and lr1.1 be contin.ued for at least. a f'ive ye. r per i o0 . o nt h r Pn,ior he.-lth problem in Colombia-i h.s beer so intensively studied, no naS 'h - a well. pla)nlirod o0 so imbitiou;s a program been devisedi against otiher iriV jor health problems equivalent to tha-t current.ly under way in this country-iride attack on mnalnutrit.ion. Yet the extent of the problem is so great, the liactors contri buting to it, so complex and the implications for the tot.al economic and social (development, of' Colombia so pervasive that meazsures short of those plarned would be ill advised. Table II-16 shows the categories of nultritional deficiencies identified in sampl]e studies conducted by the Insti Lute of Nutri Lion, according to urban- rural residence and fanilv i.nc-rte . For all classes of the population only two nutri tional requi.rements are adequntely met - those for iron and vitamin C, whereas caloric, protein, minerail and other vitamin needs are significantly deficient. Additiornal data- are avai.ilable demonstrating that malnutri ti on is heavily concent.rated ir! early childhood where growth requirements are high and where nutrit.ional deficits are directly reflected in increased susceptabili ty to intercurrent i nfections and retarded physica. and intel- lectual development. A second. highly vulnerable group i.s made up of pregnant rnd lactating mothers. Although direct measurements are lacking in Colombia substantial evidence derived f'ronm studies in other countries indicate that the efficiency and product:i.vity of t,he total working population is reduced when their nutritional requirements are unmet and that absente6ism and learning curves of school children are comparably impaired under similar conditions. . Tuberculosis and Other Chronic Infectious Diseases 76. In recent years both the mortalitty rate and the prevalence of tuberculosis disease have been following a steadi:ly downward trend. Table II-16. ADEQUACY, IN PERCENT, OF DAILY PaR CAPITA INTAKE OF CALORIES AND NUTRIENTS FOR URBAN AND RURAL ZONES AND FOR SOCIO-ECONOMIC CLASSES IN 10 OF THE 11 LOCALITIES STUDIED IN COLOMBIA BY THE NATIONAL INSTITUTE OF NUTRITION IN 1963-1965 /1 Zone and Socio-Economic Calories Proteins Calcium Iron Vitamin Thiamine Riboflavin Niacin Vitamin Class A C URBAN Very Low 76 67 39 109 56 82 47 77 91 Low 80 80 43 108 54 67 55 87 101 Average 93 106 69 112 107 77 92 102 148 High 1iL 126 87 165 135 110 110 124 200 All Classes 88 87 50 126 86 85 71 93 127 RURAT. Very Low 77 64 4O 108 50 81 54 89 174 Low 9C 82 54 125 68 77 68 94 192 Average 87 82 49 140 56 88 60 93 161 High 98 97 66 124 84 98 74 95 216 All Classes 83 72 46 115 56 83 61 90 178 /1 Exclusive of study in El Trebol which did not include tabulations for socio-economic class. Source: Report on seven years of nutrition programs in Colombia 1963-1970, Division of Nutrition, Colombian Institute of Family Welfare, January 1970 (Reference 11). - )4 - These improventents are reflactions, in part, of better case finding pr,- cedures and tthe inst-itition of modern therapeutic inet1ioKt-;, including chemo- therapy, BCG imnlzization arLd chemoprophylaxis. C-u-rent death rates, in the range of 20 pe 10i0,000, can be comirpared favorably wJith those of other major Latin American comintries b:ut, are B' or more t,imes higher than those currently being observed in Korth America. Deaths and known cases are heavily concen- trated in the older age groups but the true extent of this, as yet lncontrolled problem, is obscured by the seriouisly underreported number of cases. In order to make international comparisons, -it is still necessary to adopt, ani arbitrar- ily selected "corrective factor" arid apply this -to the reported numrbher of cases or deaths. 77. Syphilis appeatrs t;o he on thle increase in oloJIi-a andl Wi. . _z*:-~":. =:J*-=_ _, -;_, _ !_- L I .'.'.. '. ... ...... '5;'' CO19 CCfO'61 | -: - ~~~~~~~. T... . . . ....... . ..... ::.::. -:::: :- ;:::5_. ...... . . . . . . . . . . . ; . 1 . ....) . ................ . . _ . .. _.. .. . .. _. . ._ . . .. . ... .,. ... . .. . . . . . . , . . _ . . ........ ..,,;;;.;;; ;,;, -, L;4 ..,...........,. ,;,, . ......... . ... ..., .._ .. . .............:,,,_,__, '-'7d~ C-'[ ICC 9 .... ... . . . . . . . . . '. . . '. '.. * ... . . .. ... .. ..... , ..* ,,. ..., ,s ... . . . , - / o,h' ' ~~~~~~~~~~~~~~~. .; i.. ... ;.... . .. . - *-*,* . A. ,................ ,..... s. rS.~.,, .,,,.... .... Ns.... ...... , . ..e....... . A>............. .... ...... 5:351-8D %.. 0!9 102.. I - t C-0 q ~ ~ ~ ~ ~ ~ ~ ~ ~ I . . . . . .... . K ... .. .. . L .- . ........ .2 A tX LX .i.2...2... . 5! :, 5 ;;; o, 9;,' - Is 0 c ;s 4t* . . . \ . k . .\\ . .... '. k . . . .> IV.A , ..K 'U . ' . . ' , . . I 91. With respect. to morh)id:i Ly, inl any ornE yeal apfproxirlrtely . millicn accidents of' all ty,pes occur, a rate oj )426 per th-ousand po)Pula- LionI. Stated alte-naaive li , four ol every Letn (.olombians experience a significant accidental inir; ry in any given year. More than one-fourth re- sult from falls, one-fifth from cnttirig and piercing inst-Irnments, 8 percent from falling or flying oh-Jects, 7 percent from vehicles an i c nercent from fire and. biurning objects. ;cncluding vehicular accidenLs, the most hazardous place from the point of view of aucideiital injury, :is the hlome, fol]owed by street accidents, farm accid(.den_-ts nUdJ a-LcciCide3lts Zait the place of work. The risk of occupational accidents is highi, accounting for the 5;J2 acc;i.dernts per 1, 000 workers, a rate (.) perc.ent higher than- tihe rate experie-Lnced by non-workers. Such occ upatiaOnal. aco:s!n ts are iqn,iivalent tI l()4 i.nca i.tat- ing acci(ientc; for each ni 1] wn hours of wrk. 92. All t-old, inL addition to. deaths, permanernt invalidity, dam.age to property and loss of incone, accidental injuries an aount in any one year for 17 million days of invalid1ity, I1 ILLi-ion medin:al -.are visit.i, 98 thousand hospitalizations (l perceent of all. hospitalizations, 12.7 percent of hospital days and 1.2 million days li- bed) 7. Dental Disease 93. In most co1uLtr:esq, dveJed or developing, the e.:-tent of dental pathology is suiject only- to gros; :.s i!rates In o lombia, however, exten- siveinformation has been gathered i,icatinlriat ha.t , percent of the popula- tion over the age of three are in needi oi` d eiJal ( care with t:e highest pre- valance during the age span.--tb, reaching a nealz of 55.7 percent at ages 15-24. No marked differentiaLs occuir with in ,mec levels or geographic loca- tion although women appear to have a higher need tJian mnen. 94. Not all those who need denital care receive such attention. Only 24.3 percent of the population consilit dental attendants, slightly more than half of those who express need for such c.are. Those who seek dental. assist- ance average 2.5 visits per year anrd this attention i.s concentrated in urban areas, in the higher incomne croups anid. in the actije working age groups of the population. Extractions account for o-ver two-thirds of services rendered with fillings and dental prostheses making up most of the remainder of care given. Dental prophylaxis, so -imtportanit in early life, makes up only a small fraction of dental care services. 8. Mental Illness 95. pubstantial evidence exists that mental illness and psychiatric disorders are serious and Lmportant health problems in colombia. An estimate made in 1967 indicates that; about 710,000 persons or almost 4 percent of the population is disabled or chronically impaired by the psychoses, neluroses, mental deficiency, epilepsy and alcholismn. One in six of all hospital beds are devoted to psychiatric care and almost 2 percent of all medical consulta- tions arise from mental health prolblems. About. 3 oercent of physicians select psychiatry as their area of specialty practice. ktegre-ttably neither time nor opportunity perrnit-ted an appropriate survey of the mental health area or a proper evaluation of the proposed mental health program incorporated in the Ten-Year National Health Plan. - 41 - D. Institutional Resources for Health 96. As of December 31, 1966, there were 658 hospitals in the country providing 46,735 beds (approximately 2.5 beds per 1000 population). 523 of these hospitals, with 87.4 percent of the beds, receive all or partial support from the public treasury and their medical policies are guided by the Ministry of Health. The remaining 135 hospitals, representing 12.6 percent of total beds,make up the private sector. About one bed in five is devoted to special health problems: chronic diseases (tuberculosis) and mental illness. (Note: In the last four years the ratio of available beds has fallen slightly due in part to an increase in the population and to the closing of some hospitals and the deactivation of some beds.) In addition to these hospitals, there are operative about 1120 health centers and health posts rendering primarily preventive services and ambulatory care. 97. Although the overall ratioiof available beds compares reasonably favorably with resources available in other countries, subdivision of the country reveals serious maldistribution of these essential health care facilities. For example, dividing the country into three major categories: major towns of over 20,000 population (45.8 percent of total population), towns of 1,500 to 20,000 population (42.6 percent of the population).and smaller communities with less than 1,500 inhabitants (11.6 percent of the total population) interesting disparities of availability of hospital care become apparent: (Table II-20). Whereas 23.2 percent of the population is judged to lack access to hospital care this proportion rises from 1.1 per- cent in the more populous areas to 87.5 percent in small communities and rural areas. Concurrently the bed/population ratio falls from 3.5 per 1000 in larger centers to 2.0 per 1000 in intermediate size communities and to 0.8 per thousand for the rural balance of the country. 98. Other important comparisons indicate that hospital resources are utilized more efficiently in the more populous areas with shorter average hospital stays (12.3, 10.9 and 15.1 days respectively per admission) and higher occupancy rates (75.4, 51.5 and 53.3 percent respectively). 99. An interesting attribute of the health facilities situation is reflected in the number of partially constructed and unequipped and un- utilized hospital (or other health care) facilities scattered throughout the country. A recent inventory of these facilities places the number of such structures in the vicinity of 856 buildings partially erected at various times during a 15 or more year interval. Political pressures, local charity boards and other sources contributed to this situation with- out reference to clearly assessed needs, national or regional plans and, alltoo often, with insufficient funds to either complete construction and equipment objectives or to initiate and maintain operation. One estimate places the already made investments in these structures in excess of 2,000 million pesos. As will be noted in a later section, the new National Hospital Plan has not only assessed these structures but proposes the completion, equipment, and placing in operation of such of these facilities as will contribute to a rational national plan for comprehensive health care coverage of the total population. Also as part of the National Hospital Plan the estimated deficit of needed hospital beds by 1975 is in the range of 15,400 additional beds (see Table II-21). Table II-20. POPULATION -wITH AND WITHOUT ACCESS TO HOSPITALS /a ACCCRDING TO SIZE OF COFMUNTY COLOMBTA 1966 1.ITH ACCESS TO - T=hOUT ACCESS TO T u T A T L HOSPITALS HOSPITALS Pooulation Size No. o No. of N TON m o. of POPULATION Cn _,__ Co . Io Over 20,000 56 8,529.707 98.9 1 92.678 l. 57 8,622.385 100.C 1,50c to 20,000 313 5,645.058 70.5 182 2,358.072 29.5 145 8,003.130 100.0 Under 1,5GO 37 272.605 12.5 306 1,905.o86 87.5 343 2,177.691 100.0 T 0 T A L : |406 |14,447.370 76.8 1489 14,355.836 23.2 895 18,80.20$6 100.C /a Includes both public and private hospitals. SOURCE: Study of Human Resources for Health (Reference 14 h) Table II-21. ESTIMATION OF THE NEED FOR GENERAL HOSPITAL BEDS it BY 1975 1966 1975 Strata PoDulation No. Beds per Population % No. Beds per Deficit General 1,000 General 1,000 ________ __________ Beds Population Beds Population I. PCL' 7,501,099 39.9 14h,61,946 57.0 PR 1,121 286 6.0 3.0 PT 8,622,385 45.9 42,975 2.55 14,961,94C 60.0 37,895 2.55 + 15,923 II. PC 2,650,162 14.1 3,220,088 13.0 PR 5,352,968 28.4 18.0 PT 8,003,130 42.5 14,240 1.78 7,678,672 31.0 13,668 1.78 - 572 III. PC 243,515 1.3 PR 1,934,176 10.3 PT 2,177,691 11.6 788 0.36 2,229,292 9.0 802 0.36 + 14 TOTAL: 18,803,206 100.0 37,003 1.97 24,769,910 100.0 52,368 2.11Zk 15,365 /a PC = Urban Population PR = Rural Population PT = Total Population *b Change in total rate resulting from the change in the distribution of the population in each stratum. /c Includes pediatric and obstetrical beds. Source: Study of Hunan Resources for Health (Reference Lh). Table II-22. CON1LIUfITIES AiID POFuLAhTGIO AC1CORDIING TO EXISTING RESOU.P.CES OF PL3C 2L, BY COI24ITY SIZE COLOI31A 1967 2Q1 II 7 WITH ,E C M DIr WITH AUXILILRY SPORADIC WITMOU cIZE ASSISTANCE /a ONLY RES OTRCES PMSOU2C CI 0 T AL _-- -. IG*1< l-T. to 1 9 ,146.215 100.0 _ _ - _ _ ,.G6.2l: Cv.C 2 7,7L11633 96.8 175.3<& 2.2 _ | _ ,-351 1.0 Q 796 7 .3& 2 1257@62 | 93.7 |99.169 0.2 .7 71 32 |7C iC 5.C /a Includes conrnmnities without health center butv ith a hospital- Source: Estimates of Sectional 'Health Ser-vices, ; ristZ,r of HIealth. 100. Ambulatory care facilities -- of the total of 1120 health centers and health post facilities, 710 fall in the former category and 410 in the latter. In addition, 657 hospitals provide out-patient or ambulatory care services as do 205 offices of the Social Security System and the National Welfare Funds. About 5,500 private physicians offices and an indeterminate number of private care centers contribute to the ambulatory care services for the population. 101. Based on the above compilation, it has been postulated that for the country as a whole over 94 percent of the population has reasonable access to ambulatory care resources. This figure ranges from 95 percent in the larger towns down to 90 percent in the less populated areas. However, the comprehensiveness of services available is disparate. For example, health centers and health posts which are called upon to render over 30 percent of all consultations for the country as a whole (57 percent in small towns and 83 percent in villages and rural areas) offer only limited facilities and equipment and limited personnel. Health centers are staffed primarily by nurse auxiliaries with occasional visits by physicians and health posts, many of which are open only on a sporadic basis, are staffed only by nurse auxiliaries. In consequence, as shown in Table II-22, whereas for the total population 94 percent is believed to have access to medical consultation when needed, an additional 5 percent to similar attention provided by a nurse auxiliary and less than 1.5 having access to none or only sporadic care, this same situation does not prevail in the smallest communities and rural areas. There, only 54 percent has access to medical assistance and 37 percent must depend solely on the resources of a nurse auxiliary; the balance, 9 percent, is unprovided for or exposed only to sporadic and then severely limited services. E. Health Personnel-Supply and Distribution 1. Physicians (4 - c) 102. Few countrieshave as much or as precise information on the number, qualifications, location and other characteristics of its medical profession. Using December 1966 as a reference point there were then 8100 physicians practisirng in the country or a ratio of 4.5 physicians per 10,000 population (1 physician per 2,200 population). Much of the following analysis is based on data received from each of the 6,323 physicians who responded to inquiries incorporated in the 1965-1966 National Survey of Human Resources for Health. 103. Comparing physician resources in Colombia with those in other countries, Colombia falls slightly below the mean of 6.0 physicians per 10,000 population for South America and considerably below the national aver- ages of 15.1 for North American counltries; for Brazil the ratio is 4.0; Ecuador, 3.3; Bolivia 2.9; Chile 5.8 and Argentina 14.9. The physician population in Colombia is young with 56 percent under 40 years of age; 65 percent have com- pleted their medical training since 1950. The practice of medicine is essen- tially a male occupation with less than 2 percent women, a rate even lower than in the U.S. All but 3 percent are native born although 9 percent re- ceived their medical training abroad. - 1ho - illh. The distribLution of physicians is uneven wi-th 74 percent located in the principa:l cities of the country serving the needs of the 31 percent of the population that resides in such centers. Thus, in these cities there is one physician for 1000 of the population whereas elsewhere the ratio drops to one for 6400 persons. Only 9 percent of physicians are in practice in communi-ties of under 20,000 populat;ion, where almost 64 percent of the population reside. This disparity would. be even greater were it not for the fact that since i95,7 every graduating physician is required to render obligated service for at least two years, usually in a rural area designated by the Ministry of Health. 105. Only 27 percent of physicians devote their energies to general medicine and an additional 53 percent are involv-ed in the specia]ized practice of surgery, internal medicine, pediatrics and obste-trics. Orly a smal:L frac- tion of physicians specialize in public health, l.3 percent, and. an even smaller fraction, 2.5 percent, specialize in psychiatry. 106. Because the public treasury is responsible for funding so large a fraction of health care services in Colombia it is not surprising that more than half (53 percent) of the physicians indicate that all, or the major share, of their practice is devoted to non-private care. This figure varies, however, with non-private care rendered by 68.7 percent of physicians located in towns of under 20,000 population. In cities of intermediate size, this proportion drops to 40 percent risiLg again to 54 percent in the capital cities. It is also of interest that concentration of interest on private versus non-private practice varies with the age of the physician. Early in their careers up to 80 percent of physicians are totally or predominantly dependent on salaried income whereas beyond age 40 the emphasis in their practice turns more in the direction of private patient care. In mature life only 25-40 percent of cloctors derive all or the majority of their income from salaries. 107. The mean income of physicians for the country as a whole is about 92,000 pesos per year, this mean varying from 93,000 in the largest popula- tion centers down to 54,000 in communities under 20,000 population. In the larger centers about one-third of physicians have incomes of over 100,000 pesos and only 20 percent earn less than 50,000 pesos annually. In smaller communities 40 percent fall into the lower category and only 4 percent in the higher. 108. A significant finding of the 1965-1966 study focused on the utili- zation of the professional time and skills of the physicians; almost half (47.3 percent) is consumed in non-medical duties or tasks which in the view of medically trained observers could be done as well, and in some instances better, by other personnel without the long and expensive educational pre- paration requisite for the awarding of a medical degree. This observation and others to be considered later strengthen the argument for a greater use of auxiliary personnel and thereby extending the availability of physi- cians for duties that cannot. be delegated to less well qualified workers. - 47 - 109. As stated earlier, 3 percent of Colombian physicians were born outside of the country and a total of 9 percent are foreign trained. However, a recent development arousing the concern of Colombian authorities is the increasing trend of Colombian physician,s to migrate to other countries, particularly to the U. S. In recent years this "professional drain" has averaged about 70 physicians a year equivalent to about 17 percent of the annual number of physicians graduating from Colombia medical schools. Regrettably,during the last several years this trend has been accelerating and this migration rate may now be approaching 25 percent of production, a serious economic drain both on the limited educational facilities of the country and on its long-term social resources. Ostensibly the main motivation for this emigration is to seek professional graduate training and experience in U. S. hospitals and institutions and many such trained physicians contemplate return to Colombia at the conclusion of this specialization experience. However, data are incomplete or unavailable in this area and it is commonly believed that a large number remain as expatriates. 2. Dentists 110. Studies similar to those summarized above for physicians have re- cently been completed in Colombia for professional dentists. Unfortunately, delays in the publication of these more recent studies preclude the incorpora- tion of the major findings in this report. However, the 3,400 graduate dentists who have been identified as in professional practice in the country establishes a dentist population ratio of 2.1 per 10,000, a figure slightly below the aver- age of 2.8 for all of South America and considerably below the average of 5.4 for the North American countries. Comparable figures for several other Latin American countries are: Argentina, 5.4; Bolivia, 1.6; Brazil, 2.7; Chile, 3.3; Ecuador, 1.2; Peru, 1.5; and Venezuela, 1.9. 3. Professional Nurses (4h) 111. Data similar to those covering the physician supply are also avail- able for a segment of the nursing resources; namely, the supply and distribu- tion of professional nurses, those who have had training beyond secondary school level, usually, if not exclusively provided in a university medical center setting. The 1965 survey indicated that there were at that time just under 2,000 nurses in Colombia of whom 82 percent (1618) responded to the study questionnaire. Of the respondents, 73 percent were engaged in nursing in Colombia, 21 percent were inactive and the balance, about 6 percent, were outside the country. Secular nurses made up 77 percent of those covered in the survey but the balance, belonging to religious orders, constituted 25 percent of the active professional nurse supply. 112. The ratio of nurses surveyed to the pcpulation as a whole was 8.2 per 100,000; in the capital cities this ratio was 22.7, 15 times greater. than in the rest of the country where it was 1.5 per 100,000. In contrast to some other countries where there are usually twice as many graduate nurses as physicians, (e.g., U.S.), in Colombia, physicians outnumber nurses about 5.5 to 1. The internal distribution of nurses iri Colombia is further remaurkable in that about 67 percent of nurses are concentrated in the three principal cit;ies, Bogota, Medellin and Cali, whlich maike Up less than 19 percent of the tot,al population. 113. About, )h2 percernt of active professiona]. nurses are work-ing in publ c hospitals and an additional 1Lh percent, n private hospitals; together the:e nurses provide a ratio of one graduate nurse to about )40 hospital beds. Another 1L3 percent of nnrses are emp]oyed, abou-t; equally divided among public health servicen, Lh'oc i ;L Security and Nlaati oal. Welfare Fund cl-i:nics andt in teaching. For tle! most- part. professionral rnurses provide little or no bedside care, inasmuch as 57 pecenLt serve as chiefs of nursing services another 21 percent as direclto is, ass,srrant di.l.c tors or ,3upervis07or's of health institutions, -t1 percent in t,eaching ro'les and Li perent in other supervisory func-tions. url.y L percent are engagead in other duties including private practice. ll1. Nurses are lOt;il well reiaunerated with the average mont;hl..y v ncone of religious order nurses abaut 800 peso, per monti rind secular nurses averaging about; 150)0 resos per nionth. In re(e,til ye:a-rs there h71s been a slightly upw-ard trend in F,he availthi-i1ty ot n.:roieiol nurse .; but this trend is paralleled by a: increasing eigratLion of nurses from thie country, with about 11 percent of the graduate nurse supply in foreign residence, about haLf of these in the IJ.S. 4. Auxiliary Nurses 115. Auxiliary nurses or nurse aides provide the bulk of traditional nursing services available in Colombia. However, no inventory comparable to those undertaken in medicine, dentistry and professional nursing has yet been initiated and thus only crude and somewhat contradictory estimates of their number in actual working si-tuations are available. One estimate (1965) places the number of nurse auxiliaries at about 11,000 or 8 for each professional nurse. Another estimate (also in 1965) places the number of employed nurse auxiliaries at just under 4L,000 and a more recent assessment (1967) indicates that there were then 3,500 "certified" auxiliary nurses known to health authorities and that an additional 12,000 "untrained" auxiliary nurses are employed by hospitals, health centers, and health posts throughout the country. This estimate would place the total number of "certified" and "unitrained'" auxiliary nurses in excess of 15,000. 116. These disparities arise, in part at least, as a consequence of differences in definitlions and terminology. Until recently no formal educational requirements were established for nurse auxiliaries and nurse aides,,both categories being trained on an in-service basis in hospitals or other health care institutions. In contrast, professional nurse training has been directed by acredited educationally oriented institutions. By-and- large, nurse auxiliaries have completed one or two years of secondary school education and receive two years of supervised practical experience in a - 49 - hospital setting; nurse aides usually have less formal educational back- ground and receive less than a year of practical trainiing on the job. Accordingly, large numbers of young women employed in hospital or ambulatory care services, many fulfilling complex and highly responsible tasks, cannot now meet newly established standards for certification. Nor would many of the institutions in which they were prepared for work satisfy even modest criteria for training accreditation of nurse auxiliaries or nurse aides. 5. Other Health Manpower 117. Modern medical. and health care services haVe become singlarly dlependenrt upon a large number of specialized aides, technicians, and other supportling persormel. These skdlls vnor represent, in developed countries at least, Ut.o 6a0 percent of the total supply of speciralized health workers. This ri.F'fere.iation of healthimanpower and the need for delegation of responsbl-,e functions b,,r the phys;cia.n is clearly recogniz7ed in Colombi-a particularlyf in the liJni Jesi Kr edical Centecs. However, thi.s recognition is orlfy now reach-ing We t.-ge at which national authorities are begi ruing to bake invenl,ory of Lthis segmenlt, of the hewltl minpower pool and to establish standardcs an.] norrmts cY personmel reRuJrremenelts in order to assure the smiqo-oth and effecltive opoenlIicn of -ite health czaLre system. Amon-7g thie cat-egories of health workers Uiat aLrc jdue for sluch conTi&Lderation are: health adRministrators, phanri.pc:isCJa, op ti ciuL.s and optomettriL,ts, labora-tory .and other technircias, di.eti.c:ians and nu-1tr-itonis-ts, mnedical and dentaL aides lhealth educators arld hel. ibh promoters, ies t:i) and ci. i 't1l attendants, san:iJ. ti .i'S anId san:i ray r1nspec tors arnd engi n1001'. F. EducatiorL anld Training for tue leaL-th Occupations 1 . Medical Education 118. In the 20 year periol si.nce 1'O the medical educmational system of Colombia has rnade a remarkable forward thru-st, Despite limited internal resources the ua-iversity medical schools making up the Association of C,olomb'an Medical Faculties, have made ma0jor revi-sions in their organization, teaching programs and objec.tives and simultaneously have provided unprecedented leaders,hip to the developmentl of'rogressive national health policies, resources and programs. (The reader is referred to the report: StLudy of Human Resources for lHealth and Medical friucati on in Colombia, Methods and Results. January C1J9f>, Bogota, for an excel lent revi.ew of the soubject) ILl). FPr-i.0or to l?'i, t-hree medi.cal schools gra-idu-ted .about 2i)ii ph-sicianls annually. wasolltment ws open, I Ilul.te.; nre sm.xI- and almost entirely part-time and the teachin.ng plan was based largely on the older Continental [-uopean pattern. A relilit.;,ve? smLall fraction of student,s beginning medical studies compIeted t;heJ r course and. raduates were not. u-wi l'ormly iO f' high caliber. Four a-ddLtitional! -sehnoolls began conI-Ibutirig graduates in -the earl'y IL'0s ndtrg`0,e i- .'he seven jrtvcal school:-, hive -lineost dou)fleld 'thlle cpt . 1 piySJc:i- ans . Tr- sen(-:or schoc's atrc> nonJ accUenti_dg students a Ii i w Wl anincrewet s o t inioto -all sctools tlhe rnumber o]l' srrradua-e. s-oisl 4 approacli 600 a lLy by :rJ- 011 Ol;,viu of 'th;s ora ii t-r'i ly ned a al ii C. '. re s-,ori)eCisrJ r)-\ flwi-vate instti lti' n ; ,fir;i, t ) L :tei; L - -rrent,ly mat- ri-j,1lated in the seven yc.n eiou';; a eyU et l ! , ii "'eon rlrrrir aLre no-t complete:Ly -wri ror I l,iiOUfhtl ). .I'ii' I3iri'itS Is he le :.qtreed to by al 'i 9 l 'I i . l t-i urnLi i r a i.!ll., with an overall aveol ci LII ) in Ii a'; li a' . tl. /-i ;i l. ion lile to acadendic fail rn rH'r-it i ' k'h !,t. Lt.i, l i rndi to at ill. ()&rI,e f'or the total seven ye ar ,)p- ;;rli tb l. ; nt-:tol wf. OC. .r l r th'rle first two years. 'l'he en rnI fli"e r; , if wcrlniel ha,; iri.12l fran cider' ' ocr r r- , ent to 12 percerit. 121 Th'e re''L :tp_; .1p:7.1:i i;ni0cr_. 1cii1e Canafl:ian Jnstitu liJons -j Jt nt r,. ul 51 ti.1 (Idli I . . ii e _ C i S -.'a trairring and carefull;r sur se,i n l i . ! ". pu - : . u ve n.e;3ie i ni ind public health a.re "ei ri(i p. ' ! .. c'irrno in the cir:riculium - irn view ,, Li r' 1jiLi. at .,; ii VUA . 1 . ; ! ec In 011 health problemis hoe-, ;.' -. i i u 'a o'v t ichiexcd. the saune degree of acceut;oucc SI!O ia'; ; t ! ' ; I he muil> un ! ou; anid traditiornf,1 Iire ca. *. it I er' mrredi, a.! ci iL ies are growiing wif.t ri or I a:i c-act L *.LUle Oil .. Ll Jt. althoiugh half-!im aik p 1 1 -- In. J ,rntl I.' nt IIt. 'otinuc iO represent irtore than 50 oerce I, o t ir mi i c:a:l ., r,il i-; tro. j i I In 2 i -in l*,onY undergraduate metir,cj edlm''' the I.,-alt.ies of rreica1 sntv'OS , w- a in post-graduatoe edalO 'i thf 'n @1 va.tli; ti 1i the WI v ' to losp:i tj.s , r'ese.arh'T't ani, i nc:''' '' V r' arm:i U "' hea] 'L '' S t -we I i thfe Lra_iri j-i r, n' l l C ;;;JOtv t 122. The ruost of maintrairing tUe rriediLcal .,chools is iiij Ii aid the six schools (of a total of 9) fo" which data are availabie required over 5C) million pesos a year for operatioi:.Ll costs, without reference to capital outlays or those for replacernerr -t or purrchase of new equipment. None of the schools has income of its own. The two private schools w,hi-ich receive the smallest public contribuitions are aLmost entirely dependent on enroll- ment fees for their support. Only one school has received substantial financial aid from abroad and only three have private funds from Colombian sources. The seven public schoo:Ls charge an annual enrollment fee scaled to the income declared by the parerits of the stujdents; the two private institutions charge a fixed enrollment fee considerably higher than is charged at the public institutions. The degree -to which this system affects the choice of medical careers is not clear; yet 'the sonls of merchants represent more than 25 percent of medical school Matriclan-ts. 123. Projections foIr the future supply of physicians have been developed by the Association of Colombian Medical Faculties based on current and anti- cipated resources of the training institutions. The population of Colombia is expected to rise from its present level (1969) of 20.5 million to 28.8 million in 1980. With medical grad.uates rising -to about 600 annually and with a loss by death of 70-90 physicians a year (emigration of physicians is not considered) the physician popula-tion ratio will rise slightly from - 51 - its present level of 4.3 per 10,000 to about 4.9 in 1980. It is thus appar- ent that Colombian authorities are not counting on a major improvement in the existing physician-population ratio as the means of overcoming the large backlog of health problems now confronting the Colombian health system. 2. Nursing Education 12b. Nursing education in Colombia has remained relatively static over a period of years. Seven nursing schools were in opera-tion in 1956, the same number as in 1965 when the survey of th-is field as well as of medical education was made. One of the seven schools is not included in that study; of the six schools providing data tlhree are located in Bogota and one each in Yedellin, Cali and Cartagena. Five of the six are integral parts of a university education system. 125. Between 1955 and 1963 the number of applications for acmission to the six schools rose from 150 to 348 and the number of first year students from 1311 to 167. However, only one nursing school was able to select one in four of its applicants; the other accepting all or a considerable majority of theirs. 126. Two-thirds of all students come from major cities and less than 1 percent from rural areas where half of the country's population resides. Three quarters of the matriculants completed their secondary education in private schools and though educational fees are low there is evidence to suggest tha-t candidates for nursing education are drawn from reasonably well-off economic strata of Colombia though perhaps somewhat less so than are students choosing medicine as their career. On a national average 75 percent of the students entering nmring school complete the program although this figure ranges from 97 percent in one school down to 57 percent in another. 127. The lack of appeal of nursing education appears to be linked with high academic requirements for admission to the schools and more recently to the lengthening of educational requirements. In the past the nursing trairLing program varied from two to three years depending on the individual school. More recently with the introduction of the general studies program in schools of nursing the duration of the required course has been lengthened to four years and on graduation the term "general nurse" has progressively replaced "licenciate in nursing." 128. The cost of nursing education is also high and is largely borne by the university budget. The range of cost per student per year varies from a low of 2,800 pesos in one school to 16,600 pesos wfithl an average of 6,740 pesos per student. 3. Auxiliary Nurse Education 129. It is stated that 30 schools of auxiliary nurse education are now in operation in the country. Other information suggests that this figure is low and is limited to "accredited" training institutions. The M4inistry of Health estimates the number of "graduates" each year from these "accred- ited" schools in the range of 700. In all probability twice or three times that number of new recruits annually enter employment as auxiliary nurses without proper training or preparation. By crude calculation it is possible to arrive at an estimate that no less than 100 "accredited" auxiliary nurse training schools are needed with each turning out no less than 30 or 40 graduates annually. 4. Dental and Other Health Professions and Occupations Education 130. These systems have been or are in the process of being studies but published or other data are not presently available for inclusion in this report. - 53 - III. TH, NATIONAL TEN YEAR HEALTH PL)N FOR COLOMBIA (:968-197?) A. Origins and Evolution of the Plan 131. A number of strong, converging forces have been at work in initiating and consolidating the Ten Year Health Plan now in effect in Colombia. This document, Plan Nacional de Salud, 1968 -177, criti- cally assesses the significant health problems of the country, catalogues the resources available and needed to resolve these pro- blems and, eqlally inportantly, crysoalizes a series of long-term national policies and -plans to guide tn'e governmental and private sectors in achievirng attainabl-e national goals. In the brief period of time in which it has been in effect miany of its innovations have proven feasible. Moreover, though a period of ten years appears to be a short span in whiTh to accomplish its mualtiple objectives its practical directives have aroused the confidence of the health administrators of the country and have mustered widely based support both within the country and among international authorities and ob- servers. 132. Among the prominent forces that have givern rise to the plan is the clear recognition, at the foreTwst levels of the Colombian Govern- ment, that economic and social development are inseparably interwovren, each with the other; advances in the former area cannot proceed at the expense of parallel progress in the levels of health, the educational status and the living conditions of the Colombian people. Stated alter- natively the development of modern social institutions are not dependent solely on, and cannot be delayed until, the prior accumulation of indus- trial capital and economic vower. Rather, a healthy population, educated to participate actively in a modern society and living in relative hoTneo- stasis with its domestic and working environment is, in fact, an essential condition of full economic development. Such a national determination has also been incorporated in the charter of the Alliance for Progress signed by Colombia and 18 other republics in 1961. That document calls for a national health plan as an integral element of a national plan for total economic and social development. 133. But even in advance of the Pun Li. del Este, )eclaration, the Government of Colombia began in 1$(6 Io draft a lorng-Lterm public health plan. The technical .ssislance of [tie World H-ealth Organization and the Pan Aierican hiealt.b Organization w;s en]iLred as was the help of the United Nations Children's Fund. These efforts gave rise to an initial ten-year hesll:h plan (-162-1971) Ibu-l, even more significantly. revealed many of the severe limilt-:ions and constraints under which the healt.L authorStiies in th' -t countciry were lorced to function. Dis- persed and fractionated responsibilities were the order of the day, ftinds fromi a mtlti[ ioiity u' source-s in Anadcluate amfJounts were expendeds without, reference to prinr-l-v rjeeds or tt.itoLiorL1 planc, and unqualified peis[noniel subrjecl l-: L ntron-age apc}oi.ntrnen i. and ramoUl.nl were) cosmpletely 5 4 - devoid or pro 1' ,-;.si ori.L gl idti-cke andi Lu- i :)(-.V i.jiv.100 . Bt U, no, -t,he 1 eas1 of the (lil.ficul s idi llJ I-j i :d wa lh Ia oh ic-of reial)le data ch.-rackeri- -ing eve tWe , mosL prev-i 'ti, nt o hefal j,lt pr'oldcoines and prov idi og a reasonable ban.l.s forl evalm.;.itillor ttI.f' e lJTf'le;t-LiVeen.,,:; of, est LabLisho(]d aIc ,i- vities or thie sliork1Jleon ieo,; of L.l Li urea I u Ile so.! ireil )-i&-tt.e ens some of which dated back I/(J lie wt e i ofa. 13L. I-t Wax i.in Q.t!iE; I &oeV(iw k e t1 t ai We Mi r-i:;l;ry ol I lealli wao; to respond creat.ively i )ri L.o Uhe ,V( P H d' thie C,o]lomb,i.a A s- a- tion of Medical. Facultie.s wh i oh was fi erei eci r g Ik, plan ai coo.rs : o,l act,ion f'or, itS own, th0erl tven,[S! i t H I I (Hi I en m41 ers tor L duE dcveltciferelt of an adequate nat:icrnal UijI .ppy ofl ( ace! thier XLec I Lb manpower and to adapt their eduect,eill t.is t.(-,oi Hr,reporary Cc ta,erVitionaLlry accepted professional ,tarindards. TInhe an A`m.rici me [lea]Lb C) rga]Lza.Lio) and a private interjo ULOn,l ft1ulonda .i _on, thfe MiJlb:ji-jK Mem rwi Jal Fa0 ed uf New York, agreed to provide toedhnica.1 ars iistanLce an1d financial aid. 'lhus, the way was paved fCor the nati oriwiJd collaborative stud:j- of flealth Maan- power and Medical] EducationIre ir %)ombia (i'.nc-ut&e) incorpoirating a scientific apprai E.'_A of the health condition; an(d totl healthl rescurces of the country - a trj.uly National Health Survey, 135. This National Hlealth Survey, a unicle undertaking in a develou- ing society, has placed, for t,he lirst timte, ire the hands of healthl authorities and planners i.n Colombia a fund of scientdific knsowledge on which to base a sound nati-tunal health p_lan arid(1 pprogram. Its findings form an integral part, of the Natiorial 'I'en) Year H1ealth Plaan, 1968-1977. But, its benefits have not stoPped there for, i.n addi-tion), the study's economic and soc.ial profile.s (-C the populat ien, its analyses of' rates and patterns of population inerea-e an(d t' ot,her demographic characterist- ics have been of inval.uable , to other nati.onal ministries and agencies of government, as, For exaannple, th-e Ministries of Ed.ucaticn and Labor as well as the Nationa-l. Deto)arl-lmen-its of P1l,an,ning and Statistics. It is also noteworthy that the *'-es.ign arid applications of' this national health planning procedure is beisrg inarearsaingl,y emulated in other Latin American countries as well as elsewhere. 136. Important national legislative enactments have accompanied and paralleled the forrxRlatiore of' thle Nati(onral Healt,h Plan, incl.uding Decrees 3224 of 1963, 1499 of 1_966 and 24Y( ol i.)6'8. These have authforized andl foimalized institutional and( adninistrativee reorganizations required for sound development of national, reginal_ anld local, act-ivities in the health field. Specifically, the above legislation provides for the reorganization of regional (Depart-amento) and local (Minnicipic) healt,h services as a descentralized functiorn of the Ministry of Hea'lth; fosters the coordination through a National liealthli Counrcil-, chaired by the Minister of Health,of the efforts of previously dispersed entities of' government responsible for fractional health funct.ions and f'or- the unification of their financial resources; the organizatiori and consolidatdion wi.hin the Ministry of Health of the mechanisms for supervision, control, programming and periodic evaluation of heal.th activity at all ILOvels of government; and finally, defines the fields of' activity as well as creating the new organizational structure required to carry out the new health programs called for in the Nati.onal Plarn. A more deta.led appraisal of the new organizational pattern in the health sector is presented elsewhere in this report (See Chapter I, Section B, above). B. Major Elements of the Plan 137. Following a general description of the geography and climate of Colombia, the major demographic attributes of' its population and the significant economic and social circumstances influencing the standards of life throughout the country, the National Health Plan, 1966-1977, critically assesses current mortality and morbidity rates for Colombia and takes note of recent time trends. Each of the major causes of death and of illness are reviewed (see Chapter II, above) for various age groups of the population. An appraisal iE then made of the availability and utilization of health care resources in the various geographic zones and among the various social strata of the population. Thus, utilizing the extensive data assembled in the National Health Survey, the health authorities of Colombia, have been placed for the first time, in a position to formulate on defensible grounds a series of health priorities to guide both immediate and long-range programs. 136. For purposes of planning, diseases or other health problem,s have been arbitrarily categorizecd into those that are "reducible" or "non-reducible". Among the former a.re listed the major communicable diseases in the following order: the diarrheal diseases, intestinal parasitism, tuberculosis, measles, whooping cough, malaria, syphilis and gonorrhea, diphtheria, tet. nus, leprosy, polioomyelitis, smallpox, rabies and yellow fever. Two other conditions not of infectious origin, are includied in this list of "reducible" conditions - abortions and endemic goitar -- and it i<. somewhat surprising that at least two other condiLions known to be highly prevalent in the coujntry, contri- buting significantly to high morbidity and mortality and also clearly susceptible to preventive measures, are conspiciously omitted from this list. Malnutrition and to a lesser extent, accidents are, in fact, given high priorities in the subsequently developed health plan. Additional challenges can be raised to the justifications for placing other significant health problems in the category of "non-reducible" conditions, but, i.n the main, those too are covered in the subsequent developmrent of programatic plans. 13Y. 'The major prograLms developedt in the Thn Year Plan are listed as follows: (a) Reduction of morbidity and mortality from "reducible causqes": 1. Program of basic sanitation (di.arrheal disease and intestinal parasitism). 2. Tuberculosis program (prevenlive vaccination and treatment of the sick). 3. Five-Year m; va( -,i.nition c.oi^ )aign (inca 1x;, wIo o pi nrF! di oh theri_La, T trn s F,()rjjio Inyyeliti ar)i (I `pox ll. Teln-year iarii eradi.e a Lion MrI i af m. 5. venerea I iea n e r rg am. t. Famdily planning, program (abortAonj. 7. Lepiosy con trol 2rogram. O. Goiter control progrm.rM]. 9S. R. hies control progra-m. 1). Aedes Aeg,ypti eraWI .ca,tion program (yelloow, ever :11. Yaws eradication programn. (b) Reduction of Mortality from "Inon-reducibleIi causes: 1. Nutrition and feedi ng vrogram. '2, Occupa)8tiornal health program. 3. CoinnrehenFLve health and inedical care program (hospitals, health centers and healthn pol,ss). L4. Mentail heall t.h program. 5. Dental he . tyh progr-m. (c) Organi-zation of the health sector. ]. Develop-ment. of hea]lth paolicies and Programs. 2. Evnluattion and sip,errvision of decentralized health activities. 3. IThe training and organization of health personnel. 4. Health investigations and research. 5. Budgeting, for health operations and investments for health. C. The Ten-Year Health Plan - Analysis and Comments 140. Neither space nor time permits a detailed analysis of each of the programs and activities outlined in The Plan, and now in the process of implementation, beyond the observations and diEcuEsions provided in earlier sections of the report. In general however, each of the projected programs and activities is based on a sound assess- ment of -the magnitude and vulnerability to attack of the problem, a clear appraisal of the resources needed and available and reasonable projections of the time and funds required to achieve desirable ob- jectives. Whether the goals sought by the Plan will be achieve or whether it will fail or fall short of its goal - as was the case in earlier Colombian efforts - depends Le;3s on its scientific and tech- nical elements - which appear sound - the n on tthe pol-itical climate in which this Plan has evolved. In this- connection a number of items bearing on the prospects for success of the Ten Ye;.ar Plan warran-t further consideration. 1. National Support for the Plan LIll. In the past, and even in the present, health as one of the social sectors in development has not been assigned a high priority by the governmental, industrial and economic leaders of the emerging nations. Erroneously, health and medical care expenditures have been considlered consumer goods and prevailing oolicies have tended to favor inves,tment opportuntities in physical capital. Only with rising national output has there been a. willingnesis to devote part of -the increment to the financing of additional heal.th services. As mentioned above the charter of the Alliance for Progress did not precede the adoption of new policies by the Colombian government for concerted social as well as economic development for the country. Since the mid-5Q'Js Colombia. has been seek- ing to formulate a national health plan. Furthermore, the support given by the President of the country as well as by other high officials of the government to the 1Wational Health Survey attest to a revision of priorities that has been in process in Colombia for some time. 11h2. More recent legisl.ative enactments implementing the Ten Year Plan, and others now pending, indicate that thi. national level support has been maintained and perhaps even strenghtened (see next section). However, it should be recalled that these developments have all occorred during a period of continuing risies in national productivity when there has been a larger share of the gross national. product available for the support of the social in.stitutions of the country. l4i3. The National Health Plan has been able to provide reasonable esti.xnates of the direct costs of he.l1th and medical care services now avai, lab]Ie and ts:ome approximations of the indirect, costs accruing from lo.;ses dule to premature death and preventable disabi]ity within its human capital resources. Unfortbnately, technical skills are not yet. sufficientl,y advanced to weigh in exact terms, the relative benefits of equal investments in extending health care services or in, for example, additional industrial plants. 'Thus, choices of alternatives or the determination of balance remains a. oolitical rather than a tech- ni.cal. judgeinent. At present in Colombia, there -i.; every indication that pulblic expenditures for, and thus national support of, the natiornk] Health Plan will continue to receive f..vorable corsi.clerition. 2. Support Within the Health Sector Thb. As has been pointed out earlier, the Hinistry of Health, which has been responsible for the drafting of -the Ten Year Plan and now has primary responsibility for its implementation,is only one of at least a score of national agencies - governmental, quasi- governmental and private - that share major responsibility for the provision of henlth and medical care services. Moreover, at regional and local levels previouund beneficiaries. Expendi,tures for this small segment of the population, esti-mated to constitute no more thla.n 5 percent of Col]ombia's total population, has risen 80,) percent per individuail. E-.penditures , for the-ir hos-pital anld medicl c.re now represent over half of' the total costs of health care in the country. The implicra- tions of this observation are worthy of special consideri tion with reference to the Ten Year 11,alth Plan, l906-lWyi. That Plan, having taken account of the major unmet health needs and the existing defi- ciencies and ineqpuiti-es in health resources aivailability, proposes new= organizational arrangements and new,j heal3th programs for t;he bene- fit of the general po1nilamion. Yet expendituiires for suIch genere l services have renmaired essentially constant on a per capita basis.. (9165, 52.0 and 58.5 pesos per capita for I'?l, 1>c69 and 1)7`0 respectively). - 60 - i52. Grarited that, w1nitth the economies evii greater efficiency of operation called, for in tle Nati.onal Hea-l.:Lth P'lan adi i t` onal and irproved general health services will. e Jurthconing at lower per U-nit coSt; as the Plan becornes esta- blished. Yet it appears unrealistlic to zisslnie that evern the most urgent of the country's health prob)lems cani he overcome m(.reyIT throuagh the reallocation of available funId's and wit.h,out sJize;aibte incrente,;r L of new funds for general hea:Lth services ,W-v the [t.o iO.: population fif (lombia l-3. All. of hile 'Ilc'"-;it, . .ypitp 'J or hi I urnoc' slu- t1le last ten ycars, ha ir\f(-ronu11 2 I I I ii' p1 :'ce i!i.".iJ).U O iin'0a5OC i i th(ct popul ltion and tipre( v o- t; e .) i nUrtrn c. o.L Ulu peso. I gJ ' the varioll-o so c on ii! of tlleP i Lu :id t,n' l,,in e:lir or le,sser dUe, the amounts of fund;s cqu re lo h i ob icc 9;v s, -the d;t-a arc no ,rc- sented in a forwat pcit; i ci -) re;': nLiPo aplvOYimation o,f the totel:! b)udI,- getary nieeds fcri- a yii a (wil"i' i llis L),hI e .'..7 oi- 1975) for sO health programris conduc4i9d h,y or unde:r 1,il r cc Upeurt_iscllo of' i,he Lii ni si!f 0o He a-lth. A crude calculation, which sho-l10. t.5 I .TrLed by i.:-tut,}hor Stulry ajid analysis, would place t;hi.s aii:, to .t.boui; 7.-60 presos per capita cor.paro(o wi th the present ,)l.5 [Xesos."3 L5h. tAn. ;,Jddiii.onYl ;-.ii fo lo so,;-;o.n tr i.hle fin.-aricial requircc--,nts of the Tenl Yeav Plan and t.:lf . mp1et-cim.Jn ,!sli Jdon can be derived fron s special analys:is of 126$ t. I onI hTsalLlroxnendt_ lures Thereirl a dicho tomy was developed dJiv-idin.g coss lro i.tose J'or' ca.-i.re ol the sick -- hospitaliza- tioIn and cura.tive or poai;.i'L;vc cor.- ices; and, secondly, all other se.rvices, primatrily of a rirevontio ol he Lt. pro(iii;,live.! nature. Of' the ot',otI o. [,G9l million pesos exoended that ~y'r l neron'C.t (928 nrril]ion pesos) was devoted to the former category and only ' perceit iTu lillion pesos) to preventive services. There are, of course, serious It.imitat-i-ots to so sharp a d.Effereni-:iu- tion of one category from t,he ot.her since mrany dut;ies pe-rfformed by a physician or other attendant in providing mTedical treatmienst have significant preventive implications. However, in a ucuntry sichI as Colombia where so many of its serious health p.ob lensm. arc aLfienale l.o strictly preventive measuras suc.h a differentiatior- ct serOe a usct:rul purpose. The Ten Year Plan maces a stronlg case for the strengthening and reorientation of medical care services to pro- vide a more comprehensive and readily available program for the total popula- tion. But sound planning dictates that a larger segment of this program be oriented toward preventing illness and promoting health through such activi- ties as intensified maternal and child health activities, health eduication including nutrition education, vaccination, and improved environmental health services. It would not be unreasonable to increase expenditures for preventive services to 20-25 percent of health care cost instead of maintaining it at its present level of 9 or less percent of -the total. 155. Another cribtco;l. insig,ht inwo the financial requiremnents of the Ten Year Health Plan is provided by its initial recognition of the need for the special funding of capital investments for health facilities. No conso- lidated estimate of construction and equi.pDent costs or the present value of the existing health plant, of the country is available. In view of the 658 operating hospitals (46,7-35 beds). the 1,120 health centers and health posts and the large number oi'f;rater treatmen-t and sewerage systems existing - 61 - throughout the country it is evident that large sums of money have already been invested in such health facilities in Colombia and their replacement costs, in terms of the present value of the peso, might even be considerably larger. Also to be noted are some 860 additional partially constructed but; not, at present, utilized health structures existing throughout the country. The investments already made in these incompleted strluctures has been estimated. to exceed 2,000 million pesos. The completion and equipment of some of these structures forms an integral part of the Ten-Year Health Plan arni will require additional capital investment. 156. In the past, the building of hiealth facilities was in almost total measure a responsibility or function of loca.l authorities or of local philanthropic or charitable groups. No nationial plan or standards existed to glide or control such undertakings and not infreq-uently appropriations from the national treasury were made -to assist loc-al hospital or health center construction with .funds awarded large:Ly on the basis of political patronjage. The Ten Year Health Plan est'abliishef for the firs-t time a rational and systematic approach to such long trermrnostal investmen-ts in healt;h facilit.i-es by creating the National Hospi-tal i?and to set standards, review and approve construction plans and award fmids on a competitive basis according to a National Hospital Plan; also, the National Institulte for Municipal Development now :incorporated within the fraunework of the M'inistry of Health, will serve the same functions in connection with the construction of water supply and sewerage systems in communities with populations of over 2,500. (See Water Supply, Vol. IX). 157. The following table indicates the funds available at the national level for the building and eq.ipment of hospi-tals, health centers and health posts: Tabl.e ITI-l. F[FNDS AVAIALNABLE AT THEll NATIONAI LEVE,L FOR CONSTRUCTION OF HELALTH FACTI,.TT.E AND EQIJ I PMTBNT (in -Lhou.sands of pesos.) Appropr;iat-liJons Na-i;onal Year i nistry- of iHea:l.t Lb osp-ital_ Find T. (. .S. qTotal 'L t)2 O.,O25 11, 0 25 19S6 3 23,)0.9)F 23,'L 9) 1,9 64 20,, 82- 2 u, 8?25 ' 190'5 8,12(, _ ; 2(26 1'366 CS.46,87 - ,( , I 96) 7 )49, 790 26,837 21,106 97,73 1968 /a 4.8,8oo 37,5()8 31,971 118,279 1)969 - b.2,5no I.,()oO J, t, 974 12047.!7 1970 /b 50,000 51nC , 00( 5)i , COO 156,o0o - Data not a.vailable. /a Nati.onal. Hospital Funrid e.tabi iihod. /l PreliMirlary estima-tes. - 62 - 158. Iti may be seen that in recent1 years funds available from the N4ational level f'or hosp:i.tal, hea'Lth center and health post construction and equipment are :i.ricreasi.ng subs1tantially. However, the NQational Hospital Plan, 1970-1972, assesses the immediate construction and equlp- ment needs in t.his area in excess of 800 million pesos. Future needs, part-,icularly t,hose f'or facilities recuired foIr the training of esser-tial personnel have not yet been firm.ly established (see Water Supply, Vol. TX, for estimates of capital requirements in that area). 159. As in the recent past both the Ministry of liealth and the C,olcmbian Institute for Social Socur:iurt,y will allocate f'rom their regular budgets, funds earmarked for capital construction. To these will be added the loan .unds availL able through the National Hospital Fund and borrowed from thie 1.C.S.S. trust funds. Repayment and the financing of these loans will ultimately be bornre by Ministry of' Health appropria- tions. Since the effect.ive life of constructed facilities and fixed equipment is a reasonabDly long one the new financing mechanism created by the National Hospit.0l Fund offers a suitable dlevice for the satis- factory management of' external. investment funds that would accelerate the constructioil and. equipment of' needed health facilities. 4. Manpower Requirements 1oO. Throughout tlhe various segments of the Ten Year National Health Plan there are substlantial references to and documentation of serious shortages of essent:ial health manpower. 'These sho-rt;ages apply notU only to physicians, dentists and nurses but also to auxiliary nurses, nurse a:ides, nutrition workers, laboratory and other technicians, sanitary engineers and inspectors, statisticians and medical record aides and to administrative workers at all levels. These shortages are conmpounded by such factors as the concentration of health personrnel in the larger urban areas at the expense of the smaller comumunities and rural areas, the emigration of trained personnel. abroad and. the lack of formal train- ing and rapid turnover of auxiliary supporting workers. The National Health Survey further revealed thaL the full utilization of even the limited supply of' trained professionals is crit,ically impaired by inad.equate facilities and equipment, the expenditure of too large a seg- ment of the physician's, dentist's and nurse's time in non-professional tasks which. could be done as well by auxiliary workers and faults in training which do not, prepare or encourage the professional workers to use their skills efficiently and effectively. 'rhus, the combined problems of training, utilization and organization of health manpower give rise to probably the most difficult obstacle standing in the way of the full implementation of the National Health Plan within the ten year period set for its accomplishment. 161. The traini'ng of higher level personnel is expensive both to the individual and to the society which must underwrilte the ccsts of needed educational facilit:ies and subs,idize a Large fraction, if not all., of the operating expenses. Large investments of time are required before rormal- tra-ini.ng,, is completed; for the physiic:iar seven to ten years for the dentist five or rnore and the nurse three t1o four years of univer- - 63 - sity level education are required. In Colombia, the Colombian Association of Medical Schools has given much time and thought to developing ways of improving the educational patterns of all schools of the health professions and to extend their influence to the training of auxiliary and supporting personnel. More recently, and as an outgrowth of the Ten Year Plan, the Ministry of Health has created a high-level adminis-trative unit Within its organization to give direction and leadership in finding solutions to the most pressing of the country's healt,h manpower problems. 162. At the present time, no consolidated and comprehensive plan has yet evolved for the whole heal t,h manpower area although there are indications that such an overall blueprint may be forthcoming within the next 12 to 18 months. Nonetheless, a number of important guidelines have already emerged indicating the direction this plan is expected to follow: a. The nine medical schools, by increasing the combined number of their graduates from the present, level of under 400 per year to 600, will be able to maintain the present physician-population ratio of il.32 per 10,000 and possi- bly raise it to close to 5.00 per 10,000 despite the anticipated increase in the total population of the country. Curriculum changes now in process will give even greater atterLion to preventive medicine and will. stress ttlie role of the physician as the health team leader and the responsibility to delegal,e to and super- vise the work of o-ther members of -the team. b. Education for professional nursing, which has not been an attractive career with less lhan 150 graduates annually, must be greatly strengWhened to prcovide al, least 900 new trainied professional mnrses each year. This would ultima- tely bring the nurse-population ratio from its present level ol' 1 per 10,000 to i per 10),000, a figure comparable to the proposed physician-population ratio though still grossly below the avai:labilit,y of nurses in most developed countries of the world. Concurrently the training of auxiliary nurses will have to be increased. and improved to at least double the present numbers of 3500 certified workers and at least s:imilar augmentation must be achieved in the training of nurse aides and rural health promoters. c. Specialized training at all levels of public health activity at the Colombian School of Public Health, University of Antioquia, is already underway and these programs are being strengthened. ci. Intensive efforts must be made to improve the working environmenl, of health workers in hospitals, health centers and heal]th posts l,hrough aupienlation of equipmentl and facilities and, by better organization of health staff. Through such efforts and the delegaiirlon of tasks to supervised auxiliary workurs the efficiency and productivity of the total staff' can be erdliarced. i-, I1['rn C)w(1 :7;::M. i fiiS * U:)p Fit'.tloi t,;,s Icrt' c'aP'ec P ;-liv;l 'j 'il''ri i, 0 TluL ) . - L .' ;i1 i ; ;iI }!l b) :np'. ULLS i i s h c ;ci, eu 1i Ld :/:IC' ( -4c2, i I .;t I L. I '. i . i r iA Iri :r I ,[, aI I. t J L I i 1.e l :.,, h ( ; LiX l rV c_z.i rL p; :t rl t l uly rl;;u ,:CV nir te ria . fll(l'e f'li 1..' .' i JI(! 4:(ui l. -/ L'. In ii j) : ii , I (J(t(:( j P7tZ.(,t-i- fl i -? c l r ' ioiri malt, c:^a c ' r-. f i i-e iie fli__ .-:,wrdi LI.i i.iiO 2'' tr1 1Li v i c . - ' s (I(Jw,I (:tAl ;'i 'I-[rea1.'\ a-urt[''i.t' mr i4-if wili ELiiVe L;) 'I:.:7;liu r00'j ',l't,i r l :; ID<9!lSi~~~~ ~~~~ i1i ! f4>'< .}t),rt i ':i III tl } I.IJ i [i, f l ;l J '_tI :t' 00 a S , 1 i.' ; 4]) t'. UKLO ']LulU i l,Y 4 0. I re: r.D :V LIlF(l .t::; Wli -. I :1 f ! i k:)C p)fjti* 3 iIn i(uiii''A-lti .. 1o63. rh 3 1st, (t i.f i Ins 1 L'- ' i \ JiJljrI F li If l.i ri],;t j I j' r Mli health manpower Irai n.n,g )I,L (J tar gel. ufldeLinLus cLxal. S a r,Uabl . we: 1 beyond the presenLt o! inril cip;ated ! -)Si)UJ;; of LOu edauca l;)rla! in i.I concer-ned or of the M nistrv -)f (ea_ LG. Maz:reover, to da'.e, tihose gr i ):!i with the problem have largel-, il nut ex(LUsi.vely been iji ' *i tL tne health professi-onals worki.nrg within t,he confines o-9f the hcaalth secI;orm 1t1e - '. Collaterally, t,here is lit.tLe evi-Ldeice thalt t,he Mini-1stry uf' .EiEduratlianr, ald many educational insti. u Lions, o WLer thian til(i nine Utnivera.1 ties whilch opera-te a university medical school, h.vve yet considered Ihe roles they ultimately must, play in the pLeparatlio and training of auxiliary and supporting health personnel. 164. Based on the above considera-tions the time seems right for a con- certed extension of the analysis and planning activities of the Association of Colombian Medical Colleges and the Ministry of Health to a new level of national planning for essential health manpower training and development. Essential data are now available, reasonable goals and objectives have been determined but the means for meeting these educational needs and require- ments have not been fully mobilized nor have the minimum costs and the appro- priate sources of funds for meeting these costs been clearly identified. It is clear that the medical schools alone or even the nine universities which sponsor them cannot by themselves find adequate solutions to all of the problems and needs that must be met. Even the Ministry of Health working with these institutions is not capable of mustering all of the required resources. The overall problem is a national one involving multiple ministries and agencies of government and many other institutions as well. A tentative plan for an immediate and direct attack on these problems calls for a large scale develop- mental study over a period of 18 months to two years and is outlined in a suggested Preinvestment Studies Program (see Study 3-1 in appendix). 5. Suggested Areas for Further Development of the Ten Year Health Plan 165. During the period when the Plan was in process of preparation it was clearly recognized that neither all of the major health problems nor all of the possible approaches to their solution could be fully explored. Priorities, based on data then available or the liklehood of achieving rea- sonable goals in limited time spans, had to be established, leaving open for future consideration areas that might then warrant or be amenable to inten- sive study, analysis and planning efforts. Thus, the plan was offered not as a static or fixed set of proposals but, preferable as a starting point possible of extension and revision as circumstances and opportunities permitted. Several areas touched on but not fully explored or developed in the original Plan, published in November 1967, now appear to merit special attention, 21 years later. Health Advances Dependent on or Arising from Advances in Other Areas of Economic and Social Development 166. Throughout the various segments of the Plan extensive atten- tion is given to the positive correlations found in the National Health Survey of a wide range of social and economic variables with the fre- quency of illness and its severity and the equally significant negative correlations of these same variables with the availability or the utili- zation of health services. Such correlatiorns do not always establish cause and effect relationships hut they do, at least, confirm the inex- tricable bonds that make it impossible for the health planner to depend solely upon his own limited resources. They also reinforce the need for those responsible for planning at the overall level or in other sectors to consider carefully the implications of their own planning efforts for the health of the population. 167. Since 1968, and formalized by a legislative enactment, the Ministry of Health has been working cooperatively with the Ministry of Justice in tackling the multiplicity of problems arising from the special need of protecting the welfare of mothers and children. Working through the Colombian Institute of Family Vklfare, a semi-autonomous agency attached to the Ministry of Health, a concerted effort is now being made to bring together the previously uncoordinated and dispersed institutions of social assistance under the policy guidance of the Colombian Council for Social Protection of Minors and the Family. The former National Institute of Nutrition is now merged as an integral part of the new entity. 168. However, similar innovative approaches appear worthy of explora- tion in the fields of education, housing and commmnity development -- both urban and ruiral -- and conjointly with agricultuire, industry, public works and other sectors of economic and social development. In education two significant areas of activity deserve high priority. Even in developed coulntries heal-th instruction in the school system has been sadly overlooked and downgraded. Content and teaching methods have completely escaped the attention or concern of qualified health experts. Health instruction materials devised 50 years ago, lacking relevance to modern day problems and neglecting singular advances in techmical knowledge, are being used by unqualified teachers who do not filly understand the implica-tions of the irnstruction they are trying to transmit. This problem is serious enough in an advanced society where deficiencies in the school may be made up by instruction and example in the home. In a developinrg country such as Colombia thfis augmentation of school instruction does not exist nor does it capitalize on one of the few channels of bringing health instruction, via the children, into the home. Health care and the proper utilization - 6E?) - of commmunity health re.ource, have always depended oii an informed arid suL- ficiently motivated. pui) i: to (1o as mu(ch f1or thei r owrn health protection as possible and to use rea-sonable discrimination in turning to available resources for thlose melasitres which they camno-lt p)rovide for themselves. The transplantation o:t twode-n andi more c:omplex health systems to a develop- ing society will niot take)1 hold unless concerted efLfforts are nLade to inforn and motivate, througlh pulblic. education, the people wlho are expec-ted to benefit from improved heaLt,h knowledge and health resouirces. 'I'hese oppor- tujities offer a spe.-i.a:L clhalLenge to both educatlional aind health leaders. 160. A second opport-uttity- for conjo]intl health and educational effort lies in the training of sorely needej healt.h mannpower. rT'raditionally such educational needs have been left, to and anssinhed by the health profession and par-ticularly by the sirJll fJration Of those professionals identified with a specialized ednacati-oiial program. (.olombi.an- leaders have now recogn.ized. that the healtlh probhiems of the courntry cannot, be resolved merely by inten- sified training of more physicians, deirtists, curses or other highest level personnel. F.:ar more auxilixaries must b)e re(crutit-ed. and trained and. specified tasks within their connpetence to perform under supervision, rmust be assigned to them. It could. be argeed that, the ideal locus for such training of sulp- porting personnel is in tLhe same env:i.ronment in which higher level personnel are also being educaated. 4fO jEver, t1lie large :tnlbmbers of auxiliary workers now needed in Colombia an^md 1,he tremend Jo;ns cost involved in adding requisite facilities in .9. medJ_.(-.-...L :Sc:hbol. setti ug dictate that many other educational institutions in the (nwt.irv reaching down to the secondary and vocational sc.hool level, becomc' -ngaged in health !nanpowaer training commnensurate with their educational capac:-it,as. Thea laiiversity medical centers should concentrate their attention on -the I r ci nang of professional level personnel requirinig university level instruc.ti._on. In addition, there are special responsibili- ties that they must share Jointly wit1h the entire educational system. For example, the establisfarieitt; of reasonable prerequisites, the development of curriculum content and.- tea(ching materials, the certification of accredited institutions, the train.ing of teachers, the examination and licensure of graduates are all functions requi)ring the leadership and supervision of the h:ighest levels of com-petence drawn from the established health professions and their institutions. To move in this directi.on appears to be *the most promising next step in resolving the health manpower problems of Colombia. An ou-tline of suggest,ed developmental plan is -included as an integral part of the Preinvestment Studi-es 'Program Study 3-1 (See Chapter VI). 170. The above are offered as examples of the types of multisectoral planning and conjoint activity involving the health sector with other prominent social and economic sectors. (A special report is devoted to the area of housing and cumm-u-ity development). In agriculture, both the protection of the health of the large number of workers engaged in this essential occupation and the augmented and improved production, distribution and use of essential food resources offer special problems that cannot be - 67 - resolved by ef Sorts in either sector alone. In the area of nutrition (See Chapter II, Section C2) interesting innovative approaches are currently being explored and Preinvestment Studies Programn-tudy 3-3 (,ee Chapter VI) suggests ways in which t,he amplification of these efforts m.iglhlt be attempted. In the industrial area, the Ten Year Plan refers to the increasing problems of industr-lal and occupational illnes; and accidents. The plan suggests a minimumLL program wi-thin the MIinistry of Health's own operations designed to combat the inost serious of these problems. EBit the need will not be met until. industry itself recognizes the magnitude of the burden of ill healt-h and loss of productivity iden- tified with industrial operations and joins with health authorities in seekcing jointly solutions to these problems. Closely associated with this areaare the problems of air and w.j.ter pollution and of the dispo- sal of indusrial wastes. Colombia has not yet reached the stages now faced by the advanced countries of thle world where the costs of correct- ing mistakes in environmental sanitation in the past are reaching stag- gering pr.oport.ions. A preventive approach initiated early in Colombia's industrial development is certainly indicated. Population Control l71. In the Ten Year Plan itself no specific program was elabora- ted directed toward family -planning per se nor was reference made to the already initiated national efforts to reduce or limit -tlle rate of popula-t:ion increase. However, shortly after the issuance of that Plan, the IMinis try of Health colla.boratedl in the preparation of a special report and statement of policy on population issued by- the National Department of Planning which reports directly t-o the Off'ice of the President. This more recent document (lh-b) is highly sensitive to the cultural, religious and political framework in which the gove.rnment of Colomlbia must function and also takes into critica'l account the vast array of economic and social consequences of uncontrolled population grow-th in a developing society. These consequences are observable not only in the he,-ialth sector but have direct, bearing on the educational, housing and community development needs, andl have serious impli-cations for employment, the per capita gross national product a.nd other components of -the general. s-tandard of living. It can be stated, without reservation, that no single developmentaL problem basically identified wi-th health and medical -ervices has received so comprehensive a consideration from a multisectora.Tl vantage point. It is of interest,however, that the major burden of effort to alLer the rate of populat-tion increase stil1 rest-s on t,hc shoulders of the health sector whi.ch, as has been slhowni throughout this report, is seriously handicapped by severely limi-ted. financial, physical, manpower, organizational and even political resour- ces. :1'72. Family planning activities in Colombia are not new. Data assembled by the National IlHealth airvey in 1965-1966 clearly demonstrated that women in the higher economic strata, with highest educational attain- ment and with greatestaccess to the healtlh care available in larger urban - 6b - centers have had notable success in lowering Vteir fertility rate through measures involving the prevention of pregnancies. Interestingly, induced abortions as a means of restraining fert-lility is most commonlly found in women of the urban zone with a low leveL of education or low incomers. 173. Since 1)6)1 t;he A ssocia3ti-on of (o:lomlnbiLlnl Medical Col.:legres has made faiLily planni-rif servi-ces avai.lable through universitj hospiL Is and- affiliated health ccnters. In ;iddition it hia undertaken rat.her extensive educational programns at tec profess'ional level and has. been largely, responsible for suchl research, prim-a ril.y o: an operational. research naULure, as has been carried oni in tLhe country. A linost LsirmAitaneous a private group, the A ssoc;iat.iion for thle 'Je] f'.re of Lhe Colomli.lan Fami:iy, started to provide famil.y planninjg cornsu-l tations and service;* s on an extensive scale -throughi th oLfices of p riLvaLe inedical practi.tioners and through independenL cli.nics. 'These servi:Lc,es are a lso ailmost entirely restricted Lo urban centers. 174. More recently, the Mini;stry of leal-th, concentrating on the less urbanized an(d rura.l population of the count',ry, has begun a famidly plannin1g program based lTargely on increasirig the availabilityr of information and aporopria to medical consulLtations to those women who vo-Luntarily seek sLuach servi ces tLhrough its established maternal and child health programs. Elven more recently, L oie Colombian Insti tuL,e for Social Security anid the t-atic; oa P1.fare FI'rids ihave similarly improved their capability to respond to reqJuests I'or L'a.Mily planning assistance sought by their beneiiuiarie.. h reasonable esLimite ofL funds currentLy be:ing spen i on these Camqily acALvitLies is in the ranifge of 2.5-3.O miillion do-Llars annually wiL,h all but. minor amourtUs being derived from axternl sources, primarily fromi tLhe U1.5. It :is appare:tn that lack of funds, eanrarked specifical.ly for family planning purposes, i.s not inhibiting prog,ress in these -proram!ns. 175. Consolida.Led daita on -the exact nature and types of services rendered are ineagre as is information on the ninber of women reached and re-tention rates or on olilher indices essential. for scienLific appraisals of the success oL these programs. This is riot surprising in theliglht of the paucity, delayed nat,ure and unreliabilit\y of all vital statistics data f or Colombia ex(ceut those deri.vecd from special studies such as those conducrted in the National lMorbiditLy Survey of lq965-l966. (In a previous section, Chapter 1I, Section A-!, the problems associated with analysis of birth rates were reviewed; see also PreinvestrlenLt Studies Prog-ra.m-S-tudy Proposal 3-5). Barrin-g th?e availability of iar nmore accurate and current birth registration iniformation and associa-ted dato, a criti-cal reviewer of family planning activities in the present Colombian scene is unable to fo:recast, with any degree of confidence, future trends in the rate of natural increase of thWe poDulation. This rate appears to be high, in the range of 3 percentl per year. It, is either stable or gradually declining but whether present faimily planning efforts will or will. not have a de- monstrable impact in the rate is higlily conjectural. 176. The .above aissessmenti of present fami ly planning activity in Colombia does not controvert; t-.he sounrd natoian-1l pol.-icies recently adopte?d. nor the sincere cletemTnninlt,ion and effort,s of najtional leaders both within -.and outside the governmenL tto apply ajvail.abl teLchni.ca.l knowledge and - 69 - capability to such ends within the social and political framework of the country. Other and perhaps even more important constraints on these efforts are the limitations imposed by the sources of supporting funds which restrict expenditures to those which can be directly identified with the immediate process of prevention of pregnancy. So narrowly defined an approach to an objective could be self-defeating and under the developmental circumstances, faced by Colombia, with particular reference to the current problems in the health sector, such limitations may be doubly so. 177. On superficial analysis the strategy of reachirg between 700 and 750 thousand additional women with family planning services over the next five years (increments of approximately 3 per cent of the women of the country, age 15-49, per year for each of the next five years) appears to be a reasonable one. Calculations have been made indicating that such efforts would cumulatively reduce the birth rate at least 4.4 per thousand and possibly as much as 12.5 per thousand. A substantial num- ber of physicians and nurses have been or are being brought up to date on modern family planning techniques, health "promoters" are being recruited and given short training courses to prepare them to carry material and child health instruction into the homes and ample funds are available to support salaries and to purchase family planning commodities for the program. Questions can be raised as to the relia- bility of the above predictions since these depend not only on the number of acceptors - those who initially volunteer to accept these services - but of equal and perhaps crucial importance the number of women who are successful in adopting and continuing over long periods of time effective contraceptive procedures. Such prevention of conception requires medical instruction and supervision on a continuous basis and only time and experience will demonstrate whether the programs now ini- tiated can meet these requirements. 178. The programs also appear vulnerable to serious shortfalls on other accounts. It remains to be seen whether the necessary responses can be obtained from the child-bearing segment of the population in a social and cultural milieu in which only 9 percent of the total population seeks aid when it believes it needs health care for illness and in rural areas only 3 percent turn to a physician for such assistance; less than half of the pregnant women receive care during pregnancy; only 37 percent have a physician in attendance at delivery, a figure dropping to 18 percent in rural areas. Even in the serious circumstances of a pregnancy terminat- ing in an abortion (about 1 in 7.5 pregnancies) only slightly more than half (56 percent) are seen by a physician. 179. A strong case can be made for the view that an effective family planning program must be not only part of an inclusive maternal and child health program but linked with a comprehensive and total health and medical care program for the entire country. It is highly problematical that the infrastructure required for an effective family planning program can be established for this purpose alone or can prepare the way for the building of the same infrastructure required for more comprehensive services. Thus, it seems reasonable to question whether present family - 70 - plarmirig activi-ties in Colombia will really take hold until and unless far more adecluate provision is made l'or supplying the facilities :rnd manpower resources reqiuired for thie comprehensive h}ea:Lth and medicail care program call.ed for in the 'T'cn Year National lHealthi Plan ancl now in process of impl.ementation. IMloreover, as has been clearly dermonstrated by the data available for Colombia, marked differentials in the acceptance and effective utilization ot' f'amily planning practices can be identified with rising levels of education. and family incomc. It follows, then, that augmented efforts to improve educational and job opportunities in Colombia also offer direct avenues to t,he effective slowing of the overall rate of population increase in the country. - 71 - IV. RECOM4ENDED PROJECT PROPOSALS 180. Many programs and activities, forming integral elements of the Ten-Year National Health Plan, are now in variolls stages of implementa- tion. Some of high priority and following approved plans of development are moving forward at a slower pace than the need. for these programs dictate. This situation arises as a consequence of the severe competition of the multiplicity of approved health programs for an appropriate share of the Ministry of Health budget and the similar competition of the Ministry of Health with other ministries for an appropriate share of the national government's available resources. 181. Some of these programs have been singled out for careful con- sideration for external financing as a means of accelerating and consoli- dating the full implementation of the Ten-Year National Health Plan. The five recommeended project proposals in this category are outlined on the following pages. These outlines should serve as a hasis for further discussion with appropriate representa-tives of the Colombian government. - 72 - A. -- H[EALTH PPiOJWCT PROPOSAI, COLOMBIA - I 1. Name of Project: Bevelopment of Instit-utional Resources for Health (Hospitals, I-lealth Centers anx] Health Posts) 2. Executing Agency: National Hiospital Fund (Ministry of Health) 3. Total Estimated Cost: 17S $50 million. 1X. Estimated External Finarncing Required: (IS $30 Million. 5. Description of the Project: A National fHospital Plan (1970-72) has recently been inauguirated calling for 1) the modernization and re-equipment of existing hospitals, health centers and health posts, and 2) the completion of construction and equipping of a substantial number of partially erected health facilities in key locations through- out the country that have been in various stages of construction for periods up to 15 years. The National Health Survey (1965-1966) re- vealed large segmer]ts of the population failing to receive even minimal standards of medical care services. For those attending existing facilities the quality of care rendered is inadequate. The limited availablity of professional health manpower heightens the need for enhancing productivity and efficiency of the existing staff which has been severely impaired by the absence, oosolescence or malfunction of basic and essential resources and equipment. In many instances the unsatisfactory w-orking environment in existing health facilities frustrates efforts to recruit, train and -etain required personnel. The National Hospital Plan provides a practical and feasible program for meeting the health care needs of all segments of the Colombian population at reasonable cost. Operatioral and maintenance costs can be covered through the regular operating budget of the Ministry of Health and other sources of operational income. 6. Present Status: The Ministry of Health has assigned this project highest priority in the National Ten Year Health Plan. This project, broken down into four component parts, appears on the list of 1970 projects proposed by the Government of Colombia to the Joint Consultative Group. Since 1967, the National Hospital Fund a discrete national agency adscribed to the Ministry of Health, has been charged with the legal responsibility for reviewing and approving all proposals for the construction, renovation and major equipment of health facilities throughout the country. It directs the investment of health facili- ties construction funds derived from long term loans made from the trust fund reserves of the Colombia Institute of Social Security and earmarked for this purpose. Such funds are approaching 50 million pesos annually. The FPnd is also responsible for evaluating and approvring construction plans to be funded from the annual appropria- tions to the Ministry of Health also now fluctuating in the range of 50 million pesos annually. The National Hospital Fund thus provides an instriiment of ,overnment to administer the management of external funds to be applie d to +he same plurposes. - 73 - B.- HEAlTH PROJECT PROPOSAI. COLIOMBIA - II 1. Same of Project: Control of Communicable Disease by F7rpansion and Acceleration of National Mass Vaccination Programs 2. Executing Agency: Ministry of Health 3. Total Estimated Cost: US $5.6 million L. Estimated External Financing Required: US 13.4 million 5. Description of the Project: An important group of communicable diseases in Colombia are siusceptible to control, if not eradication, by sus- tained but relatively simple means of mass vaccination. These include smallpox, diphtheria, whooping cough, tetanus, measles, poliomyelities and tuberculosis. Prevention of these illnesses would substantially reduce mortality and morbidity and would release scarce professional manpower and health facilities for other essential needs. Vaccina- tions can be given, under supervision, by trained sub-professional personnel. A nationally directed campaign is cuirrently under way to achieve satisfactory levels of protection in the most susceptible segments of the population. The aim of this project is to expand and accelerate this campaign and attain sufficient momentum in the next three to five years to permit delegation of continuing responsibility for revaccination, when required, and vaccination of new susceptibles to local health programs. The ultimate objective is to maintain this preventive program as an irtegral part of the comprehensive health service coverage now in process of development for all segments of the Colombian population. 6. Present Status: The Ministry of Health is now allocating approximately 10 million pesos annually to this direct vaccination campaign and at the present pace of accomplishments will require ten or more years of activity to realize desirable objectives. A doubling or tripling of the pace during the next three to four years, with external assistance, would result in no additional direct operational costs yet could significantly reduce indirect costs in the long run. - 74 - C. - HEALTH PROJFECT ROPO'SAL COLOMBIA - III 1. Name of Project: Expansion and Completion of the National Laboratory of Health 2. Executing Agency: Ministry of Health 3. Total Estimated Cost: US $1. million 4. Estimated aXternal Financing Required: IJS $.5 million 5. Description of the Project: The National Laboratory of Health has recently been incorporated as art integral part of the new National Institute for Special Health Programs, a semi-autonomous agency of the Ministry of Health. This laboratory is responsible for the production of biologicals and vaccines used in the prevention of the major communicable diseases in Colombia, the testing of drug products sold and distributed in the country and the scientific investigation of the significant health problems in the country both in the laboratory and in the field. The laboratory has recently been installed in a new and modernly equipped building in Bogota which, because of limitations of available funds, is only partially completed and does not meet the full requirements of its excellent scientific staff. The attack on a number of important health problems will have to be deferred pending acquisition of additional funds to complete and fully equiip desirable additional facilities particularly those that would be used for the specialized training of personnel required for the operation of local health laboratories throughout the country and for the quality control of such decentralized health laboratory services. The laboratory is also providing, at cost, its own manufactured vaccines and other biological products to other Latin American countries and is serving as a regional reference laboratory in international public health activity. 6. Present Status: Construction and equipment costs of the recently inaugu- rated National Laboratory building have amounted to approximately US t 1 million. The annually operating budget of the laboratory is approxi- mately US $ .5 million with increments contemplated up to a level of approximately US t .75 million by 1972. Doubling of existing facilities is a desirable objective in the next three years; additional operating costs could be absorbed in the annual Ministry of Health budget. D. - HNALTH PROJtECT PROPOSAIL COLOMBIA - IV 1. Name of Project: Expansion and Development of Training, Planning and Research Programs - Colombia School of Public Health (1970-1971h) 2. Executing Agency: Ministry of Health 3. Total Estimated Cost: US $)J.2 million 4. Estimated External Financing Required: US l.6 million 5. Description of the Project: The Colombian School of Public Health (ITniversity of Antioquia, Medellin) constitut;es the sole specialized training facility for public health practice in the country. Its major support (9n percent) is derived from annual subsidies from the Ministry of Health. During the five year period 1964-1968, 755 individuals received graduate, post-graduate, intermediate or sub- professional training at the school. A plan has been developed to overcome the acute and severe shortages of public health personnel by training at this institution during the next five years a total of 2700 physicians, dentists, nurses, engineers, statisticians, administrators, nutritionists, etc. The school is about to move into a new building constructed by the Ministry of Health which will facilitate the expanded training, research and consiultation programs of this institution. 6. Present Status: A five year budget totaling approximately 75 million pesos is required to finance this essential program. Reasonable forecasts indicate that the Ministry of Hea:Lth will he able to allocate about 2/3 of this amount (5( million pesos) from its annual appropriations during the next; five years. The balance, approxi- mately 25 million pesos is required from external sources to assure the underwritirng of this hasic buidgetary financing. ' (!I ,( Will [Af - V! 1. Name of Pro-lect: ol'' h.Dko i. L.-tt; in o1 hart WaLer n>plins 2. lxe,,it,tiig Agency: Mirii.,tA!y 1 OlfEe:d] l 3 . Total Est;imated ci oct [: i;-L hrtiml1-i-on 1 h sLtmated External ai Lnao(:L lg he qic rod: [MI, I; nIih [01 D. Lescription of the P ro i(cc t: 'I-i p ecl;.aiit:; at thc redlp : jun by 1/-' to 2/7Yo.r7 deriL i:,.i. es in I It!, o :hJAi.lheoo,l onuliI on Li i treatlmeTnt, of 'r h i :ntrly l.Y at cp L l Up k c) o0.,o Or the pu1pra!:t,i-r over lUie age. ofI lhI .-: piese. Y- ;.n rt(ned oi Petita care W:it.l a pe-tck pr (-vaJ:-nl ot i.rl ,he aib' v.wrrmp 1E :II (5- 1) ( perce00t. LimitLedl resour es [utave re.st,v i.o U.ed cdrltaL care. I'he u1lk 0f ''ervi cc.s is corifiried Lo av I-Tac:j,f.ons [illjfi-Lig of cavitLies wwith reiatively little attel-tt ion givert to deitil-- _-)rophyiut s. T'wenLy-fi-ve years of experietnice in developed contvrties of the world has (demonstrated that controlled addi.tion Or f UOFIia e ;oraiLs into commuity water supplies carn significan-tly reduce cI . na.vities ;I] children (t minirnal cost and withi no harmf'ul- effect,;. fAlIostc 90( percent of the uirban popula- tionl has. ac(cess tLo comnimn;.l l. rY sluppil,, provi(ling a sa.mple and direct chattiel for l;n impi - t;.on of an est,.ah!iishel preventi.ve measure benefitting a sultst i lracLtion olf the cotmntry's chliijIlood populatlorn. f. Present Status: The denita I anh environmerita' health staffs of the Ministry of Healtht have developed detail.ec plans to reach P&C Dercenit of the urban popila.tion in1 the five year tp.eriod l'Y71-197".. Initia.al investments wi:l1l provide essen t.ial. eqniprmtent anoc t;he L.raining o1 water supply p)ersonnriel. (OperatioraaI cos:ts and slppli.es for cottinmia- tion of the program are II:.LrrTPi.Itln. - 77 - V. INVENTORY OF DEVELOPMENT STUDIES IN PROGRESS 182. As stated in the main body of this report, the Ten-Year NationaL Health Plan, 1968-1977, is not considered by the health authorities of Colornbia as a complete and all inclusive document. Rather it was designed to serve as a starting point of comprehensive activity based on data available at the time of the Plan's preparation. Goals set were determined by assessments of the urgency and priority of proposed programs and the reasonable likelihood of their attairvnent within the forseeable availability of resources. Thus, refinements and extensions of the Plan were viewed as essential and continuing responsibilities of the Ministry of Health and other concerned agencies and groups. 183. To this end a series of studies have been initiated and are currently in progress. During the course of this review of the Colombiari health sector a number of these developmental studies were exlored with the principals engaged in their conduct. For purposes of illustration, six have been sirgled out here to indicate their nature and scope as well as the prospects of the availability of new data and/or plans to guide the further implementation of the Ten-Year National Health Plan. A. Human Resources for Health - Phase II 184. As one of the major objectives of their 1965-1966 cooperative effort the 1ifnistry of Health and the Association of Colombian Medical Colleges attempted -to take stock of the available supply of health manpower in the country and the resources of the training institutions essential to maintaining or increasing thLis supply. These efforts were limited almost entirely to physicians and nurses. More recently similar studies of dental manpower have been completed andi are shortly to be published. A continuing registry of physicians was established and is being maintained providing useful information on the location, na-ture of professional activity ani other significant characteristics of the available medical manpower supply. 185. C-urrentLy, the Ministry and the Association are jointly engaged (Phase II) in extendling this system of current registration to other health occupations and in adapting such a system to the need for a continuing evaluation of the critical manpower requirements of the new National Hospital Plan now in process of imp,Lementation and designed to provide comprehensive health coverage for the entire population. Ou-t of these 3tudies it is expected that within the next 12-18 months reasonably precise information will be available on the number of health workers in each category actually engaged in the general health care system, the number of' currentl,y vacant positions, and appropriate norms required to make the system function at desirable levels of productivity and efficiency. These and re:Lated data to be obtained are essential to such important plannling .functiorns as: (1) the detailed organization of comprehentsive health ser-vices, (2) the basic training of all categories of health per;3onne'l; (3) the ectensio of graduat.e and continuing education oL' such persninncL; ().I) the fornu La tiori _ 7 - of appropriate salary scales and employment incen-tives; al-Et (5) the revision of obligatory national. servi.ce requireinents now -limited to medical school graduates. These studies are being L'inatced out of the regular appropriations to the Ministry of Heal-th with some ass:i.s-tance from the Pan American Health Organization. 186. When these studies are completed it will still be necessary to mobilize an ambitious national program of health manpower training. To that end a preliminary proposal is suggested in Chapter VI, Section A below - An Action Program for Education and Training in the Health Sector. References are also made in Chapter II. Sections C-4 and C5a to the need Cor such a program. B. Experimerntal Study of Hea:Lth Services in Colombia. - Phase II 187. Since early 1969, the Ministry of Health and the Association of Colombian Medical Colleges have been conducting studies in the field designed to test the hypothesis that relatively- simple, yet, important, health tasks can be delegated by the physician and the professional nur3e and performed uinder supervision by au:xiliary nurses, nurse aides, and health promnoters - personnel who do not require as lengthy or as expensive a training period as do the higher professional categries of+ heal-th workers. Success in this program would reduce the cost. of ba;-3_: h.-aLtii services and extend the pro- ductivity and effectiveness of the oh.ysicialn. Studies are in progress in three centers, under uniiversity medlcal center auspices, anxd are focused primarily on health services rendered in ambuLat.ory care facilities - health centers and health posts - find in home care services. The study design includes the definition of tasiks appropriate for delegation. the development of health care manuals and instrictioncS, ithe recruitment, training and supervision of necessary complements of' auxiliary personnel. and the careful evaluation of performance and resuLts. P'hase I involved the technical and field preparations for the study; Phase II - now in progress - is actually testing the plan under ..ie.l conditions. Completion of observations and analysis of results is schedulled for early 1971. Tihe Pan American Health Organization ard the U.-. AgEoncy for International. Development are providing financial assistance to this tty. C. Develoomte.it of a Compre'henisive Health Planning System a,t; the L.ocal l.evel - Phase I 188. The Pan American Health Organization has long been in the forefront in the development of systemnatic approaclies to the planrnirng of comprehensive health services in the developing countries. The success in applying these techniques in recent years in Co-Loabia can large'Ly be attributed to the pioneering program sponsored by P]AHO in association with the Institute of Economic and Social Planning in Santiago, Chile, in which more than 200 health planners f'rom 20 countries have received intensive training since 1962. Many of the leading hea'lth authorities in Colombia have benefited by this program but the impact has Largely been felt on the national level and is only now beginninrg to t'il-ter down to the Levels of Departmental and local health activity. - 79 - 189. More recently, the Division of Research and Communications Science (RECS) of WHO in Geneva has developed a plan of study and experimentation designed to foster comprehensive health planning approaches to local health problems based on the thesis that national programs should reflect sound planning and development processes in the community rather than the other way rolind.. Moreover, methodologies applicable to macro analysis and planning mnay not be applicable in small systems. Thus, new planning procedures must be de-vised and tested in the field specifically oriented to the types of problems encountered in the day to day operations of local health programs and within the framework i.n which the multiplicity of local health agencies and personnel cope with speciLic health problems. 190. This study plan has gained the support; of the Ministry of Hea-Lth and other health organizations in Colombia. PAIiO and a number of American research and training institutions have manifested their interest and desire to cooperate. The site for the initial experiment has been chosen as the Department of del Val:Le in South Western Colombia incllding its regional center and capital, the city of Cali. The University del Valle Medical Center has accepted responsibility for leading the study and WHO-RECS plans to install at least six of its staff members to work winth locally selected counterparts at least f'or the initial year or 18 months of exploratory efforts. Financial support in the range of $150,000 a year has been pledged by WHO. If exploratory efforts are successful and a decision is reached to continue these efforts for at least a five year period additional support, including external assistance, will be required. D. Integrated Nutrition Program of Applied Nutrition - Phase II 191. In the body of this report, Chapter II, Section C-3, the present ambitious program to combat malnutrition and to improve the feeding habits as well as the food sources of the people of Colombia has been reviewed. Activities are centered in the Department of Nutrition of the Colombian Institute for Family Welfare but affect the operations of all parts of the Ministry of Health, other ministries and agencies of the nationai government (Agriculture, Education, Interior and the Institute of Agricultural Marketing) and the decentralized health and other programs in the departments and communities. Such innovative programs are involved as the Integrated Program for Appliecd Nutrition (PINA), the National Program for Nutrition Education and Supplementary Feeding (PRONENCA) and the National Plan for the Development of Foods (PILANALDE). In brief, the total program consists of a wide variety of activi-ties ranging from basic nutrition research, the trainirg of' nutritionists, technicians, teachers and "multipliers', the preparation of mass education materials, applied research (preparation of new food supple- ments and genetic adaptations of foods to improve their nutritional qualities and at the sante time retairing their acceptability to Colomb:ian dietary patterns), to iarge scale feeding programs and educational campaigns to improve eal;ing and nutrition patterns. - 8n - 192. Beginning in 1965, a pilot supplementary feeding program was initiated in Caldas Department (Nutrition Study - Phase I). The National Federation of Coffee Growers, assisted by the Inter-American Committee for Development and using food supplements provided by WFP, demonstrated the benefits accruing from special feedings for pre-school children and pregnant and nursing mothers. In 1969 this program was expanded (Nutrition Program - Phase II) to major scale and with its completion in 1975 will benefit no less than 900,000 pre-school and school children as well as pregnant and nursing mothers in all of *the 29 Departments of the country. The total cost of the nutritional education and supplementary feeding of these vulnerable groups is estimated to reach about 75 million pesos with the WFP providing 57 percent of the cost (42.3 million pesos) in the form of food commodities. UNICEF, PAHlO, AID and other irruernationa:L bodies are also assisting. 193. As vital as this program is, it can only reach a fraction of the population (5 percent and possibly 20 percent of the particularly vulnerable segment). Moreover, althougrh this program does include the use of some local food supplies it is still largely dependent upon the importation of supplementary foods. The ultimate goal is, of course, the adequate nutrition of the total population, the full mobilization of indigenous food sources and the education of the Colombian families to select and utilize in their diet nutritionally adequate foods that are available to them within their financial resources. 194. As stated above, the program is planned to continue for approxi- mately five more years, until 1975. However, there are indications that even at its conclusion it will not have achieved an essential objective, namely that of assuring Colombia an adequate nutritional status based on an indigenous complete food supply available to the entire population within the economic resources of each farnily and readily available to these families at the local level. To further consolidate the gains of the present program an additional and relatively modest development study is proposed as Phase III of the Integrated Program of Applied Nutrition and briefly outlined as Preinvestment Studies Program - Study 3-3 (see Chapter VI, Section C). E. Family Planning Programs in Colombia 195. Although dating back to 1965, the family planning activities of the Association of Colombian Medical Schools, the Association for the Welfare of the Colombian Family and the Ministry of Health were intensified in 1969 through the combined technical and financial assistance of the Population Council, the Pan American Health Organization and the Inter- national Planned Parenthood Federation. Funds for all three of these programs originate in the U. S. Agency for In-ternational Development. Additional external assistance agencies are also involved, e.g., the Ford Foundation and the Pathfinder Fund; the Governmen-t of Sweden has also indicated its intention to provide assistance in the very near future. It is estimated *that expenditure for these programs now approach $2 million a year. - 81 - 1L96. Responsibility for the coordination of the -otal program rests with the Ministry of Health which also has assumed responsibility for famiLly planning activities in the general hospitals of the country, the social irnurance hospitals, largely in urban centers, and through local health cen-ters and mobile units. The Association for the 'Welfare of the Colombian Family is concentrating its efforts in providing family planning services in the larger towns, through private hospitals, in the preparation and distribution of mass media pub.licity and working with other groups. The Association of Colombian Medical colleges p:Lays a key role in conducting and directing both biomedical and sociological research through its own Division of Popu'Lation Research and through its member university medical schools. It also plays a key ro:Le in conducting extensive sraining programs, evaluative Eollowup of the enLire program and by conducting post-par-.im ami:ly planning services in the 20 or more university hospitals and health centers affiliated with its member me(dical schools. It is estimaGed that family plauning services are niow available in a-t least 200 centers ani clinics and tha-t more than 300,000 women in the chi.-Ld-bearing ages have already been reached with the goal of reaching over 700,000 more in the next five years. 197. The objectives of' the Ministry of' Health programs have been stated to be: (1) to increase coverage of prenatal care; (2) to prevent provoked abor-tions; (3) to gradually sa-tisfy demand for information and medical services to space births or treat sterility- in the couples who justifiably request them for medical and social reasons; and (4) to contribute to the ear.ly detection of cancer of the female cervix through vaginal cytology in women of reproductive age that request mother and child protection. 198. In the text of this report (Chapter III, Section C5-6) some of the shortcomings and possible points of weakness of these programs have been touched upon. It is t,oo early to evaluate ful'Ly i-ts likelihood of success or failure but it is quite clear that its limitations are not identit'iabl.e with lack of funds spec.i.Lically earmarked for family plarning acti-vities. F. Nu-trition and Development - Phase II 199. Soujnd scientific data are lacking to firmly establish a causal. rela!,ionship of malnutrition irith physical and mental developmnen-t in ear'Ly c.h.ildhood and t;he e-tlenl; to wlhicihl supplementation of the diet wit,h essential nutrienl,s can reverse developmental, deficJts once these stigmria, presumed to be due to malnutrition., appear. The Harvardt chool of Publi.c Healtth and Cornell University- are currently working wit,h the Colombian Institute of Famil.y 'Jelfare (Department of Nutrition) in an ef'.t'ort to resolve this int.terrnatLionally importarit scientific issue. :N)0. The planrning phase of this study is now completed and a -two year pilot study is currently in mid-passage. lf these preliminary investigations, beinLg condiucted in selected urban and suburban popul.ation groups in and arouiKl fogota, are successful thlie large research team plans to undertake - 82 - a 5-6 year definitive study involving no less than 600 study families. A multidisciplinary team of nutritionists, psychologists, social anthro- pologists and ecologists are involved and have been drawn from university centers in the U.S. as well as from indigenous sources of trained research workers in Colombia. Approximately $250,000 have already been invested in this scientific investigation; the cost of the total definitive study, if undertaken, is not available at this time. - 83 - VI. RECOMMENDED PREINVESTME PROGRAM PROPOSALS 201. As a means of further refining and extending the Ten Year National Health Plan, and to accelerate its full implementation, a number of key pro- gram areas have been identified for additional intensive study, including the development of detailed operational plans and reasonably precise esti- mates of program costs. Each of those areas selected for such a Preinvest- ment Studies Program merit high priority based both on the importance assigned to them by the Plan and on judgments made in the course of this survey's evalua- tion of the Colombian health sector, its development problems, policies and prospects. 202. The six proposals outlined in the following pages (ANNEX 1) focus on program areas vital to the present effective operation of the total health and. medical care system and to its future development. These areas include: health manpower trairing and the education of the public in health, the efficiency of health care institutions, national nutrition, health care and the extension of social security, improved vital statistics and periodic studies of improvement in the health status of the popullation. The pro- posals should serve as the basis for further discussions with appropriate Colombian authorities. ANNTEX 1 ,ORM No. 386 INTERNATIONAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL FINAhCE Page I (11-69) ASSOCIATION RECONSTRUCTION AND DEVELOPMENT CORPORATiON PREINVESTMENT PROGRAM - STUDY DATA SHEET No.: 3-1 (1) IArea: Country: Sector(s): South America I Colombia Health 1. NAME OF PROPOSED STUDY: ACTION PROGRAI FOR EDUCATION AND TRAINING IN THE HEALTH SECTOR To develop long range projections of the educational and training needs in the Colombian health sector and to formulate plans and strategy to meet these educational and training requirements. 3. SCOPE: This study is to be conducted in two interdependent yet separate segments. The first will focus on the manpower requirements at all occupational levels of the health "industry" - professional, technical and supporting personnel and will concern the nine medical training centers, all other universities, the technical and vocational training i institutions and the secondary school system. The second segment of the study will con- centrate its attention on achieving in the general population, a level of "health literacy"' and effective capability to use readily and efficiently available health informetion and resources, thus involving the general educational system of the country 4%. BACKGROUND: (a) Related Studies (b) Other Available Data (c) Expected Data Problems The Colombian Study of Health Manpower and Medical Education (1965-1966) revealed gross shortages and maldistributions of physicians, dentists, nurses, auxiliaries and all other i essential health personnel. A major result of the study is the recognition that greatest emphasis must now be given to the training of auxiliaries and supporting personnel to whom can be delegated, under supervision, responsible tasks that do not equire the lengthy and costly training of higher-level professional personnel (See also Item 3 Study Data Supple- ment). 5. TIMING: (a) Duration and Phasing of Study (b) Desired Starting Date 1970 Both segments of the study should be conducted simultaneously. Total time requirement: 18-24 months. 6. COMMENT ON POTENTIAL STUDY SPONSORS: The Association of Colombian Medical Colleges should be assigned the leading role in this study, with the active participation and support of the Ministry of Health, the Ministry of Education and other national ministries and associations. 7. PROJECT(S) EXPECTED TO RESULT FROM STUDY (if known): (a) Description (b) Estimated Investment (US$ equivalent) Guidelines and plansfor long range educational and training programs; definitions of curriculum (c) Financing Need and Potential Source content, training schedules and if needed text-books and teaching materials; also reliable forecasts of manpower needs and available manpower resources for the future. 8. ORDER OF MAGNITUDE OF STUDY COST (US$ equivalent): Sheet Prepared by: T. D. Dublin, M. D. 400O,000 Dept. orAgency:Health Advisor, Colombia Date: April 3, 1970 Mission A 9. STAFF'S COMMENT ON PRIORITY RANKING OF STUDY: Sheet Revised by: The need for the immediate and broadscale mobiliza- I tion of all educational and training resources to em(s) Revised: meet urgent health problems, warrants the assignment Dept. or Agency: of very high priority to this extensive study. Date: ANNEX 1 FORM NO. 386.01 INTERNATIO!AL OEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL FINANCE Page 2 (I1-69) ASS0CIATION RECONSTRUCTION AND DEVELOPMENT CORPORATION PREINVESTMENT PRO(RAM - STUDY DATA SUPPLEMENT No.:R- . (to be filled in when possible) i. TENTATIYE STAFFING Type of Specialist Number on Team Total Man-Months (a) Foreign Professional Staff: Total: (b) Local Professional Staff (c) Local Supporting Staff 2. TENTATIVE STUDY BUDGET (US$ equivalent) Foreign Local Total Currency Currency (a) Professional Staff Costs (8) Equipment (c) Other (Travel, non-prof. staff, etc.): (d) Total 3. OTHER CO4ENTS The National Health Survey conducted concurrently with the Manpower Study indicated that most of the major health problems of the country are directly correlated with low educational achievement and that even the scarce though available health resources are seriously underutilized and used inefficiently or ineffectually - a finding also correl- ated with low educational levels. Studies in the educational field confirm that the general educational system is not achieving its goal of preparing the population to live effectively in a modernized society nor to provide adequately for meeting their own needs for healthful existence. No country has yet done an effective educational job in this area yet the Colombian situation suggests that this country is a suitable one in which to initiate a pioneering experimental approach. Much preparatory work has already been und9ortaken in Colombia. A number ol international bodies - wHO(PAHO), UNICEF, UNESCO - as well as several foundations which have already made sizeable health investments in Colombia, could provide technical assistance as well as support to both phases of the proposed studies. Further detailed development of study plans and scope, as well as a definitive budget schedule, will require additional consul- tation with ,olombian principals. Supplement Prepared by: T. D. Dublin, M. D. Dept. or Agency: Health Advisor, Colcmbia Date: April 3, 1970 Mission Supplement Revised by: Item(s) Revised: Dept. or Agency: Date: ANNEX 1 FORM No. 386 INTERNATIONAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL HINANCE Pae 3 (11-69) ASSOCIATION RECONSTRUCTION AND DEVELOPMENT CORPORATION ag PREINVESTMENT PROGRAM - STUDY DATA SHEET No.: 3-2 (1) I Area: Country: Sector(s): South America Colombia Health I. NAME OF PROPOSED STUDY: Study of Medical Care Institutions 2. PURPOSE: To assess the effectiveness, efficiency and minimal operational requirements of the existing medical care institutions in Colombia as an integral step in the implemen- tation of the new National Hospital Plan. 3. SCOPE: The study will be conducted in two phases. Initially, each of the 634 general hos- pitals and the 800 ambulatory care institutions in the country will be visited by a team of specially trained investigators (medical students, supervised by competent senior personnel" who will assemble uniform inventory data according to a carefully developed and getested schedule. The second phase will involve an intensive in-depth study of preselected samples (146 of 634 hospitals and 100 of 800 ambulatory care institutions). The data to be collec- ted and analyzed include information on: (a) physical plant, equipment and other resources1 (b) sources of income and principal categories of expenditures; (c) staffing patterns, qualifications and utilization; (d) demands for medical care consultation and hospitaliza- tion; (e) systems of referral and movement of patients as well asbases and levels of satis- faction derived from services rendered. | 4. BACKGROUND: (a) Related Studies (b) Other Available Data (c) Expected Data Problems The new National Hospital Plan contemplates the construction (completion), equipment and staffing of many new health facilities over the next 2-5 yrs. However, the health care sys- tem will remain highly dependent on the efficient use and operation of existing resources - thus emphasizing the need for evaluating and upgrading currently operating facilities. Pre- paration for this study is already under way; survey materials have been developed and pre-I ested in completed pilot studies thus facilitating the early initiation of the proposed in- ventory and in-depth analyses. 5. TIMING: (a) Duration and Phasing of Study (b) Desired Starting Date 1970 Phase I - Inventory 6-9 months Phase II - In-depth Analyses 9-15 months Total Study:15-24 months 6. COMMENT ON POTENTIAL STUDY SPONSORS: The study will be conducted jointly by the Ministry of Health-Institute for Special Health Programs (INPES) and the Association of Colombian Medical Schools (ASCOFAME) which have est4 ablished records of effective scientific collaboration (See also Item 3 - Study Data SupJ3e 7. PROJECT(S) EXPECTED TO RESULT FROM STUDY (if known): (a) Description (b) Estimated Investment (US$ equivalent) Major hospital construction and renovation 25-30 million dollars programs, expansion of other health care fac- (c) Financing Need and Potential Source ilities and adaptation of existing buildings to modern medical requirements. 8. ORDER OF MAGNITUDE OF STUDY COST (US$ equivalent): Sheet Prepared by: T. J. Dublin, M. D. 250,000 Dept. or Agency: Health Advisor, Colombia Date:March 27, 1970 AMission 9. STAFF'S COMMENT ON PRIORITY RANKING OF STUDY: Sheet Revised by: High Priority for immediate implementation. Item(s) Revised: Dept. or Agency: - Date: ,~~~~~~~~~~~~~~~~~~~~~~~~~~~______________ . _________________ ANNEX 1 FoaM No. 386.01 INTERNATIONAL DEVELOPMENT MNTERNAT ONAL PA1K FOR INTERNATIOVAL FINANCE t I 1.692 ASSOCIATION RECCwSTRJCTI1ON AND DEVELOPMENT CORPORATION Pag 4 PREINVESTMENT PROGRAM - STUDY DATA SUPPLEMIENT No.: 3-2 (2) (to be filled in when possible) I. TENTATiVE STAFFING Type of Specialist Number cn Team Total Man-Months (a) Foreign Professional Staff: See detailed budget incorporated in proposal: Study of Medical Care Institutions, Ministry of Health (INPES) and Association of Colombian Medical Colleges, Bogota, 14ovember 1969. Total: (b) Local Professional Staff (c) Local Supporting Staff 2. TENTATIVE STUDY BUDGET (US$ equivalent) Foreign Local Total Currency Currency (a) Professional Staff Costs (b) Equipment (c) Other (Travel, non-prof. staff, etc.): (d) Total 250,000 3. OTHER COMENTS DNo high level consultative and technical committees will assist the study, the former to include the Minister of Health, the President of ASCOFAME, the Director of the Colombian Institute for Social Security, the Director of the National Hospital Fund and the Execu- tive Secretary of the Colombian hospital Association. International advisors will be called on as needed. The technical committee will be comprised of the co-directors of the study. Three representatives of the Itinistry of Health (Medical Care, Office of Planning and Cfiice oi Administralion of Human Resources for Health) and two representa- tives of the Colombian School of Public Health. Such sponsorship and srticipation pro- vide assurances that tne study will be well executed and its findings utilized. This study has been under consideration by FONADE but was rejected for local funding as not the type of study funded by tnat agency. In discussions iath FONADE the question was raised as to whether the in-depth phase should not include all institutions rather than only sell- ected sampiles. Based on other findings of the health phase of the current Economic and Social Development Survey of Colombia the medical care problems of the Country are too central to the critical issues now being faced by the Government in implementing its new ten year National Health Plan- to warrant either the abandonment or delay of this study. Investments in medical care Jacilities and equipment either already made or contemplated during the next few years are sizeable and operating costs oI the health and medical care system are mounting rapidly from 1.1 billion pesos in 1965 to 3.4 billion pesos budgeted for 1970. The p-opoGed study will assist the country in deternining how to obtain the maximum return on expenditures. Supplement Prepared by: T. D. Dublin, .A. D. Dept. or Agency: HIealth Advisor, Colombia Date: March 27, 1970 M4ission Supplement Revised by: Item(s) Revised: Dept. or Agency: Date: ANNEX 1 ! ORM 10. 386 INTERNATIONAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL FINANCE Page 5 (11-69) ASSOCIATION RECONSTRUCTION AND DEVELOPMENT CORPORATION PREINVESTMENT PROGRAM - STUDY DATA SHEET No.: 3-3 (1) Area: |Country: |Sector(s): Area: South America | Colombia Health 1. NAME OF PROPOSED STUDY: NUTRITION STUDY - PHASE III 2. PURPOSE: Tc improve the nutrition of the Colombian population through the adaptation ant use of domestic food sources and by changing dietary patterns through public education. 3. SCOPE: Under the direction of the Department of Nutrition, Colombian Institute for Family ivelfare (Ministry of Health) this study will develop practical and integrated plans for the exten- sion and expansion of existing national nutrition programs, including (a) the National Program for Nutrition Education and Supplementary Feeding (PRONENCA); (b) the Integrated Pro-ram for Applied Nutrition (PINA); (c) The National Plan for the Development of Noods (PLANALDE); and (d) a group of other research, training and feeding programs supported domestically or by external agencies (AID, PAHO, UNICEF, WFP, FAO, etc.). I4. BACKGROUND: (a) Related Studies (b) Other Available Data (c) Expected Data Problems I The nutrition problems of Colombia have been studied intensively. Multiple programs are currently under way to meet the most immediate needs (Phase II). These programs are a largely dependent upon the importation of foods from abroad for feeding supplementation. Long range solutions to the country's nutrition problems require the full mobilization of indigenous food sources and the education of Colombian families to select and utilize in their diet nutritionally adequate foods that are available to them within their financial rescurces. 5. TIMING: (a) Duration and Phasing of Study (b) Desired Starting Date 1972 Approximately 21-3 years will be required to complete all phases of this study - due in part to the complexity of organizational patterns and the multiplicity of programs and activities requir- ing coordination. Timing of completion of study should coincide wi t.h trrnyi nqtJi nn nf present. Ph;.p TT of thp niit ri tion progrAm._ 6. COMMENT ON POTENTIAL STUDY SPONSORS: This planning and development effort will require the coordination of the programs and activities of many separate agencies of the national government including the Ministries of Health, Education and Agriculture. (See also Item 3 - Study Data Supplement). 7. PROJECT(S) EXPECTED TO RESULT FROM STUDY (if known): (a) Description (b) Estimated Investment (US$ equivalent) The goal of this study is to demonstrate and assure that Colombia can be self-sufficient in meeting its (c) Financing Need and Potential Source food and nutrition needs. If successful,further ex- ternal aid should not be needed. 8. ORDER OF MAGNITUDE OF STUDY COST (US$ equivalent): Sheet Prepared by: T. D. Dublin, M. D. 250,000 Dept. or Agency: Health Advisor, Colombia Date: April 1, 1970 Mission 9. STAFF'S COMMENT ON PRIORITY RANKING OF STUDY: Sheet Revised by: This study merits very high priority but may not be possible to initiate before late 1971 or early 1972. Item(s) Revised: - Dept. or Agency: l Date: X I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - ANNEX 1 FopM NC. 386.01 INTERNAT1CmAL DEVELOPM1ENT INTERNATIONAL BANK FOR NTERNATINAL FINANCE Page 6 (11-69) ASSOCI ATION R:CONSTRJCTIOtN AND DEVELOPMENT CORPORATION PREINVESTMENT PROGRAM - STUDY DATA SUPPLEMENT No.: 3I-3 2 (to be filled in when possible) 1. TENTATIVE STAFFING Type of Specialist Number on Team Total Man-Months (a) Foreign Professional Staff: Total: (b) Local Professional Staff (c) Local Supporting Staff 2. TENTATIVE STUDY BUDGET (US$ equivalent) Foreign Local Total Currency Currency (a) Professional Staff Costs (b) Equipment (c) Other (Travel, non-prof. staff, etc.): (d) Total 250,000 3. OTHER COMMENTS Additional con.sultations with Colombian principals are required tc develop the detailed plan ana scope of the proposed studies and an appropriate budget. As a bare mriimml 4$- millicn (US) per year are now being invested in applied nutrition programs and these ex- cenditures will be continued over the next five years. If the costs of other nutriticn and food activities, the economic lcsses due to malnutrition and the costs attributable to the medicaa care of nutritional disease are added, the costs to the Colombian eccnomy are far greater. Thus a relatively smaller expenditure for planning and developrment of a self sufficient and continoin-, nutrition pro, ram for the total populations should be a sound investment. Supplement Prepared by:T. D. Dublin, M. D. Dept. or Agency: Health Advisor, Colombia Date: April 1, 1970 FIVssion Supplement Revised by: Item(s) Revised: Dept. or Agency: Date: ANNEX 1 I ORM No. 386 ItJTERNATIONAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL FINANCE Page 7 (11.69) ASSOCIATION RECONSTRUCTION AND DEVELOPMENT CORPORATION PREINVESTMENT PROGRAM - STUDY DATA SHEET No.: 3-h (1) IArea: Country: Sector(s): South America Colombia Health I NAME OF PROPOSED STUDY: HEALTH CARE UNDER THiE SOCIAL SEURITY SYSTEBM 2. PURPOSE: To plan the extension of health and medical care services, under social security coverage, to a larger segment of the Colombian population as part d the new Ten Year Health Plan. 3. SCOPE: This study should comprise the following tasks: (1) assess the quantity and qual- ity of health care services currently provided to Social Security beneficiaries, including present and anticipated costs in relation to premium payments; (2) determine the cost and other requirements of expanding comprehensive health care coverage to the spouses and other dependents of present beneficiaries; (3) assess the feasibility of merging the Nat- ional Wblfare Funds for governmental employees within the Social Security System; (4) ex- plore possibilities of extending comprehensive health care coverage to other workers(and their dependents) not now covered; and (5) formulate long range plans for the further integration of health care services under Social Security with those administered by the Ministry of Health for the general population. 4. BACKGROUND: (a) Related Studies (b) Other Available Data (c) Expected Data Problems The Colombian Social Security System now provides the largest single source of funds under- writing the costs of medical care services in the country. Legislation is now pending in the Congress, and approval is expected this year, to authorize the extension of social security coverage. The new law would direct the Colombian Institute of Social Security to develop new regulations extending such coverage, subject to final approval by the President Also proposed is a plan to regionalize the administration of the program and involve the Institute of Agrarian Reform with the expectation of inclusion of agricultural workers. 5. TIMING: (a) Duration and-Phasing of Study (b) Desired Starting Date 1971 Approximately one year. 6. COMMENT ON POTENTIAL STUDY SPONSORS: This study should be undertaken by a national committee, under the chairmanship of the Director of the Colombian Institute of Social Security (see also Item 3, Study Data Supplement). 7. PROJECT(S) EXPECTED TO RESULT FROM STUDY (if known): (a) Description (b) Estimated Investment (US$ equivalent) As the purpose of a soundly planned social security system is to apply prepayment and (c) Financing Need and Potential Source savings principles to meet current and anti- cipated social needs on a national scale, the proposed studies should reduce, if not obviate, ds]mqnd&q for fitiir P trrngl finnn^ring in his nr.en 8. ORDER OF MAGNITUDE OF STUDY COST (US$ equivalent): Sheet Prepared by: T. D. Dublin, M.D. 150,000 Dept. or Agency:Health Advisor, Colombia Date: March 31, 1970 9. STAFF'S COMMENI ON PRIORITY RANKING OF STUDY: Sheet Revised by: This study warrants high priority and should be in- Item(s) Revised: itiated with a minimum of delay upon adoption of pen- Dept. or Agency: L ding legislation. Date: ____ ____ ____ ____ ____ ____ ____ ____ L __ ____ ____ ____ ____ ____ ____ ___ _ _ __ ANNEX 1 FORM No. 386.01 INTERNATIONAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL FINANCE Page o (11-69) ASSOCIATION RECONSTRUCTION AND DEVELOPMENT CORPORATION g PREINVESTMENT PROGRAM - STUDY DATA SUPPLEMENT No.: 3-4 (2) (to be filled in when possible) 1. TENTATIVE STAFFING Type of Specialist Number on Team Total Man-Months (a) Foreign Professional Staff: Total: (b) Local Professional Staff (c) Local Supporting Staff 2. TENTATIVE STUDY BUDGET (US$ equivalent) Foreign Local rotal Currency Currency (a) Professional Staff Costs (b) Equipment (c) Other (Travel, non-prof. staff, etc.): (d) Total 3. OTHER CtMENTS The ColDmbuan Institute for Social Security, the Ministry of Health, the r.inistry of Labor, the National C2jas, the Nationnl Hospital Fund, the Institute for Agrarian Reform, the National Decartment of Planning and the AssociatLon of Colombian Medical Co'leges are some o the naticnal bodies that should be represented in the national study committee. Inter- nat-onal bodies (WHO, ILO) and external consultants could make significant contributions to the findings and reccmmendaticns of that cbmmittee. Further details on scope, study plani Pnd budget require supplementary discussion with Colombian princiaals. Travel to and study in other countries on the part of committee members and the extensive use of external consultants is essential to the study in the light of exoerience gained and mistakes made in recent years in other national social security systems. A significant fraction of the domestic costs can and should be borne by internal sources such as the Social Security System itself. Supplement Prepared by: T. D. Dublin, M. U. Dept. or Agency: Health Advisor, Colombia Date: March 31, 1970 Mission Supplement Revised by: Item(s) Revised: Dept. or Agency: Date: ANNEX 1 rORM No. 386 INTERNATIONAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL FINANCE Page 9 (11.69) ASSOCIATION RECONSTRUCTION AND DEVELOPMENT CORPORATION PREINVESTMENT PROGRAM - STUDY DATA SHEET No.: 3-5 (1) Area: Country: Sector(s): South America I Colombia Health 1. NAME OF PROPOSED STUDY: VITAL STATISTICS AND MORBIDITY DATA - RE1lISTRATION AND ANALYSIS 2. PURPOSE: To modernize and improve the Colombian national system of registration, tabula- tion and analysis of essential vital statistics and current morbidity data. 3. SCOPE: This study should comprise the following tasks: (1) prepare recommendations for the revision of existing national legislation pertaining to the registration, collection, com- pilation, analysis and dissemination of essential vital statistics data on the population of Colombia; (2) develop detailed plans for a revitalized and efficient national vital sta- tistics system; (3) define the requirements of physical resources, equipment and personnel needed to establish and maintain this new system at the national level and for decentral- ized activities, including capital investments and operating budget; and (4) prescribe the professional and technical job descriptions to be incorporated within national civil ser- vice personnel requirements for employment in the new vital statistics system and propose long range educational programs for the appropriate training of both professional and technical personnel. 4. BACKGROUND: (a) Related Studies (b) Other Available Data (c) Expected Data Problems Accurate, complete and current vital statistics data are required for the effective and ef- ficient administration of the new 10 Year National Health Plan - particularly in connection with its recently decentralized health care services. The marked underregistration of births and deaths and the cumbersome, delayed and unreliable mechanisms for handling these and other essential vital statistics data, seriously impede appropriate program evaluation and planning not only in the health sector but in other critical areas of national economic and social development. Some preparatory work for the proposed studies has already been uinrJrt.,qk-n hy P-geh nf thbe natie Zn7l hnr;ieg that. will 'he JuvolvAd 5. TIMING: (a) Duration and Phasing of Study (b) Desired Starting Date 1971 Approximately one year. 6. COMENT ON POTENTIAL STUDY SPONSORS: A national Committee, under the chairmanship of the Minister of Health, and utilizing the advice of appropriate international agencies (e.g. PAHO and WHO) and consultants, should undertake this study. The Ministry of Health, the National Depart-} ment of Statistics and the National Department of Planning are directly concerned and shoul hp invnlud in +he stuldy IINlP, IINTCTF ns TSATn y y mipprt t.his stlndy.- 7. PROJECT(S) EXPECTED TO RESULT FROM STUDY (if known): (a) Description (b) Estimated Investment (US$ equivalent) A new system for the registration and analysis of vital statistics and morbidity data. (c) Financing Need and Potential Source 8. ORDER OF MAGNITUDE OF STUDY COST (US$ equivalent): Sheet Prepared by: T. D. Dublin, M.D. 75,000 Dept. or Agency: Health Advisor, Colombia Date: March 30, 1970 Mission. 9. STAFF'S COW4ENT ON PRIORITY RANKING OF STUDY: Sheet Revised by: P. Engelmann As the absence of a proper system of vital statis- Item(s) Revised: 5(b) & 6 tics affects investment decisions in many areas, this study warrants high priority and early initia- Dept. or Agency: IBRD/O.D.P. tion. Date: October 18, 1970 i _~~_ I ANNEX 1 FORM No. 386.01 INTERNATICNAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATICNAL FINANCE Page 10 (11-69) ASSOCIATICN RECONSTRUCTION AND DEVELOPMENT CORPORATION PREINVESTMENT PROGRM - STUDY DATA SUPPLEMENT No.: 3-5 (2) (to be filled in when possible) I. TENTATIVE STAFFING Type of Specialist Number on Team Total Man-Months (a) Foreign Professional Staff: Total: (b) Local Professional Staff (c) Local Supporting Staff 2. TENTATIVE STUDY BUDGET (US$ equivalent) Foreign Local Total Currency Currency T (a) Professional Staff Costs (b) Equipment (c) Other (Travel, non-prof. staff, etc.): (d) Total 3. OTHER COfMENTS Only the general outline of this proposed preinvestment study has been developed at thzs time. For additional and more specific details, further discussions with the Ministry of Health nnd the National Department of Statistics would be required. The suggested budget is offered as an initial approximation. Registration of births is still dependent on bap- tisms, a ceremony usually delayed for a period of approximately 7 months; underregistra- tion of births has been calculated to range between 29 and 19 percent with even greater var- iations noted in different parts of the country. Underregistration in mortality rates appears to be even larger than in birth rates (between 38 and 33 percent) with most marked deficits In the early yesrs of life. Procedures currently being followed involve an overcentraliza- t>on of the registration system in Bogota with insufficient attention being given to the ac- curacy, completeness and quality of data being registered at the local level. Essential data remain unt-bulated and unpublished for long periods of time (up to 5 years). The registrat-ior of not-ifiable diseases and morbidtty indices (admissions, discharges and duration of medical care) are equally cumbersome, delayed and unreliable. For a period of more than 17 years, the Ministry of Health, the agency most dependent on the availability and reliability of vital statistics, has lacked direct responsibility and in- volvement in the major phases of vital record collection and tabulation. The National Dep- artment of Statistics, which enjoys a fine reputation for the quality of data it produces in other sectors of the national economy, is well equipped in Bogota with computer and other necessary central facilities. However, it lacks qualified and experienced staff in the heelth ares and is dependent on an outmoded system of local registration employing untrained and technically Supplement Prepared by: T. D. Dublin, M.D. unqualified personr.el. Dept. or Agency: Health Advisor, Colombia Date: March 30, 1970 Mission Supplement Revised by: Item(s) Revised: Dept. or Agency: Date: ANNEX 1 FORM No. 386 IN1ERNATIONAL DEVELOPMENT INTERNATIONAL BANK FOR INTERNATIONAL FINAJ'4CE P (11-69) ASSOCIATION RECONSTRUCTIClt' AND DEVELOPMENT CORPORATION Page 1 PREINVESTMENT PROGRAM - STUDY DATA SHEET No.: 3-6 (1) Area: Country: Sector(s): South America Colombia Health SAMPLE STUDIES OF THE HEALTH STATUS AND HFALTH RESOURCES OF COLOMBIA 1. NAME OF PROPOSED STUDY: 2. PUROSE To reappraise the major health problems, health facilities and health manpower of the country in order to determine progress achieved since 1965 in meeting national goals and to establish objective bases for revision of national health programs and acti- vities. 3. SCOPE: Under the aegis of the Ministry of Health and the Association of Colombia Medical Colleges a second series of investigations will be undertaken, utilizing modern sampling techniques and linked with the periodic national population census (1972), to determine the needs and demands of the country for health and medical services. These studies will take into account the socio-economic status of the population. They will be modeled on the pioneering and highly successful national studies of 1965-66, to facilitate comparisons and reliable measurement of progress and change, but will also incorporate newly developed survey methods and examination procedures. 4. BACKGROUND: (a) Related Studies (b) Other Available Data (c) Expected Data Problems Since the initial surveys in 1965-66 major reorganizations and reorientations of health programs and activities have occurred in Colombia. Concurrently significant advances have taken place in other sectors of the country's total economic and social development which have either direct or indirect bearing on the country's complex health picture. The scien-l tific measurement of these interrelated changes, through national sample surveys, will pro-l vide essential data useful for program evaluation and planning in the health and other related sectors of national development. 5. TIMING: (a) Duration and Phasing of Study (b) Desired Starting Date 1971 Three and one-half years will be required to complete the study Planning and Preparatory Phase (1971) - 12 months Field Studies and Surveys (1972) - 12 months Analysis and Publication of Data (1973-74)- 18 months 6. COMMENT ON POTENTIAL STUDY SPONSORS: The Ministry of Health and the Association of Colombian Medical Colleges have demonstrated their capacities to undertake this type of national health survey and their pioneering i efforts are now being emulated in many of other developing countries. -I 7. PROJECT(S) EXPECTED TO RESULT FROM STUDY (if known): (a) Description (b) Estimated Investment (US$ equivalent) A more efficient and effective health and medical care system appropriately responsive to the health (c) Financing Need and Potential Source care needs and demands of the Colombian population. 8. ORDER OF MAGNITUDE OF STUDY COST (US$ equivalent): Sheet Prepared by: T. D. Dublin, M. D. 400,000 Dept. or Agency: Health Advisor, Colombia Date: April 2, 1970 Mission 9. STAFF'S COMMENT ON PRIORITY RANKING OF STUDY: Sheet Revised by: High priority - initiation in 1971 Item(s) Revised: Dept. or Agency: Date: ANNEX 1 FORM NO. 386.Of INTERNATICNAL DEVELOPMENT INTERNATIONAL SANX FOR INTERNATICNeAL FINANCE P (11-69) ASSOCIATION RECONSTRUCTIcON AND DEVELOPMENT CORPORATION Page 12 PREINVESTMENT PROGRAM - STUDY DATA SUPPLEMENT No. (to be filled in when possible) 1- TENTATIVE STAFFING Type of Specialist Number on Team Total Man-Months (a) Foreign Professional Staff: Total: (b) Local Professiona) Staff (c) Local Supporting Staff 2. TENTATIVE STUDY BUDGET (US$ equivalent) Foreign Local Total Currency Currency (a) Professiona1 Staff Costs (b) Equipnment (c) Other iTravel. nor-prof. staff. etc.): (d) Total 3. OTHER CODMENTS Additional consultations with Colombian principals will be required to develop the detailed plan and scope of the proposed studies. Preliminary cost estimate is based on expenditures of 165-66 studies (covering the period July 1, 1968-June 30, 1967) which amounted to $382,000. Forty percent of the cost of that study was defrayed by Colombi.an sources. 'This proposed study complements rather than competes with preinvestment study proposal 3-5; Vital Statistics and Current Morbidity Data - Registration and Analysis; and will also complement the next Colombian National Census of 1972. Supplement Prepared by: T. D. Dublin, M. D. Dept. or Agency: Health Advisor, Colcmbia Date: April 2, 1970. Mission Supplement Revised by: Item(s) Revised: Dept. or Agency: Date: - 8L4 - VTT. EXTERNAL ASSISTANCE IN TH}E COt O1MBIAN HEALTH SECTOR 203. Over a period of manyr years,irite.rnatioonal. agencies, the govern- ments of other countries andl philanthropic foundations have extended technical assistance, commodities and equipment as Iel as financial aid to the health sector of Colomrbia. No list, of the donors or a tabulation of the amounts of their contributions has been compiled. Conspicuous among the assisting international organizations are the World Health Organization and its Regional. Office for the Amnericas, the Pan American Health Organization, the United Nations Chi.ldrens Fundl andc the World Food Program (FAO), The U.S. Agency for International Developrent and its prediecessor agencies has supported many important hea.lth activities in the country for maany years. The Rockefeller Foundation, the Kellogg Founidation and the Milbank emorial FlFnd have also been involved in sup- porting specific health projects, particl.arly those related to mecdical eduication and research. 204. To illustrate the extent and natiure of this assistance a recent compilation of PATIO aidl to Colombia can ble found in Appendix A. APPENDTX A Page 1 PAN MIRCNHEALTH ORGTANIZATION PROJECTS5 IN COLOMIBIA_(1960) COLOMBiA-.0200, Malaria Eradicaition Financing th~e program hlas inot presented problems., inas- much as the Government has assigned it ani annual butdget JPurpttsc: Eradication of malaria, of 52 million pesos; moreover, the administr-ative organiza-l IProballc flth-ation: ] 957- lionl is effective. /lssisi(fqIC providcd: 2 uticdical ollicers, ( I (ifi he posts Mieclt gs" Were hield wi tli mnalariologists from Veneztuela, witS vacant (11hiring JiarTt of the ye:ar), I Sanitary cnginecer, anti at oilier meetinigs ilie campaign staff discuissed prob-. I vi'ipttniologist, awil 4 Sanitary itrsptc:itrs: antiulalaria drugs li-inis aniti e-siatllisijed chitirirels of collaboration andi coirdlini- arnd vitt-noligiaal sutptlolis: 'tidt 2 short-termu fel lowslhips. tutul. WForIc dieno: IKi~rly ill I961 ini tIrle b,asis of hel cv.alua- liesearch wats stat-ted itt diei fl(ieds (if tlitrativ itic! ettlo- hiim cctndlt:iocl in Ntos'tmlme- '1907, the( intti;triotis are.a of mo.ligy. C'0I0fTbiZL Wa dtVidV LIS 1.'j . :PAHO/RB, PAHO/SMF UNICEF 'I act 1 ~~~~~~~~1 222.(J00 100 970,1149 1 IX) C onsolidmationt phlse 7.ttl:t.lOO 69.5 1 54.458 16.0 COLOMBIA-0201, Study of the Chemotherapy Attack phtiise 3,202,000 28.5 769,391 79. 2 o aai Prep)aratory pthasc 2171,000 2.0 47,000 4.8 o aai Dunring ili he 1ittI spt-ay rtg cycle,, icCtrriedi tint rit lit, first I'uirlosc : Asse~ssmlent of tire usefulness of a 3-day, 3-drug lrat uterit fo r tine ruiaila I atre of Plcasntodi ori vivpax in fee- htalif of lth Yc eair. 449,4331 Itlse Iti S' vci'! tsprat et ( 92.8%, -ili itT the~ Target), withi 2,120.499( iiuletl,iiiaol, sprotected., 'Tic hurts. : 96.98 218)Ii ('yflo wa ltt bg titi ini . ijly; itcl!riCtInitg lit esti naf es. A.~N so /t *ir oltOid.-d AdisSir;- y n-rvictis iby stall i-f litad - 47-4.556 tiiistcs wi-me to) lit spirayied. At Olt end- otf No- 11re,alIo 14jul01.tbaP10,aI b vmnber-, 394.,281 liouses (83.1%," of tlie target h bailiteeri t2thrira trdim ifiitiitttiic (it)ltinivriip-4211(I aizrttt~ 41a cots Sprayeid, with] 1.934,145 iiniialitattts JIriltcit(A. li ado-ljjkin .irdiitiSt~et pr i i i-ltiss 4- Ituarerly- spmrayings wi7re ;trmrnt iist':it riie ithite: A fiti:i trial wtas iitade of Ctiii Cxi'riiitt11-1iitt eleCts, treat rut-itt ~~~~~~~~~~~~~ ~~~~~~~~withll] tiitit' ptriniaqii. aid, 111 i yrritliviariunmlc gkii't otit 31 (v ars ;t raicjial -tire (if P. tCivfi irifi'ci-il 6t,f33 iiitsms i ti: hst t ttttilr trll .5 t) iittsis i ii,' ot-il tts1c Isictl1--is lyct' titeittiii'rtd witl mltlitnit (t1iiie citl il h 6J I' ttjPv int fl uit Ii l m 0t o.miiprith (tJ7am l 6, i1 hitciis.s il tlf -3i 1i AS f,f No~vembriic- 7i91.2:2i) liltiil sititttar ai I, tad cx it-ll x IIri' is wit- sit- t11. rrt;tcht-io' III vxS', agc grittt p, attd tll cIr tnlittii-d, is-ili 25,527 3.2'-; b,ido tti loll tisitlivt. 'PrItacpr- ft-.il'ti 2 mue tjte --e'.iCti.r-si-tmtl- i-t-tttacm-- if ltii-.i ivity [ti-- tttsi,hilci tot- Cttti attai-k-jhtttse a ill thehi:xtme-iutt'rrtalariilathe ilsaui-al hea hint ; (li mits ace(.6';-' amit 5.2<.rtFt'ttiiy tltiril, zi ltritnita Nitltitirt niatiria. was tni'ati'd with1 pritirri;tiintm '[lit-anti --ti I-rriett ittms ill rttst tltit rrsmt 1mtolt- iltti-iig H-I olamvs tti itsti- I'r tltctt fitt latent1 infect ion was pmmt'sei't. (t)ot tCIitmtpii ii ork. it IeMtn-i 'itliitii iie li"tr itl Was Iteitin iti April 1946 ainti (iintintri~dm'(lttil SI> itXi i iirti t it l i ucttlielfs ill t i- c Y11 w . fil riijc- 19641. hitc tsc if thei hii g rate Ill p piittlation inobti ity Thi-'itfat irii200 ni t-y.av. rua (-lio i-al tO1 (f .111 Ci -)0( l) , ,1 ,' l it tpt-tIut'rIctI i tt I ICICtSIiICCII 1 lt t09 1 rIt i-hurst,- ideti ! IIf l It I s t ItI. SW-IMi kmi - '.igm im i,it t-tmi-itli- I. t1, -r-: 2 71w . 20tuit-0 V i r s ; itliCii IItlt f IK was IlaI-t I o -i I- Ii flIt- tII u IIs I t I l fit- II tti-lirltirtCt- I ftistilI mhtI. - (Ii I-t It t Jirnign.~~~~~~~~~~~~~~~~~~~~~~~~~i 1-nmlijroflloi. raniTtw~liiltl at- APPENDIX A Page 2 117irk r/l,Ii: lirhteatli c-vili:ro I,:l. pl;irirll jol COLOMBIA-3103, Special Public Health tIrecilyif C.:nt coriiiicll Il.Ie ar.1li,o '.it, Will, g-ir Administration Programs rcsullts. ThuI p1itt-: lrinpr-trvc-rrernt iii adinhiiistrlative iiitirrods andl Dur ing tilie year a rt.ineSrr)r:sthit n % rt i f s PI IN Ijs tr\ -d in I " c . 1Io'lI p caI111lr Ie t1 iim l ~ lim p o Surveillance rif airports; and plorts riurig Ilie Atl:uiltic Pro/ftildlrl' uti oni: I (07-19t70, coast WasitS coritjllLIC(l -1ssistaric-i- ploviillii/: I Shlor-teylli co01511 Itarit andii hil- Eleven ellow feVelr cajst'S were pu -'Irtei 11zi ,I' e 11rti vikr-v svv,c l)y file PAI I0 /WllO Country lcpr:Jtt:s-i;I- dUr-ing thle veal. PAHO/RB Il ia/~~~~~~~~~~~~~~~~~It'lliu: 'I'lir letgal s Incic- rea id fr n'it ions o, f tlit- Na PAHO/RB ~~~~~~~~~~~~~~~ii.oial Institirir for Spec(iail I Iraltlh lPrrtgiariis I NIEIS. ItI'Irlo]ir I hatI ItI,. wr It vstI a I rishiud Ity cxrrcli i vi dIrrr ItI slifatit es zi-airI 1909 ltimdllg: wc:r appit~rovedl. iri acc:tIdarl r-I %il i COLOMBIA-31 00, -Health Services tlet ii,.iv lr-;;il plorviSirtis. It, orrghrrri,atirrri, ifilttii:il ir-glili- I'n;jtit l'i IldIlirtli f a ifi lInat1 IrritirII tzi Lt; It rr:iigtli. i4 Ils, ann41S sa If wt:e rrrrlt:rc r st IrIdv. I [I(],l t Ilhe 1rr-g~ P aii1izti.l r) Ciling oif tlr rinstyit Mlii- IIrIltlr:dIc Irillih a-l ld i rljuw tir:i olrf tile NillinSt, tltr: Iristitriti:' s -lSt worikirig rr-lituiri.lirtil i-md ti--ilsn:vir: rxltisitil n) irt-giitrr lialti srvil: wifiti li O Nliiii-[r-y war- rIri;lyv tlrfincdt. Midttr localt ex iitrlti nsio nl t1 rillii rif.Siirra in1 INPES is rrspollnsibilr frtr it4 forllowinig piogranis: trainl- all X ha lY Ilerstrri Ire1 rig~~ ~~ I f ptrti-srrir:l. jlo~irsial ardif-clurctnr, ircseai-i;l prottcctt., l',-tibu/r/c dr,rolio,i.: 195I-1 99~I~) i,i-isrt rral Saritait iorr, riie:i inlpetiiion, chldii we1 far,. rirllo- lngn, arid I irn administrative iitirl.I nurilse, I sanit iiv PAHO/RB crigilneer. 5 short-termi oiriusrlailts tiii (Pf luicn mnade Nsits), anrd I ternp)lrirary ailvis,e :r,flipii ur-n t al( sitt Siptties t-mminiri services;~, airri 2(0 shor -tcrn auIit 7 iiii-19-tiril ti-I- COLOMBIA-3301 , National Institute of Health in ws lips. (Carlos Finlay) Ifnrk: i/tine: DuorinIg tie yr-ar tire otigri.tnr f lit'! I'nrplos: St iingtiliciirg nif tire serivir:is rendlricd biy [lir- lkinlistry otf Pubilic Health Avis -aierIr(il tnt git rig II gredite eriirw Ft:vt:r Srctriii rrf tirt! National Instiliftt (of IlIraitl t4. adilirnjvtrat ivc tIexihilitv ki-rd Irlorir altlittoilly Cver thle dc- oiii i r o unt irS ini vnrniertiio withi the lienisplierrr-widli cent rjlalized iisjitlites engagitd in, rcali ir A,i k. r-auripaigil agailist yt:ltrw ICever. illitith ar-eas 4rf Ir svir-ch.1 hias breconi il the keystonic 4ifithi- lr-alt I, itcli-int rs. IMajot /urrol,uI/i/ (11,1i : 195(1. Inleflinigs were eldt- to u;otrsidiialac tlir ptotc.~s~ i:ihlal-ii it. 'Issishinri- ptrtird>/ih: I iabirratlirx riolistiltairt andl adlvinijr arid pit it uIl ritit itnrtion iii 196i9. civics Io ieit I'AII0,/WIIO Cirroitr Irtrsriat, Efotitits it ttlrtiilliate~ t i-l- t iis tii rIi vii i- ial its. tinlt id, wit I a view to est altishuiti a fatikirral healthi sysicini JF"olk P/inlc: Urtiiler tl liecrernre rerirganlizilig tw l iitMrst rx (::ir:iitiill f a atirnil helth (.iuiiiii -nt in oirrstuill I f l'iililicI; I:altlh, tire National tirstittirti of lraltlh beceane level Signirfiidi nrajri)r ptroignr .Ss il II IrIIis PIi1iritllll. i-ln agi'lrlv ltr.f-Iivnsible 1nt tile Nat irnal nstlit ni: filn StuCCial A tillicy anrn spnecific ~ir-grailirlr-lri.wt ua s-ti II-ll Pnrogi i-urS ii IE1S). SUtiplieS Wcie siildierd and tdrawri rip. tliritirglr tiei-ir aciil of A i-onimrilicit. tliesidi:i irver by tire D)irlicttr oft INI1lS, Tle ili-isil- saitrationiul 11gr.win-i hits air irrrprcssivn s,tiittiiic of tiht Inistiliti:. Woik trii ilt icinw iistallai-ionir riVCirird of ;tt--ltmplilhniclit, wvis ci:i -ioiit Ia hwart1 It I nurr:l was15 iitii iririeil. aspiect lviii liecilllic tilte ir:sptrnSibllty ,I' hr Nat iriial inst i- Rf!scvrarlh un1 arltrrviiiis infectionis, letrir-Sy. tfrvpaintsolitmhr riefrl Spiecial Ilea-klthr Irrgrarnls, sit ;is t) vinsure gri:i-itrr sris, anti entomolorlrgy was carried fonrwardl. rilnuinist rt iv.: fii:xlii ity. nT:c lnrduclli:tin oif 1niologic:als dutrinug tire, pnerod was as lireoluject tniniaternial and1 chlrir lair: arid famiily ptirt I ow~ yellow fryer vai:lint:: 1,625,000 dtises (30.1,50(1 teci inn was in itsOnna I stages. .ltses; diis rliritind inl the Crouintry arid 908.00)) airotad) teclie wnrgasln for Iiiolstagesin:i itgfit-lln tl ya rneozc-flricrl srinl;nhpnx vacinrie: 7.992.200) dlii.ss (III whniich of l t pio raimnfo l tipprintw inth helth- iacvi tafs ri y alilrj 3)1(,0001 welt: Shiipiped to Ecuadori)r ; awiirahie.S vai:cirre fti \tChaiigc o cr.ulbtcntl elhsrifso Iltj iriirriarr us.:: 4(1.629 ]14-uolnnvctu-aimenits (8,)10)t fri:aatru:its aind tire .javeriana University ( Bogtti i-) Ithas cninh t ited aird wt:re shipped t(i Veneznnlai *t antirablies vaccine ftir Cnn I'lielieafli prmoter por was reourgan izedl, aie 25, 6 us( 21,(0viiiutheiiEu d 'theano phealtcipromoter nurse lowl l iram c arnn lie vaccine: 6)10,000) ilidivid rial diises; diphitheria to)x,irin 32,(000 teogamof thyscin deandnrsmesta wevo willli tiaii hred ifte doses : Sehiick toxini 60,000) (i)Ses ; antit yploid vai;cine,: (irogam atthe dpartmntal evel as trined.180,00(1 (loses; BCG initradlermic vaccinle: 3.1 43,000) dilris; A major, large-scale stupervisioni programn was counductedl - arld BCG oral vacicine: 125,10(0 doses. at the iiatit-otial level. As~~~~\t of Octobier, 6 cases of ye1 Iow fever were- diagvni -ed. PAHO/RB, WHO/RB, WHO/UINDP PAHO/RB APPENDIX A Page 3 "Shooild ilii- 4-Ixt-inriirian l recatinentl hi; SliiiWri to lbe Usable, Itogoiit. National aitjlhoiit ii; andIi th, P-AHOI( Zone ;dvisi;r large siitis couild lie saved in trfea1nicnt i;oss anin maniy inirde inispec;tion t ripos toi all tIhe tuberi-iulosis programls. er-adicat ion pirograms WoUld lie aile to give radical-ciire mnkiiig it pissilIi to ~vstvimatizc t1le work in aicordanei treatmnctt ini iirciiirnstances in which it is niot feasibile to do withi istabilishied guide-lincs. At ithe Girard(iit Pilot Ceiiter. so) witlh the classical 14-day scheiiiiie. Ohi thic other hand. whiich faiced a crisis earlyI inii th Year, thie apptiintirient of sliotld]( thn t reatmerit he provenl t(o he low in per;ccidtage of a flill-tiniw dlirectoir iointrililteild to a notahle imnprivicint radic;al cueiis cffccIti;d t hi; Organiization will have evidlience in li1i Aiork hiriing tlic siecoind half iof lie year. li noidil of witlh whiiihi io cionvinice nialioinal servic;es that its use wouild iperations jirvtarcdl iy (irardoip was aidiiptcd in ithier parts lie ciirniter-pirdicln;ive arid( watsteful of recsoiiries. iif ti1 le iiiinty. tart iclarly in Cali. As a h)y-firoiuiie-t oif the priiject, a mnarkeid effict hais beiie A conisililtii stiiiialiteil in BIC( tiroduct n ihser%eid tile noted on the powduatiiin iof the sttijily area. '[his toiiiirltionl, tnitpara limi iif vacc;iiiti tl 1;w National Institutie of Heialthi livinig in an areat which latiks general or i)rivate hecalth scr- and sihilnitted a scrii~ (if recoitinrneidatiiiis. Nsvlitii we-re, vices, was at first r'ather ci- ispiiioiis of the mriazlii c;radliia- lh-ing tilt iliiti ilfit-4. tioiri opecrations bln LlItiMately caime to retly upon the naz- At hiw Sclo1l if I'ihliic 11ialtih of Antioiijiia 1[iivi'isity. tionatl irojct persiirncel andi to caill uipon them iifi- assistance in Mi;illl in. t lii si;iiud couirsc (3 inonths) intiiirilii withi their nialaria attacks and( also withi othier hiealthi prob- cpididcmioliigy and cont 'il wNas held, with 1S national stil- lenms. Ilii,s thcir attitude tiiwaril tIe G(;vcrnnwnen's healthl dents; ili attvildani.. acitivities was comipletely altere-d. PAHO/5MF COLOMBIA-2200, Water Supplies hirlfji)im: I nrlli'ii(l~Ii'i0cit On f thC nnatioinal W1'11t- SHlitily COLOMBIA-0300, Smallpox Eradication priigrainu inc-liuding ilit pilannrinig, design. finanicing. i*iiii- Puarposc: 1'radiicatiiin of the idisiase froinr tlin- coijiiitry by strucltioli. alld iterlir l oi if nnuniniiipah walten- suppitly sci;viiecs. niwalis iof vaciia;intiig 9()t% (iit lie popital iiii in a 4-year, P J1oliI/i i/Iiir(1tiiii i :1960 1970. pl iodil. AIssislllif iii piivu/i'i/ I sari itaIry cligiticir., 3 shli ertt nn Prcoboiebc (dnratitiori 190(7-1972 init.nt in admiliii'irat ivc not liilos. nilt( advisory si'r-vice Assi.sloici; providi'el: Adlvisiory swirvi;i;s liy tIlii' inn-fiial liy Zione I V OJtlici -. alf. thificir assigtic;d tii truicji; AMIHO-0304, etuiptirilin and1( sotp- IP'pirk do,ii: Recoiimmii-ndirit us in teichnic;al aiidi all- plies; aii(i I short-te~rn felloiwshipi. Inilinist at ye aspi-its (of hi program icontinued to lie inl- II' ork dlories Duiring [tii! year, 4,597At092 pci;rso were jlncniid anid an iiitiriven 't1-1, Wals note(ill Iin Ip inIVestnieiit vaci;inatedl. Sinice thet start iof tii;( i;anliaigii in uldy 1967, a aild otpeiationral i:upilidilyit of tile National NIuinicipal De- 35S.2%,,, coverage nf itIn population has l)cii;i achuievi;d. A v-lpiunienit I nstitutti- I IN,S'FOP'AL,I. A good( deal if emi- total of 203,0l34 persons were vai;iinatedl furf the( fir-st tiine phuasis was jila-ud on adiminuist ratlive, operational. andl andh 16.3.283 wer.je ru;vaci;uinatedl the propourtions iif takis m1aintienanlce aspecu-s if1 tlii; water snupply systemls. were 89.9'j~, aridi 77.7%.( respiectively. I NSFOP'A I ucontinum-d tii initpleninet IDII Plan Nii. I, '[hei mor,Hiidity rate has renuainedl at zero sinuce 1967. Whuich as oif 30 sutitenihiir iripri-sented an inuvcSi;tniu- (of 'Iule hotrizontal naltiire (if the tirugrain was setting a niew Coil$317,356.467.7o t 1807'~;; iif tIe total fijnuds) . liii; invest- pace cif uipiratiuunu fir lthe locual hlealthi eirviuics if tIe 22 mliuIr malic idirini- Ihc veor wvas CiiI$49.]tt6.040.83. dep)artmentls ini whiich it is Ibeinug caririedi htl, aniti oliii Althlii sanie tunei. withi national fundi(s, INSFOPAL con- irrunuirnuizatioon activities. sticil is 11CG, DF)I', alld Yc yilowi ii nuiii;il t :iruay utl p iii4l u ndur the 1967.1970 Fol ii-Yv:u1 fi-vir vail inatioini.. %Arre luicing incoipojuiuatud iiitii li- trip- P~lan. ( ;il13.133,053,3t having, lucen inuvu;siti-d ufliluinu itw gri n. l'i-st lItl f oftlu' year. lyv cseiiutive, hdecree tIhe fihlds (if WHO/1R1 act ion were dii iii'id and liw in list it its thatt will assrimle respilni- uinnldc; the1 dliriut-cii,ui of ilii- Ministry o~f l'iih1ii ilcalili. It is COLOMBIA-0400, Tuberculosis Control bIi ul-v' il 1t at t his luc;isunu'4 a ill leadtii ti rajuun- ilentuiilts iti troil puuuguannl, beuginnuing withi a1 %vi:ricluaioru area ill I '['lie Autiorionimiiis N111iuuiuiial \Vatclr Supply anal Se-winagi tari uialtlh disitrict, wbich incidiu;iis 12 ljnlunic;itialitii;s of Ainlioiilitcs u;arrivil wl a laurgu-su;alc iniprovrivimilt anid ilii; Dpitaitnclnlts ofi C1i)(imillunrat j o ujill I ntl! ionl prougirai iiiiiigil t1w ycar. P'robaleoi durettion: I 966-19i70) WHO/ RB AIs.sisitini c purov;ided: Ad vi siory se rv icc b~ y te P AHIO / WIHO (:iiirt riy Rcimtieseiitativi; arid biy .lie niu;iical ofiicier ass~igincdi Ii proiject AMIHO-040t4. COLOMBIA-2300, Aedes aegypti Eradication Wlor-k (lone: Wiitluiii tle struititmir of the MIinist ry oif l'tiill, I healthi, tuilii;iiulosis conitroul ceased tii bei a vertical P'arpise: 1trai dllatlil iif A. unigypti. Iriigririn and was illi;irpoiralted iriti tire Divisiinli of Mediical Prohah/lc d/nu rr,/i(oi : I1951I- Caiii;. 'Illii riti;gra-itiiiri of tun1,luuuiuluusis prigr;iliis iritii this /Issisu'nii' piroiideiuI I saniiiary iinstiel;tor and adivisoiry reguldar ac ivitii;s of lthe huu;;il1t I services piroceueded niurnil;lly. sur-vilus liv t Ib P AlHO/W\ 10 l() inilry Hkpcii.sciitative; equtip. Ill tIlis cionniictiioni a roIpichiu1l- o granill was dlrawnl Ut1 ill Uliil t and 'Ii ppl ii'. AP:PENBTX A. COLOMvBIA-61 00, School of Public l-Health 41144 on1 cinb1ical 4144m 11414'4114y wa's ollied'1 al Iilit /Nationa44l (of i lic IInI4cr'4,i[Ly (o1 Aniifiqi411i4I ill 1(4rdcr Io adc14111iatI'y p414- 'I' i:I44lall4 uIlrdi,4al I14111c1in (.arlet, tnf;difw'4 rmIt in11d14 44144 j('14('5i14II1 I44111 ~ii NI 144'V II 4445444 ill 4 41441 I IV 'lm ld iIwdN14 disfi (41441Ii1r MI'- 111481- I.111'4'llI'oi '4444' roii>- I wn (ledls of tile Ilolirit r'4. /'4144411/4 I/11'44'.464 - 96. )(4 I.ssist41(inc p1'1iorided: 2 s1111 -14c4(144il4I8IS I 141.11144. PAHO/RB iriry aIdvistr4. and11 ad(visoty "I4vivicrs .y li 'A lW/Wli( ColI(iltfry Rl4lrescl4Ia1ive' 44ililiil4lvlt :1114l1I sholr-II'rill 141I COLOMvBIA~-6203, Center for the Teaching of 14W51hi1(. Pathology Wir' on'1/4u41: 114hiricenI4gi~ 4441554 '4 11''4It~: 44.,44~ I'41la15flf1114('It ill ol4l1j4inn'-I 1441.1 ll 1141 lotal4 of 2(1) '.11d44'411 I,rl of 141 1144111 ojlj441 4'1111'I..11'15If liallIioloy Iof lh14: rN4t4io1a UJ4ii.'14sily, flt- Ul IIi'4'I'4.sit ' 441l14S A''(4'4'4IItII1441o4 11114 'c4 1441tl' 14,1 1111 II'ltrinling oIf t148clli41g. II(1514it4al. a41d II.- DIfril'iuig IfiI yoi4ll' tIll' Sc'41441d l'4IS 4'~lI'IId III Il li- 4144' s4(*4j*4h 1I(rsonn44iIlII in 14 lio 1 fiId f j1Ia1holo4gy in Lailini Anwica:144 inAl4' ct4'lt4'." int1IlIdling a1 4'4'14I4dgist. al(4 4''4I44lonl", '' 4'i444(llelidicIng Iof Ila14i1(ig 1111.gian111 for techn14ical1 4144d a14xilia11'v 1141ntr11111nist. pcismi~~1llI ill Illis fi4l1hl 441111 viw44444'ag144n1Cnt (If i'I'51car44h a'1 WHO/RB [lift poA.I I'dnlc levell. Ass141istfnl prm/14d1'i/Id. I shil irml con sult4111ant. a11d ad6. isory4) COLOMBIA-6200, Health Manpower anid Medical ,:rvicc ('' Ifi' Ined1(icl('1 (Iiler a(ssignedl to 4')ro.I('fIt AM IBO- Education Studies 4513 4141 1I)'r lie 1"AAH0/WII0( Cmintry ReCprCesentative:. Ifo(Ik (/44,41: Atu assssier5(it wa(s made (If illtC I)roIlrI's (If 1'u4rpo44: Stijily oIf 111:4114 4144444JIp1'4cr 4'411114i;cl4i'lt'.1; 41441l Ill4' p4441ining i4tciviIii4S IwIinlg carr'4i(4d 14141 tIlli' tIl 18tin itIe 44(e441IS for inicoeting t1wlinl 4(41iltil clletion41 of~ dz114 foi ;i A\41Ir'ica4 Pro'1gram44 for lII'iIIiIiig ill PathoIIlogy f11 l'l. i. wo4IriIIntatiIn oIf medical44( ed(lcaii4111 ar44( 11w411114 J4al414i41g :4144 II'i lIroI5pIc41't oS f fil inrIgram1 was dra'4fted this 1tarnplle1t f(4r developing a1 wo'rkintg Iinethdll4lIIgv tlaf 4(114) s41r44 :t5 ~t is ii(44i4(y concl14rn'd1wilh411 dIescrIibing thi cuie 14(''I(I .14t14 (If mnodel for o(tlier c114 1tr'iIs. paihollllgy a4nd( witl promot'iniIg thiis Sj(1411tC ly. 'I'li 114'4Ift wa1, Nitration:I 1 964-1908. -evewcdI hI) Illc444e( Inc eidws fit Ilic :41(1441 Colia in Go(inin(It AssistlSf1c1' prIllidiI'd: A'1iol'Iy ~ltlviles l~iv I44lcal 4ltiar'ls, :414d for'warde(d to) PAHOI I Headquar41t11ers f(14' f1441l r4Viuw, Re 14If 5I-S 'lta Itive 1 II (S111 1.4 1(v14r tIll'jIItI iII, I,1": :11111 jI iIIlI iI I di SI i'iI((i Ii(oIf( (81)' Iy e XI ye444r. a4141o11 t. (If su4IjP1jvs. Al iei( incelinIg o(f th~e P'LAP' Coord4(inlating (>mnllttle held 11 fork 1/4o11: '1 mb' 1411 :4144 .'ifilII4 111 Health1/ /l/114;1,mlool'r 14(114 inl Jl. 11 4(' (h)rganfizaItionr (44 r(tpri's.entC4d by) Il inedllli- (11d41 A dl/il/ Edi/alion1 01 i14 (CIII4loi /1i4, V' / I. It/, 4 44111 M1('4(1i(I ca officcr' zis1ign Id to pi 'i I'l AMHI -35 13. I/4'ports ofJ f/h iI'Il//'cI/V C(nfrlf'ri'ce 1bIll' 19671) Nv45 iS- D)oring the1 flust 4( lilf of Ihc yc4444, 11h14 delCtartnicnis of Ila- S14(41d iII 14141 S14441isli 4111(1 Eaiglis'1i. 1t wa widrk1'14 disiH'l11t1ici, IhlllIgy tIf An4ini(414l]4iVI44'11,f-y, fli(4 Na4tional4 UivcrIiV4'ity, 4(4d parl4'i1444lrly to the Ii(44a1111 aniorlt ics'tj' If 1141c 1. ''4 iiiinci'IIts On,1 Unl(Irsily 1f Vail44 r(c'Iivttd tl1(4 laborator11(4y equj(4ij44(1t II ll 441 '444 .AnwC4iiran4 l'(cdera411in oIf As4'o,i4i:ltionI' IIl NII',4I;iIl ac(Clii4ii-ed by PAul) will funll(s alloca44te4d iri 19)67. ~'4'lIII1. II ie444111(141 4541'lIt1145.4(11 utIl SlllIk If A c1(145ultani( visiled 3 Centrl( AmIeri'ca1n coun04tries4 411n1 p14'1i'1b1. 441c1 l44'4(ll4l,lllil-, IIi id4g 41(1 I'llit 5IWy m 1111 I k' exi4-o iln ordo11r toI pr1(rn41it tIle i4'(Igra44n, int14rviI'w poilliaelt41 PAHO/OF Milbank Memorial Fund ii144rns4 11t1 silIjbicts rla'41td1 tIl w(itlhol((gy. lie also( 44tter(ded 111(4 PathololIgy ( Ai,rlg(s, Iof Central Arneri'ca4 anld Nlexi'o tlhat w.as held in M4I'jt(l:l, Y~444tict4i.n Vlexic'o, iln Deemer4lfl(1. COLOMBIA-6201 , Continuing Medical Education IFhe s(411c1 i(1n (If felIlIws V.w4s I(4gl41 tIle first fedl Iwxshili .(waidedI will goinlo(1 I-GT4i4t) J44an4fnar(y 1969. liar1ticu14arI'y fIoll' tinofcss5i4n141 vNi44kinIg iII sinall clon14m4fli4- 1i4!s: and4( jIniblicaLiiifn (of a 1wr(iiival4I1141 in :iI 14111 ltl Im lIiz ngii loillitogra44)hici; Ilcial'4 444(d Ilipicld in4fIrinaifuI 4 COLOMBIA-6204, Experimental Sfudies on Health 1'rohld/u1I1/4: l//1/iIrII I 65- 197.74 Services ,'.'siSbohlee prelllid/1d: Advisliy) byriIC lI4 (4"Itu1't4' 4/rposI': D)('5i4.n of an414 (j(ral 1411al sIllIly 1(4451d 4(f4 the4 a444d /'onc~ [V( ()f1i1e s14(fT and4( bv' ( I'i AI IO/)WfIO C(ISIIiIIr\ find1 ings of tIlc I lealthi Wr4i((ow(4r a1n(1 MedIical4 Edncilit 1n hiellres(4t:nitlke: gra11ts: 4441d 2 shol-41tter(4( 44f4(1 I lon4g-tI'lln StUid% a144(1 aimf(4d at tcstinIg in1 sp(ecially s1l4t(4ct( health 441'(aa fIl lwsliips. ~~~~~~~~~~the oIptinlot'm systfems flIr thef trainin ', and i. til izationl of II 444/4 '/444'. NVith the I'IvlIIie-i':4i14n ('if tlie Naii4444 44444di4'al au4\1i3iary Ier-onnel. Schols(41. illIrI' tl444ii 50) p1445t r:(dllltC courscs44 w44rtrI offered, Prob/i (le/ dIlrtition: 1967-1969. 37 living held at IilC Unkers'1'it"4, (if 'VJite. ApproxIiminaetev .ssistanI' proiidd4d: 1141 PItin 1)',ar a(dvi-er alIl( adviso5rv 611 1)hvs4Yic'ians1 114(V ioipaled in fthese! cmilrsI's. ser'vices by) tie 1'AHO/WI't( C.onnI ry RelIir('5nt4itt lve It coiii''4irs4'es we-re held in tIlic depa4rtmnental ' apitals : gr4(nts : (4quiIrrment and il(j)ldi(4s. APIiENDLX A COLOMBIA-41 01, Clinical and Social Pediatrics \1 ilk ,ctittples w~i cii vri-il iruary for analyses. A Colonihia irigiitiir i%;s sentiii 1'io erti Rico for- sptc- I'llrpiosc: U-gairi iiatiott if yicail) soia It I ti I ili trics cotl sis- ialIiyc41Il I t:in in g. for jI)to fessours otf ji)ediat trics c IttirSes o(I vI dijat ItItIf IIs ill III(( Ii - seri ees to- pjitilrtt ic hospit als. COLOMBIA-4601 , Air Pollution I'ro)aible tbiraiio,t 1904 (tinder AM BO-4-1IOtj-196'. As.sistanitce proirt)ded: Ishoi,rt-lecrtn contsutiIant anti adl- Pu rpoisv Planitntitg andl est aidinsitent of a iiit itjoralI oc-. vistirv scrviccs b) thle PA11O/WHl( Countttry Btepresenittlive; cnplat,ional health nuti.; and insiallationt of air- samupling eqtItIi patfieit t a 1id suLi 1Ii es. stat ions, ill the nutijot itlics of Ilse c,-otuntry. Wlor-k donv 'rite I\V Lat itt Anttriciican Coi i sc in Clinical Pr'oliithlc dn ration: I907- (1070 anti S)ocial Pcediatrics was held on scheilujle anti withi suec- Assisiurti -irotold: Ailvisorysrie tytl A 0 vesin thei DJepartnitit of Social Pedliatrics of theq Sitool of WI ()(i0 i Coli1v B1nstttv Metdicinte of Aritioquiaii Untiversity (Medlellin ) ?-if was lVoiuk i/one: Wit t tiut O rganization's assistancie, a 70- :ittended by 16 students, 5 'if theita l'AIIO fellows fronit hoitti riitrTMc ott inditsni al Itygitne was olletrtd to 5t. poio- Birazil, I-aiti, Paraguay, 1'erti, andl Vnezncttla. 'I'ite colirse fes'-ioitals. A 1 .00Ot-pap! ntitiiiial oni the cotirse was prie- lasted fromn 5 Auigust to 31 October. and for Ilie fir-st timeif tiartcil. 4 itiirses took part, f(ir piurtposes o,f a tclani-trainitig trial. Duriing I I!( year several stuieiiis related to) ventilation piriil- As- part of the- iwitrse, anil witlstIte assistancee i-f za social- If-ills were calrriedl ou[t. og,ist anti at planner, a fieII ldsiolv qf a titiial conintitnity It Blt.oi`t Ii te pieriniaiuctt stat ions for the dletermIination of was carruetl outi. air tlolhiitont andl rt(ialaioni levels continuted their operationis, The1 StUdJeats were gjveit a fieldi assignment on h'iert-o antol plaits wire startedl for thc insisallation oif anothler station B3errioi, where thecy cundlucetl a ritittilitin suirvev anrul a semni- it Nlicdcllin. nar in maternal antI eltild serviCes. One of t lie- ittises in- Basic satu;plittg, for airi piolIltitou wais carriedl fttiward inl ~trciwtors spent a nmonth atl. dlie Clinicial aitd Social l'ediat ries several privitt.iail tttitills. Coilse littid ill Chile, ini order. to guii lt fdit ioieil ixpieriencte Afu octitipliotntitl Inalih i tiit Iflueant alterations in thse S;pe- in coiit ses (of this kindl. cial I)sritof Ittigit:, WHO/RB COLOMBIA-4900, Health and Population COLOMBIA-4202, Nutrition Training Center Dnmc PtI 1) J.%/i'S I:xtciisitii of inaletital autd chil licai:lth i and I'irp)osc linroviricienett (if tlti nittritiiinal stattis,i iii the famnily phibining s,ivtit-s ti rittal arias. count ry, i)v ptrovi(ling traininug int appl1ied nut ntrio ittitnil fooid Prilmid,c u/uruntion. : P)OB1-19'70). e'Conomnies tii 1ersons lioldinig key goverrimetit , managemenet, lIssistircec ptovit,did I niit-ilival ofi iier. antd tei-ching posts relatcd itii agrictultitt-c andf fid poi ify. 117ikr, dorte: Wor-k was startedl on thle dlevelopmentt of ithe A1ssisl(lftce p)iiiidcdl: Aulvisiry services- hy tlt, VAMIO/ iti:tiialda fiihutret WHO0 Counttry Repre.sentative. PAHO/OF AID lVork eloIte: Atpprival waIs givent lwe tpin if opetratioins 6or puffting minii etfeu:t this jointi prjiti iif the Nationial Utti- versity. thle NationaLl Nitrit ion Intstlititfc, IiJNI CEF, FAO, COLOMBIA-6000, Medical Textbooks and af( ii (Itli Or ga nizat ioni. Teaching Materials Airttntgerntents for stpite luh( '4itipiticnitt fi,t- the Cctlter were Ieing ma-d. IPurpose: Estabilisinitin iif af systeml fit- the distriliutiiin. [Ilie bst curitse ott 1tttt it iiin wvas held, withk cotshidiraltle sale, aniti riestld if ticxtIti)ks sincuess ;18 stitiflerits from several etmitt-it is p1:1- tititteId. 1'rol(ti)lel duruliuii: 190i7- Plans Ncl.(- flade fo loddig a "imlar coli-sc in1909, issis.ince p'firid ihud: At v isior y services I iy tlite PA11O/ I iuit ueit tuate fr I iil ig s tii I icii rs ii 169 WHlO. Coii,, ry Retr citistt live. Work doune: All Ilie aitedlical sechoiols of the 9 itiiversittics COLOMBIA-4500 (-4507), Radiation Protection ilii the coinititry lhaul ~igiicul tlti- ictter-agcellent etof lil- hittettce to tliti Ilasic agut itiiwiit witl Ilhe Cove'tinniint. Ii iroui,: Estalilishitnent of a ritutlitont prtuttitont service 'Ilt, 0 rganiizt ion itutdl av;tilaloli 1i Ilie schiuiols thc Ilirst 2 oll It naitolnal scale! iii itlo coitpi witl Ittlie oivir-allI tirili- t xtil ,,ks issitil( tiolcii Off ittigrihi i I'atuuii i ehc 1 Ji/)i)g le,nt of rail at iiit cxptosit ir, 1),li it t ctutpat itna Initel if t lii: arid I?/oqu/lliiku.I lir (list ri hutiiiri i i I lii l:tsis itf ret-itcsts. girl-ttlil 1dict At ilii yi-i" cids Ittl8 schoiis htiol rciliiisteil a otai-tl f 1.078 b'hai ( c/b du/ratint: 1 907-197tt. tuitics tif tlof furnwtr itol 1.1072 tif tlie, litlir. Alssisfaui,iu jiroviri(b: AdIvisorv' sur-vites lIy t li PA IIO/ lIn aItfilititi. t liv latuitl ii Aulutiiristrativt anuuiluu. td WIlO Coiii l i t- t u ii,s itutlfitrins for tIli proitiutu (sO Ics an( r1 tital liccip t- ll'ol/ ii: lIt Iiglitisuttvill:iucu satitiu uuoiiiituil tiril turds. tnotrthi1lvupiurust w;re tprtvidcul. its tf-guillar t tu i- tiling stiitlltIs ful.rio-a.litiii aiial- Ettii siliotul atptuuittl ;t staff inmnetr Iio liutinIc thec APPENIDIX A Pacge 6 RUork done: Ini accordanice' w Ivi ll) ii;:- plan I opejlatioireS Ii nildc, ;i (lcpaIi lirtll 1, riI\ flic ,;cthoois of AMledicine and preparation of the theoretical iridetl of at ivilivs wvas 90',i , o I Irr )IIisI t i . cachII of IIrose arIivI isit ic : anII d SI taIIl IsIelli t comipleted arid: preparation t0f the Inarorals f.ir 1that InOdlil ,F a ;,airer fur rescarir.1 in ;,,wl g i- l and pnlbie li,;iltli (ien.- wals 8)1,1, completed. According to pi-c(le:ti:rici,:dl ,,rinti;,, Iist rV. all III eXI erirneTCal) stlody areas were sel:t(cl ziid i liarilinilig piohleiI/c dlrIa// io. 19(0 1-1)97 1. of tlie model for the initial appraisal of tlhes lsts wa- s wt AIsislm/un p)rovioed: :3 ho -e(.rrl colistiltaillts :1 erinpo- COnCluded. Application of tile model in a test rtimricipllity rary adlvisers. andl advisory servirs by the( dentlal Ceul.slIttitnt vtas earneid iriit, as were the seletion