The last time you went to the doctor, how long did it take to get to the doctor's office? In France the average time to reach healthcare services is 15 minutes[i]. Close to the European average. But in Colombia, territorial dispersion represents an obstacle to ensuring access to healthcare services. The city of Tambo, the second largest in the country in terms of surface area, is an example of this. There, in a territory of 3,280 km2, with a population of 60,000 (94% in remote rural areas), there is one doctor for every 7,500 inhabitants, well below the national average (15 per 10,000 inhabitants). And from one community it can take several hours, on foot, on horseback, or by car, to reach the nearest medical centre. Under these conditions, reaching the hospital in Popayán, the capital of the department, can turn into an odyssey costing up to 100,000 pesos (€35), according to Eduardo Villa, physician and manager of the hospital of Tambo. An unaffordable luxury for most of the inhabitants in one of the country's poorest departments, where the average per capita income is 250,000 pesos [ii] (€100).

These factors partly explain the dramatic perinatal mortality rates in the city up to a few years ago: 34 per 1,000, double the national average and nearly 10 times higher than in Spain. When he arrived at the hospital in 2012, Dr Villa decided to address this problem by seeking the support of key stakeholders in this mainly indigenous and rural territory: traditional doctors and midwives. This meant adding the experience of Western medicine to the experience and ancestral knowledge of midwives. Dr Villa created groups for exchanges and training with the aim of improving monitoring of pregnant women, and for prevention and detection of high-risk pregnancies. Luis Amaro, midwife and traditional healer, was a member of one of these groups. He's been assisting in births in isolated indigenous communities, day and night, all his life, sometimes walking for up to four hours to get to them. He knows everything there is to know about the territory, its inhabitants, their living conditions, their backgrounds. A cross between a family doctor and an epidemiologist, without any type of official degree. Since he's been participating in the midwife group, he now quickly identifies high-risk pregnancies and sends the patients to the hospital. With a mixture of modesty and pride, Luis Amaro tells us that he does it voluntarily, that it's his duty as a “community leader”, and that he doesn't want money in return.

Another initiative launched by the hospital was the opening of a “hotel for pregnant women”, to facilitate early admission of women with high-risk pregnancies at no charge. The combined result of these two measures is noteworthy: in less than three years the perinatal mortality rate in the city fell sharply and now is close to zero.

The primary healthcare strategy of the hospital of El Tambo arose out of the need to adapt to the zone's inherent difficulties as a territory that is extensive, rural, very culturally diverse, and marked by years of armed conflict. It is based on a preventive, territorial and intercultural approach; and it includes other training initiatives for 400 “points of reference” for promoting health and prevention in communities, integration of “traditional” health agents, multidisciplinary teams that travel around the territory, etc. The results are so encouraging in terms of improved access, quality of care, and savings for the healthcare system that El Tambo has become an example at the national level and has been an inspiration in the design of the new national comprehensive healthcare model.  

This model represents the new paradigm for Colombia's health policies, and it aims to achieve “access with quality to healthcare services”, in the words of Fernando Ruiz, Deputy Minister of Health, “so that problems are solved mainly at the primary healthcare level”. The model is centred around family and community medicine, for care that is closer to patients, understands their social context, and puts the accent on promotion of health and on prevention. Five thousand family doctors will be trained for this purpose over the next 10 years. The model also aims to reduce territorial gaps in healthcare through the opening of clinics closer to the population, the creation of “mobile health brigades”, and a system of incentives for family doctors in remote areas. Implementation of the new model is already underway in the department of Guainía after a three-way negotiation with the local authorities and indigenous representatives. In 2015 it will be implemented in other departments to achieve full coverage in the territory by 2016. The opening of another 15 university programmes in Family Medicine is also anticipated.

EUROsociAL, the cooperation programme of the European Commission with Latin America for social cohesion, supported the Colombian Ministry of Health in designing the model, sharing the experiences of France and Brazil in the area of healthcare in remote areas, and that of the United Kingdom, Spain and Mexico in the area of family medicine.

A boost to a strategic policy to ensure the fundamental right to healthcare. And so that in within a few years the success of El Tambo is not the exception in Colombia but rather the rule.

Por Peggy Martinello, Técnico Senior FIIAPP del Programa EUROsociAL