Mental health service delivery following health system reform in Colombia.

BACKGROUND In 1993, Colombia underwent an ambitious and comprehensive process of health system reform based on managed competition and structured pluralism, but did not include coverage for mental health services. AIMS OF THE STUDY In this study, we sought to evaluate the impact of the reform on access to mental health services and whether there were changes in the pattern of mental health service delivery during the period after the reform. METHODS Changes in national economic indicators and in measures of mental health and non-mental health service delivery for the years 1987 and 1997 were compared. Data were obtained from the National Administrative Department of Statistics of Colombia (DANE), the Department of National Planning and Ministry of the Treasury of Colombia, and from national official reports of mental health and non-mental health service delivery from the Ministry of Health of Colombia for the same years. RESULTS While population-adjusted access to mental health outpatient services declined by -2.7% (-11.2% among women and +5.8% among men), access to general medical outpatient services increased dramatically by 46%. In-patient admissions showed smaller differences, with a 7% increase in mental health admissions, as compared to 22.5% increase in general medical admissions. DISCUSSION The health reform in Colombia imposed competition across all health institutions with the intention of encouraging efficiency and financial autonomy. However, the challenge of institutional survival appears to have fallen heavily on mental health care institutions that were also expected to participate in managed competition, but that were at a serious disadvantage because their services were excluded from the compulsory standardized package of health benefits. While the Colombian health care reform intended to close the gap between those who had and those who did not have access to health services, it appears to have failed to address access to specialized mental health services, although it does seem to have promoted a change in the pattern of mental health service delivery from a reliance on costly inpatient care to more efficient outpatient services. CONCLUSIONS Health reform in Colombia improved access to health services for the general medical services, but not for specialized mental health services. Although the primary goal of the health reform was to provide universal medical coverage, by not including mental health services in the standardized benefits package, inequities in the delivery of mental health services appear to have been perpetuated or even exacerbated. IMPLICATIONS FOR HEALTH CARE AND POLICY FORMULATION: If health reform in Colombia and elsewhere is to provide universal coverage and adequate access to comprehensive health care, mental health services must be added to the standardized package of health benefits and efforts to develop accessible and effective mental health treatment at the primary care level should continue. IMPLICATIONS FOR FUTURE RESEARCH Mental health services research in Colombia should focus future studies on the differential impact of health reform on access to mental health services across regions, and between urban and rural areas.