Un programa de atención primaria en salud basado en voluntarias en Cali: Metas vs. realidades

Abstract

Para determinar el grado en el que se lograron satisfacer las metas propuestas con respecto a su estructura y sus actividades, después de varios años de operación, se examinó un programa urbano de atención primaria en salud (APS) en un distrito de muy bajos ingresos en Cali, Colombia, cuyos servicios los prestan trabajadores de salud comunitarios, especialmente a través de visitas domiciliarias. Los elementos estructurales del programa tales como la colaboración entre las organizaciones públicas, privadas, las características de las voluntarias y los incentivos usados para retenerlas en el programa, se calificaron satisfactoriamente porque las metas propuestas se ajustaron a la realidad. Las actividades del programa se evaluaron satisfactoriamente en algunos aspectos y no lo fueron tanto en otros. P.e., los servicios preventivos y educativos que prestaban las voluntarias se ajustaron al diseño y el programa ayudó a promover la equidad social; no obstante, fue muy difícil llegar a los grupos socioeconómicos más bajos. Por otro lado, el sistema de información resultó ser demasiado ambicioso, la supervisión de las voluntarias fue deficiente por el alto número de ellas que se asignó a cada supervisor y la cobertura del programa también fue deficiente. Se hacen algunas recomendaciones para que los programas de atención primaria en Cali y también en otras partes alcancen con más eficacia las metas propuestas. An urban primary health care (PHC) program that relies on volunteer community health workers (CHWs) for delivery of services, especially through home visits, in a very low income district of Cali, Colombia, was examined after several years of operation to test the degree of achievement of important goals for its structure and activities (process). Methods of study included interviews with samples of volunteers and their supervisors, review of those volunteers’ records, dscussions in focus groups and conferences, and reading of reports on the program. Some of the goals of the program’s designers, often bsed on aims for use of CHWs found in the literature of primary health care, were well achieved in reality while the application of others was only partly successful or even deficient. Important structural elements of the program collaboration between public and private organizations, characteristics of volunteers, incentives for volunteers, and avoidance of diversion of volunteers’ efforts by their paid employment outside of the program, showed a satisfactory match between the goals for them and reality. For example, there was a close formal collaboration among the Cali public health agency, the departamental university and several private foundations. Over half of the volunteers had outside employment, but there was no evidence to show that it interfered with their efforts in the health program. Activities had a mixed record. The services provided by volunteers matched well the designers’ emphases on preventive and educational services. Targeting the population of a low income district helped to promote social equity, but the lowest socioeconomic group there proved significantly more difficult than the next-to-lowest to serve effectively. Examination of the information system revealed some useful records, but its deficiencies indicated an overly-ambitious scheme. Supervision had deficiencies, probably due to the large number of volunteers assigned to some supervisors, who did not receive any additional compensation for that work. Volume of service -families covered, home visits achieved, and hours worked by volunteers- also had deficiencies. In discussing the results of the study the authors offer some recommendations for improving the achievement of the goals established for the Cali program, which could be relevant also to health programs elsewhere in the world.